a 70 - pacemaker

[ArchivalUser]

A 70-year-old woman is evaluated for a 4-week history of aching bilateral pain and morning stiffness around the proximal muscles of her arms and shoulders and the hip and upper thigh. She does not have rash, neck pain, visual symptoms, cough, headache, or jaw stiffness or claudication. Although her muscles are sore and she feels fatigued, she does not have muscle weakness.

On musculoskeletal examination, muscle strength is normal and range of motion of the shoulders is full. There is no discrete tenderness on palpation of the shoulder joint, subacromial bursa, or surrounding muscles. The remainder of the examination is unremarkable. On laboratory studies, erythrocyte sedimentation rate is 55 mm/h.

Which of the following is the most appropriate management at this time?

A Corticosteroid injection into the glenohumeral joint
B Amitriptyline; aerobic exercise program
C Prednisone
D Ibuprofen
E Acetaminophen with codeine

[ArchivalUser]

c??

[ArchivalUser]

CC..

[ArchivalUser]

D first i would think before moving onto steroids

[ArchivalUser]

its a myopathy and steroids are first line choice

[ArchivalUser]

Correct Answer = C)
Key Points

* Polymyalgia rheumatica is characterized by pain or morning stiffness in the neck or torso, shoulders and upper arms, or hips and thighs in patients >50 years of age with an erythrocyte sedimentation rate >40 mm/h.
* Prednisone therapy rapidly alleviates symptoms of polymyalgia rheumatica.

This patient would benefit from prednisone therapy. Her symptoms are consistent with polymyalgia rheumatica, which is characterized by pain or morning stiffness in the neck or torso, shoulders and upper arms, or hips and thighs and an erythrocyte sedimentation rate >40 mm/h. Careful history and physical examination are indicated to exclude other connective tissue or infectious diseases. Corticosteroid treatment is the first-line therapy for polymyalgia rheumatica, and prednisone, 10 mg/d to 20 mg/d, often resolves symptoms within 24 hours.

Glenohumeral joint injection is not indicated, because full range of shoulder motion and involvement of the hips and upper thighs is not consistent with glenohumeral joint disease. Amitriptyline and aerobic exercise are indicated for patients with fibromyalgia. However, this patient does not have tender points, which are characteristic of fibromyalgia. In addition, this patient's elevated erythrocyte sedimentation rate, which indicates an inflammatory process, is not consistent with fibromyalgia. Neither acetaminophen nor codeine are anti-inflammatory agents and would be ineffective in an inflammatory disorder. Nonsteroidal anti-inflammatory drugs are not as effective as corticosteroids in polymyalgia rheumatica.