Kaplan USMLE Step 2: Woman reports constant pain and depression

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

A 35-year-old woman comes to the physician because of pain in her lower back, neck, shoulder and legs for the past eight months. She also reports severe fatigue, sleep disturbances, and depression that is causing a decline in her work performance as an electrical engineer. She is married with one child. She drinks two to three glasses of wine socially but does not smoke tobacco. Physical examination shows diffuse muscle tenderness at focal points. Laboratory studies including complete blood count, basic metabolic panel, erythrocyte sedimentation rate and thyroid function tests are normal. The patient reports being active and taking an aerobic exercise class but continues to have persistent pain. Which of the following is the most appropriate next step in management?

A. Amitriptyline

B. Fluoxetine

C. Ibuprofen

D. Prednisone

E. Tramadol

The correct answer is A.

This patient presents with chronic, widespread, musculoskeletal pain, fatigue, sleep disturbances and depression. Physical examination shows muscle tenderness at focal points. Given her symptoms, physical examination, and normal laboratory studies, the most likely diagnosis is fibromyalgia. She is initially treated with aerobic exercise, however, her symptoms continue to persist. Hence the next best step in the management of this patient is drug therapy with amitriptyline.

Choice B. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), which is not used in the treatment of fibromyalgia.