FM Patient Case Study: Mrs C

Patient presentation

Mrs C is a 42-year-old wife and mother with 3 children. She works 5 days a week in a day care center with 3- to 5-year-olds. Her reason for coming to the office today is severe pain in the neck and shoulder region that she has been experiencing for at least 2 months.

You have been her primary care provider for approximately 2 years, and in her chart you quickly peruse a number of chief complaints for which you have seen and treated her, including migraine headaches, chronic interstitial cystitis diagnosed by a urologist, and low back pain.

When you see her this morning, Mrs C states that she hasn't been injured but that just touching or gently massaging her neck and shoulders causes much pain and tenderness.

In addition to shoulder pain and the low back pain she's had previously, Mrs C reports that she feels more general pain "all over" in her muscles and joints and that she has felt this way for at least 4 months.

When asked how she is sleeping, she reports frequent insomnia and fatigue. Her sleep is not refreshing and she struggles with daytime sleepiness. She wakes up frequently and also snores loudly, according to her husband. With this information, you proceed to the workup for diagnosis.

patient picture

Personal details

  • 42-year-old wife, mother

  • Works 5 days/week in a
    day care center

Medical history

  • Migraine headaches

  • Chronic interstitial cystitis

  • Low back pain

Current presentation

  • Severe pain and tenderness
    in neck/shoulder region for
    8+ weeks

  • Pain "all over" in muscles and
    joints for ≥4 months

  • Frequent insomnia, fatigue

  • Sleep is not refreshing

  • Struggles with daytime

  • Wakes frequently

  • Snores loudly