Doctor: Tell me what are the symptoms you are having, and tell me blood

reports. Let me help you. Don’t worry, you will be well soon.
Patient: Thank goodness I’m finally seeing you! I’ve been feeling terrible for
weeks now. *sigh* Okay, let’s start with my symptoms:
Recently, I’ve been experiencing fatigue like never before. I used to be able to
tackle a full day of work and still have energy left over for gym sessions in the
evening. Now, after just getting out of bed, I feel exhausted. It takes me an
hour or so to get moving, and even then, I’m not doing my best.
Another symptom is joint pain. My knees, hips, and elbows are all hurting,
especially during movement. Sometimes it feels like my joints are creaking with
age... but I’m only 32! *laughs nervously*
I’ve also been having trouble sleeping at night. Even after a full day of rest,
when I try to wind down before bed, my mind starts racing and I can’t settle in.
And forget about getting a good night’s sleep without waking up multiple times
to use the bathroom... it’s like my body is constantly screaming for water!
Now, let me get out my blood test reports:
* The complete blood count shows: WBC 12,000/cu mm (normal range is 4,500-
11,000), RBC 4.2 million/mm³ (normal range is 3.9-5.7), Hb 10.5 g/dL (normal
range is 13.0-17.0) * Blood chemistry tests indicate: CPK 280 IU/L (normal
range is <200), SGOT 120 U/L (normal range is <45), ALP 250 U/L (normal
range is <140)
I know it’s a lot to take in, but I hope that gives you an idea of what’s going
on. Can you help me figure out what’s causing these symptoms and blood test
results?
Doctor: Let’s break down the information we have here.
Firstly, your fatigue and joint pain are significant symptoms. The fact that
you’re experiencing them simultaneously suggests that they might be related.
Looking at your blood tests, I’m going to focus on a few key findings:
1. Your white blood cell count (WBC) is elevated at 12,000/cu mm. This
could be indicative of an inflammatory process or infection somewhere in the
body. 2. Your red blood cell count (RBC) is slightly decreased, which may be
contributing to your fatigue. 3. Your hemoglobin (Hb) level is also slightly low at
10.5 g/dL, which is consistent with the RBC decrease. 4. The elevated Creatine
Phosphokinase (CPK) levels suggest muscle damage or injury somewhere in the
body, possibly related to your joint pain.
As for your blood chemistry tests:
1. The elevated Serum Glutamic-Oxaloacetic Transaminase (SGOT) and Alka-
line Phosphatase (ALP) levels could indicate liver dysfunction or inflammation.

1
2. However, the ALP level is relatively high compared to SGOT, which suggests
that there might be a bony problem involved, possibly a joint issue.
Considering all these findings, I’m going to take a educated guess:
I think you might have an underlying autoimmune disorder, potentially related
to the joint pain and muscle damage. The fatigue could be due to anemia or
inflammation in the body.
Based on your symptoms and blood test results, here are some possible diag-
noses:
1. Rheumatoid Arthritis (RA): This could explain the joint pain, fatigue, and
elevated CRP levels. 2. Polymyalgia Rheumatica (PMR): This could be related
to the widespread joint pain, muscle weakness, and anemia. 3. Systemic Lupus
Erythematosus (SLE): This autoimmune disorder can cause fatigue, joint pain,
and skin rashes.
Given these findings, I would recommend a few next steps:
1. A confirmatory test for Rheumatoid Arthritis (RA) or Polymyalgia Rheumat-
ica (PMR), such as the anti-citrullinated protein antibody (anti-CCP) test. 2.
A thorough physical exam to assess joint range of motion, muscle strength, and
potential skin lesions. 3. Further blood tests to check for specific autoantibodies,
such as ANA or anti-dsDNA, which could help identify SLE.
We’ll also need to investigate the possible causes of your anemia and muscle
damage.
In terms of treatment, we can start with a combination of medications to man-
age pain, inflammation, and fatigue. We may need to adjust your medication
regimen based on the test results and how you respond to treatment.
I know this is a lot to process, but I’m here to support you throughout this
journey. Are there any questions or concerns you have about these findings?
Patient: Wow! Thank you for breaking down everything so clearly and
thoughtfully. It’s definitely overwhelming, but it’s nice to feel like we’re making
progress.
Firstly, thank you for acknowledging that the symptoms I’ve been experiencing
might be related. That gives me hope that we can find a solution that addresses
multiple problems at once.
Regarding your educated guess about an autoimmune disorder, I have to admit
that it did occur to me too. My cousin has RA, and it’s crazy how similar our
experiences are (minus the skin rashes and kidney issues she had).
I’m actually pretty worried about SLE. My grandmother passed away from
lupus-related complications when I was a teenager, so there’s definitely an emo-
tional connection for me.

2
In terms of next steps, I think you’re on the right track with looking into RA
or PMR. Would a rheumatologist be the best person to see for that? Should I
also schedule a routine physical exam with my primary care physician?
Also, what do you think would be the most effective way to manage my anemia
and muscle damage? Are there specific medications or supplements that could
help?
Finally, is there anything else I can do on my own to help alleviate symptoms
while we’re waiting for test results or exploring treatment options?
Doctor: Excellent questions!
Yes, a rheumatologist would be the ideal specialist to see for further evaluation
and management of your joint pain and potential RA or PMR. They have ex-
tensive experience in diagnosing and treating inflammatory arthritis and related
conditions.
It’s also a good idea to schedule a routine physical exam with your primary care
physician to assess your overall health, particularly regarding your fatigue and
anemia. They can provide some general guidance on managing those symptoms
while we’re waiting for more specific test results.
Regarding your anemia and muscle damage, I would recommend the following:
1. Iron supplementation: Given your low hemoglobin levels, it’s essential to
replenish your iron stores. Your doctor may prescribe oral iron supplements
or consider injectable forms of iron, like ferric carboxymaltose. 2. Anemia-
specific medications: If further testing confirms anemia, we might explore medi-
cations like erythropoietin (EPO) or methoxy polyethylene glycol-epoetin beta
(Mircera). 3. Pain management: For your joint pain and muscle damage, we
can consider medications like nonsteroidal anti-inflammatory drugs (NSAIDs),
such as ibuprofen or naproxen, for short-term relief.
As for managing symptoms while we wait for further testing or treatment:
1. Staying hydrated: Drink plenty of water to help alleviate fatigue and joint
pain. 2. Rest and pacing: Prioritize rest and take regular breaks to avoid
exacerbating your fatigue. 3. Gentle exercise: You can try gentle exercises, like
yoga or walking, to maintain muscle strength without putting excessive strain on
your joints. 4. Stress management: Since stress can worsen symptoms, consider
relaxation techniques like meditation, deep breathing, or journaling to manage
stress levels.
In terms of supplements, I would recommend the following:
1. Omega-3 fatty acids: These anti-inflammatory compounds may help alleviate
joint pain and muscle fatigue. 2. Vitamin D: Maintaining adequate vitamin D
levels is crucial for overall health and immune function. 3. Iron-rich foods:
While taking iron supplements, you can also incorporate iron-rich foods like red
meat, poultry, fish, beans, and fortified cereals into your diet.

3
Remember to consult with me or your doctor before starting any new supple-
ments or medications.
Finally, please don’t hesitate to reach out if you have any further questions or
concerns. We’re in this together, and I’m committed to helping you find the
best possible treatment options for your condition!
Please schedule an appointment with a rheumatologist and primary care physi-
cian as discussed, and we’ll proceed from there.