Advanced Practice Rheum: Evaluation of Rheumatic Complaints Save

Transcript Summary: In this review, Dr. Cush provides a systematic approach to evaluating musculoskeletal and rheumatic complaints in clinical practice. He emphasizes three key priorities: identifying "red flag" conditions (septic arthritis, gout, pseudogout, and fractures) that present acutely, making timely diagnoses by considering the most common conditions first based on patient age and demographics, and thinking like a rheumatologist by asking whether symptoms are inflammatory versus non-inflammatory, acute versus chronic, articular versus non-articular, and monoarticular versus polyarticular. The presentation stresses the importance of thorough joint examination, recognizing fibromyalgia as a frequent diagnosis, and understanding that common conditions like osteoarthritis, low back pain, and trauma affect millions while rare conditions like lupus are far less prevalent.

TRANSCRIPT

Hi, I am Jack Cush with RheumNow.com. This is Advanced Practice Rheum. In this series, we'll review many aspects of rheumatology necessary for effective practice. In this edition, we'll be covering the evaluation of musculoskeletal complaints. I'll refer you to any chapter of Harrison's, any addition of Harrison's textbook of internal medicine that I wrote on this topic under the same name, also RheumaKnowledgy.com. You can go there and see the same chapter written for you or you can download the RK card. The RheumaKnowledgy card, RK card has much of the information I'm going to present and you can have it in your pocket or electronically. 

In this session, I want to review for you the key things to the evaluation of a patient with musculoskeletal complaints. This would be number one, to identify red flag conditions. These are conditions you don't want to miss. Number two, make a timely diagnosis. And three, provide a reassurance and a plan for treatment going forward. 

The way you can diagnose musculoskeletal and arthritic and rheumatic conditions would be first to know red flag conditions when they occur, and this is pretty easy because they all present as acute, less than six weeks, monoarthritis or one area of the joint. The differential diagnoses are those things that have significant morbidity, if not mortality, septic, arthritis, gout, and pseudo gout. And lastly, fracture. They all present as one single acute presentation. That's the red flag condition that you don't want to miss. 

Next, you narrow your choices either by knowing the numbers or thinking like a rheumatologist. What do I mean by knowing the numbers? The most common things occur commonly. Low back pain, 59 million. Trauma fracture, who knows? 15 plus million. Osteoarthritis, 57 million, 12 million people with gout. On the other hand, common cool conditions, test questions are often very rare. Lupus, 299,000, juvenile arthritis, roughly the same number, sarcoidosis less than 200,000. So Behçet's,15,000. Still's disease, who knows - 10,000, 12,000.

You have to know the most common conditions and think of them first. If the patient complainant is less than 60 years of age or over 60 years of age, you may have a differential diagnosis. Regardless of the age, you should always find out if there's trauma, which brings to mind fracture and damage and low back pain. That's like a hundred million people right there next, and those people will get orthopedic and radiographic evaluations. Next, think fibromyalgia. First, it's upwards of 5 million people and they frequently present for evaluations if they are less than 60 years of age. 

You think of repetitive strange injury, things like overuse syndromes, bursitis, tendonitis, carpal tunnel, enthesitis. That's like up to 10 million people. Gout affects 12.1 million people in the United States. Rheumatoid arthritis 1.3 and the spondyloarthropathies, PSA/SpA, et cetera, is about 1.4 million. 

If they're over age 60, you should think osteoarthritis first, somewhere between 30 and 57 million. Gout and pseudo gout is about 15 million over the age of 60. And then polymyalgia rheumatica probably over 400,000 because of the age being over 60. You should also be thinking of osteoporosis that is asymptomatic, but osteoporosis with fracture is going to be very symptomatic. And again, it's one of the red flag conditions. Acute, painful, usually one area. So know the numbers and consider the most likely things first. 

If you want to think like a rheumatologist, you ask four questions. Is it inflammatory or non-inflammatory? Is it acute or chronic? Is it articular versus non-art? Is it one joint or many joints? Inflammatory, non-inflammatory, that's redness, heat, swelling and pain. Rubor, calor, dolo and tumor. Acute versus chronic, less than six weeks, more than six weeks.

Articular and peri articular. Hard to know. You need to do a lot of joint exams, know how to do that. And the differential diagnosis on monoarthritis is actually the same as oligo arthritis. So one to three joints has the same differential and is very different than differential of four or more joints, polyarthritis. Once you have that, then you can make a diagnosis based on whether it's acute articular inflammatory, etc., and then know the differential diagnoses for those conditions. Once you've figured out that, then you can go into your history and get clues from the RheumaKnowledgy card, and it'll tell you that if differential according to age, young, middle, or elderly sex, males are more likely to get gout and closing spondylitis. Females are more likely to get fibromyalgia, RA and lupus. And then same thing for racial predilections.

And then under the review of systems, if you look at the card, you ask questions about fever, eye findings, oral ulcers, genital ulcers, rash, tight skin, nail changes, rain out sausage digits, and it goes on and on. And that's how you further narrow your diagnosis. 

You should have a patient fill out a form and a survey form. You can download that from RheumNow.com, the clinic survey form that every patient fills out, and you can get all that information and incorporate it into your note without having to repeat all of it with the patient when you have limited time with the patient. 

So then you can quickly come to not only what the diagnostic possibilities are, but what the supportive evidence is. Again, I want to reiterate that, think fibromyalgia first. These are people who often present with pain. They're never going to present with widespread pain and tender points and sleep disturbance. They're going to present with one pain that'll be strange or hard to understand. They'll have other symptoms that'll be strange and hard to understand. They ultimately, on full evaluation and exam, will have widespread pain, a number of tender trigger points, and they often have a sleep disturbance. That's the important triad. Widespread pain, tender points, sleep disturbance, they hurt all over. They have impressive histories and histories of dysfunction, but their joint exams are non revealing. Their labs are non revealing, yet the patient has total body pain, fatigue. They feel like they have a toothache. And the supportive symptoms, insomnia, sleep apnea, restless leg fatigue, headaches, paresthesias, cognitive dysfunction, depression, anxiety is only seen at 30%. TMJ pain, atypical chest pain, bowel syndrome, and dysmenorrhea. Then you move on to your joint exam. Your joint exam, everybody gets a 28 joint exam. That means you're examining both shoulders, elbows, wrists, ps, dipss, and knees.

Now, there's 66 joints that you can do, plus 18 tender points that you can do. But how do you do a joint exam? 

I would encourage you to go look at my YouTube video called the virtual Video Joint Exam. We'll tell you how I do that on virtual visits for telemedicine. But you can either be very experienced and use both hands to wrap your fingers around a PIP to figure out whether it's abnormal, swollen, squishy, hard, et cetera, warm, cool, et cetera. But if you're not experienced, you can do the cheap and easy squeeze test, squeeze the fingers, which is largely squeezing the pips, squeeze the knuckles, the mcps, squeeze the wrist, do range of motion, squeeze the shoulders, elbows, and knees. Same for MTPs and ankles. This will give you a feeling for what's involved as far as pain and maybe what's involved as far as swelling.

It's important to pick up on swelling, and it takes time to be good at that. The key elements of the joint exam are basically one, spend 10, 15 seconds watching the patient walk, write, sit down, rise. You can do a 28 joint exam in two minutes, and that will discern whether the patient has articular versus non articular or peri articular pain. You want to note the distribution: is it just PIPs? In which case it could be osteoarthritis or rheumatoid arthritis or psoriatic arthritis. DIPs is more distinctive. Osteoarthritis and psoriatic arthritis, cps much more distinctive, typical of RA and less of the other conditions. 

So pattern of joint involvement, and then specific maneuvers like a carpal tunnel test, which is the thumping of the median nerve, which we call the tinal sign. But a much better test is the Durkan sign, which is squeezing the median nerve for 30 seconds and finding numbness in the first three and a half fingers. Bulge sign: looking for fluid in the knee. Drop arm tests: looking for rotator cuff dysfunction. 

Again, distribution is very, very point. How do you distinguish articular from non articular? Note that whether they are diffuse in their pain or they point to the pain. Periarticular pain is often they point to it; it is a spot that hurts. Moreover, they tell you, it hurts when I do this. When they actively engage it and move tendons, that will then induce pain. Whereas if you passively move and they hurt, well that's going to be more true articular. 

So again, it's important to note whether the pain is related to activity, trauma, repetitive tasks, etc.

Lastly, enthesopathy, pain and insertion on tendons, is typical of spondyloarthropathies, spon, arthropathies, spondyloarthritis, ankylosing spondylitis, enteropathic arthritis, and reactive arthritis. But it can also be seen in JIA, rheumatoid arthritis, Behçet's, leprosy, Lyme disease, etc. Tune in for other videos on lab assessment.

Editor’s note: This transcript has been prepared from the original recording and may include transcription inaccuracies. Please rely on the video for the most complete and accurate information.