Differential diagnoses:
- Fibromyalgia
- Chronic fatigue syndrome
- Inflammatory arthritides, including rheumatoid arthritis
- Hypothyroidism
- Lyme disease
- Depression
On further questioning, she described morning stiffness in her hands and shoulders lasting over an hour. She felt her joints were often swollen. She noted that she had felt better during her pregnancies but that the pain gradually returned each time within a few weeks of giving birth.
She often woke in the early hours of the morning due to pain and generally found some relief by getting up to do housework.
She attributed her tearfulness to the recent breakdown of her relationship. She said her partner had become frustrated with her short temper which she attributed to her pain and fatigue.
On examination, she had swelling and reduced movement of all her metacarpophalangeal and proximal interphalangeal joints. Her metatarsophalangeal joints were also swollen. Examination of her shoulder joints was very painful and revealed a globally reduced range of movement.
As rheumatoid arthritis was considered likely, blood tests including rheumatoid factor, ESR and CRP were requested. She was found to have a raised ESR and CRP. Her rheumatoid factor was negative. X-rays of her hands, feet and shoulders were also ordered. These showed soft tissue swellings and marginal erosions. She was referred to rheumatology for further assessment. She was advised to trial naproxen instead of ibuprofen (with omeprazole) and referred to the pain psychology team for help with her mood and to learn about strategies for coping with chronic pain.
