Lab Studies:
ANA, Sjogrens Anti-SS-A (RO), Ribonucleic Protein Antibody, and Erythrocyte Sedimentation Rate were all elevated.
Comprehensive Metabolic Panel, Complete Blood Count, Thyroid Stimulating Hormone, Hemoglobin A1C, Vitamin D, Vitamin B12, Folate, Total Creatine Kinase, and Ionized Calcium were all within normal physiologic ranges.
HIV and Pregnancy tests were negative.
C-Reactive Protein, Rheumatoid Factor, Smith antibody, and Cyclic Citrulline Peptide antibody were negative.
Cardiolipin, Phosphatidyl Inositol, Phosphatidyl Glycerol, and Phosphatidyl Serine IGM/IGG/IGA were all negative.
Other Studies:
Widespread pain index screening was performed showing that the patient had pain in the bilateral upper arms, bilateral upper legs, and the lower back region over the last week for a total score of 5 (1 point for each region).
The Symptom Severity Scale performed with the patient rating she had moderate problems of fatigue, waking unrefreshed, and cognitive symptoms (two points each). The patient also indicated a great deal of somatic symptoms such as muscle pain, fatigue, memory problems, muscle weakness, headache, depression, and anxiety (3 points for many symptoms). The total Symptom Severity Scale score was 9.
Consultations:
Patient is on the waiting list to see rheumatology. An average waiting time of up to a year is expected due to lack of specialists in the area.
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