An Army Sergeant With Mysterious Pain: Crack the Case

Christopher L. Tracy, MD

Disclosures

November 10, 2014

Case of a 44-Year-Old Retired Army Sergeant

A 44-year-old female, retired Army sergeant presents with diffuse joint pains and fatigue of 2 years' duration. Her pain and stiffness lasts all day long in both upper and lower extremities. She is experiencing diffuse hand pain and stiffness. When asked about swelling in her joints, she says that every morning her hands feel puffy, but the joints don't seem to swell. The stiffness in her hands never truly abates.

The patient does not report any recent illnesses. She has had intermittent constipation and abdominal discomfort but says that her stools have been more regular since taking a fiber supplement. She also reports a history of hypothyroidism and depression. She often sleeps separately from her husband because his snoring keeps her up at night.

The patient reports that her overall pain makes it difficult for her to keep up with her work as an administrative assistant. In addition, she has had trouble keeping track of all of the various tasks assigned to her.

Something is definitely wrong, the patient says. No one has been able to give her a definitive explanation. A psychiatrist does not think her depression has worsened and has not recommended medication. She has taken nonsteroidal anti-inflammatory drugs for pain, but it does not help. An endocrinologist who has been managing the patient's hypothyroidism has told her that the disease is well controlled with her current therapy. The patient is fearful that she may have rheumatoid arthritis or some other autoimmune disease.

Medical/surgical history: hypothyroidism, depression, post-traumatic stress disorder, hyperlipidemia, and appendectomy approximately 20 years previously. She has not had recent mammography or cervical cancer screening. Because the patient has a family history of colon cancer in a first-degree relative, she recently underwent colonoscopy that was reported as normal.

Social history: denies tobacco/alcohol use.

Medications: levothyroxine 250 µg daily, simvastatin 20 mg daily (discontinued 6 months ago), ibuprofen as needed, multivitamin.

Allergies: penicillin.

Physical examination: The patient is afebrile, with normal vital signs. She is overweight, with a body mass index of 27 kg/m2. HEENT, cardiac, pulmonary and abdominal examinations are normal.

The patient has multiple soft-tissue tender points on palpation that include the bilateral mid-upper trapezius muscles, cervical paravertebral muscles, lateral epicondyles, upper lateral thighs, and medial portions of both knees just proximal to the joint line. Joint examination is remarkable for diffuse tenderness without warmth, swelling, or effusions. Strength examination is normal, without weakness in large-muscle groups. Reflexes are normal and symmetric in the upper and lower extremities. No rash is noted on skin examination.

Imaging: Plain radiographs of bilateral handsare normal.

Laboratory results: The patient brings results of a previously obtained complete blood count, basic metabolic panel, liver function tests, thyroid testing, and erythrocyte sedimentation rate, all of which are within normal limits.

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