FM Patient Case Study: Mrs C

Diagnosis

Lab results obtained in the last 6 months were normal, including a complete blood count (CBC), chemistry screen, thyroid-stimulating hormone test (TSH), and tests of antinuclear antibody (ANA) and erythrocyte sedimentation rate (ESR).

During a physical examination based on Mrs C's prior history, you identify diffuse mild tenderness throughout the low back that has increased compared with previous visits. You also find moderate tenderness in the suprapubic region upon palpation.

To follow up with these results, you follow the 1990 American College of Rheumatology (ACR) classification criteria for FM and you identify tenderness on palpation at multiple sites—
more specifically, tenderness at 15 of 18 tender point sites.1

You opt to administer the provisional 2010 diagnostic criteria for FM recently released by the ACR, and find that Mrs C has a score of 10 of 19 on the widespread pain index (WPI) and a score of 7 of 12 on the symptom severity (SS) scale.2

Based on the findings of the 1990 and 2010 ACR criteria, you diagnose Mrs C with Fibromyalgia.

References:

1. Wolfe F. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33(2):160-172.

2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62(5):600-610.

patient picture

Laboratory findings

  • CBC and chemistry
    screen normal

  • TSH normal

  • ANA and ESR normal

Physical examination based on prior history

  • Increased diffuse mild
    tenderness throughout
    lower back

  • Moderate tenderness
    on palpation in suprapubic
    region

Physical examination based on current complaints

  • 1990 ACR classification
    criteria for FM

    • Tenderness on palpation
      at 15 of 18 sites

  • 2010 ACR preliminary
    diagnostic criteria for FM

    • WPI: 10/19

    • SS scale: 7/12