Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a history of primary Sjögren’s syndrome, now reporting progressive proximal muscle weakness, fatigue, and myalgia. Symptoms involve difficulty rising from a chair, climbing stairs, and overhead reaching. No reported dysphagia or respiratory distress. Symptoms are chronic, insidious in onset, and associated with sicca symptoms (xerostomia, xerophthalmia).
Clinical Examination Findings
General: Patient appears chronically ill but non-toxic. Musculoskeletal: Symmetric proximal muscle weakness (Grade 4/5) in deltoids and iliopsoas. No muscle atrophy or fasciculations noted. Reflexes are symmetric and preserved. Skin: No evidence of Gottron’s papules or heliotrope rash. HEENT: Dry oral mucosa, diminished tear film, no parotid gland enlargement.
Treatment Protocol
Initiate immunosuppressive therapy (e.g., corticosteroids, hydroxychloroquine, or steroid-sparing agents like methotrexate/azathioprine) based on severity. Physical therapy referral for muscle strengthening and range-of-motion exercises. Continue symptomatic management for sicca symptoms (artificial tears, pilocarpine). Monitor CK levels and inflammatory markers (ESR/CRP) at follow-up.