A mysterious constant pain

A mysterious constant pain proves a challenge for both patient and practitioner alike.

Penny, a 43-year-old patient new to your practice, presented with neck and shoulder pain and extreme fatigue. 

When probed about the nature of the pain, she had difficulty localising it, saying that she felt it all over the shoulder and neck. She rated the pain severity as 10 out of 10, consistently. The pain was present constantly and was having a profound impact on her sleep and lifestyle generally. She was not employed but said that she had worked as a merchandiser, in retail and as a nanny. She denied any past medical or surgical history.

You asked Penny about medication taken and she produced multiple bottles of OTC paracetamol, codeine, ibuprofen and diclofenac, together with prescribed tramadol, pregabalin and oxycodone. Altogether she provided 12 different medications. She was a little