A 39-year-old woman presents to your office with concerns that she may have systemic lupus erythematosus (SLE) because her younger sister has been recently diagnosed with the condition by another physician. Your patient describes fatigue, hair loss in the comb but no patchy “bald spots,” a weight gain of 20 lb in the past 6 months, and achy joints and muscles. She feels weak and reports shortness of breath with minimal exertion (after climbing one flight of stairs). Her past medical history reveals Hashimoto’s thyroiditis diagnosed 6 years ago, and she has been on thyroxine since then, although she has not had follow-up for that condition in more than a year. She also has hypercholesterolemia and takes pravastatin. Her social history reveals cigarette smoking, one pack per day, which she explains helps her defray the stress of her job (she works full time in a family-owned restaurant as the business manager, shopper, and part-time cook). The family history is notable for her father having committed suicide after a long struggle with depression. Her mother has thyroid disease and rheumatoid arthritis; her sister has recently diagnosed SLE, and her twin teenage sons are healthy, but have recently been on a brief detention from school after being caught drinking alcohol on the school premises. On review of systems, she denies Raynaud’s phenomenon, hematuria, or pleurisy, but reports occasional painful mouth ulcers, dry mouth and dry eyes, trouble sleeping, and irregular and heavy menses.

Your examination reveals a blood pressure of 135/85 mmHg, a regular pulse of 90 beats/minute, and no fever. Weight is 100 kg. Skin examination shows mild eczema on the hands, with dry skin. The oral mucosa and hair density on the scalp both appear unremarkable. The eyes are moist, and Schirmer’s test documents 14 mm wetting in both eyes. No enlargement of the thyroid, cervical lymph nodes, or major salivary glands is present. The chest and abdominal examinations are normal. The musculoskeletal examination reveals full strength in the distal muscle groups, but “breakaway” weakness proximally, with the patient complaining of soreness in the muscles on manual resistive testing. Tenderness is noted on palpation of the proximal interphalangeals, metacarpal phalangeals, and wrist joints, without distinct synovitis. The articular range of motion is normal throughout, with the patient stating that the shoulders, neck, and hips feel achy during these maneuvers. The patient has tenderness to soft tissue palpation at 12 tender points.