General Internal Medicine Q 12

A 36-year-old woman is evaluated for a 3-year history of fatigue that worsens after activity and does not improve with rest. She also notes intermittent diffuse myalgia and arthralgia, constipation, dizziness, headaches, urinary urgency, memory problems, and paresthesias. Her musculoskeletal symptoms, dizziness, and headache worsen in the upright position and improve when she lies back down. She has almost entirely eliminated social activities. Medical history is significant for episodic migraine and irritable bowel syndrome. Medications are sumat riptan, polyethylene glycol, and hyoscyamine.

On physical examination, vital signs are normal. BMI is 24. Neck circumference is 36 cm (14 in). The remainder of the examination is normal.

Laboratory studies obtained 6 months ago showed a normal complete blood count, electrolyte levels, kidney function test results, liver chemistry test results, fasting glucose level, serum cr eatine kinase level, and serum thyroid-stimulating hormone level.

Which of the following is the most appropriate diagnostic test to perform next?

A Antinuclear antibody assay

B Polysomnography

C Serum cortisol level measurement

D No further testing is recommended

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