CASE 82: ACHES AND PAINS
History
A 76-year-old woman has felt non-specifically unwell for about 10 weeks. She feels stiff
especially when she gets up in the morning. She struggles to get out of bed by herself and
she has difficulty lifting her hand to comb her hair. She has also noticed some pain in her
knees and fingers. She has lost 4 kg in weight, and has noticed some sweats which seem to
occur at night. She has come to see her general practitioner (GP) because a new problem
has arisen. For the last few days she has had a constant severe headache. On direct ques-
tioning she says that she has had pain in her jaw when chewing. She has previously been
fit with no significant past medical history. She lives alone. She has not smoked for 40
years and she only drinks alcohol at Christmas. She is taking no regular medication. She
has tried some paracetamol but this has not helped the headache.
Examination
She is thin. She is markedly tender to palpation over parts of her scalp. Her blood pressure
is 138/84 mmHg. Examination of her cardiovascular, respiratory and abdominal systems is
normal. Power is slightly reduced in the proximal muscles of her arms and legs. Neurological
examination is otherwise normal.
NormalHaemoglobin 10.3 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 87 fL 80–99 fL
White cell count 12.2% 109 /L 3.5–11.0% 109 /L
Platelets 377 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 91 mm/h !10 mm/h
Sodium 139 mmol/L 135–145 mmol/L
Potassium 4.6 mmol/L 3.5–5.0 mmol/L
Urea 3.8 mmol/L 2.5–6.7 mmol/L
Creatinine 102 &mol/L 70–120&mol/L
Glucose 6.8 mmol/L 4.0–6.0 mmol/L
Albumin 38 g/L 35–50 g/L
Bilirubin 16 mmol/L 3–17 mmol/L
Alanine transaminase 85 IU/L 5–35 IU/L
Alkaline phosphatase 465 IU/L 30–300 IU/L
Creatine kinase 139 IU/L 25–195 IU/LINVESTIGATIONS
Questions
- What is the diagnosis?
- How would you investigate and manage this patient?