Initial clinical assessment of patients with possible rheumatic disease

Chapter 3 Initial clinical assessment of patients with possible rheumatic disease



Andrew Hassell, MD FRCP MMedEd, School of Medicine, Keele University, Keele, UK



Janet Cushnaghan, MSc MCSP, Epidemiology Resource Centre, Southampton General Hospital, Southampton, UK



CHAPTER CONTENTS

Introduction 27

Principles of rheumatological physical assessment 27
Overview 27

Joint pain 28
Evaluating regional joint pains 29

Musculoskeletal red flags 29

Further evaluation of the patient presenting with inflammatory joint pains 29

Assessing osteoporosis risk 29

Screening for Locomotor problems 30
The GALS tool: gait, arms, legs, spine 30
Gait 30

Spine 31

Arms 31

Legs 31

Outline of regional joint examination 31
Introduction 32

Look 32

Feel 32

Move 32

Function 32

Principles of investigations in evaluating patientswith rheumatic diseases 32
Blood tests 33

Imaging 33

Conclusion 33

Acknowledgement 33


KEY POINTS



image Rheumatic diseases are frequently multi-system and multi-joint conditions and this should be considered in the therapy assessment

image Screening for rheumatic disease in therapy assessments can be undertaken using careful history taking and simple physical tests

image Simple screening questions and physical examinations can guide the clinical assessment.



INTRODUCTION


This chapter describes the key components of screening for rheumatic disease in clinical assessment. It can be used alongside the disease specific chapters following and can be embedded in routine musculoskeletal examinations and assessments of activities of daily living. The chapter draws on the arc-funded Handbook on the Clinical Assessment of the Musculoskeletal System (which comes accompanied by a DVD on regional examination) (http://www.arc.org.uk/arthinfo/documents/6321.pdf accessed March 2009).



PRINCIPLES OF RHEUMATOLOGICAL PHYSICAL ASSESSMENT



OVERVIEW


Successful identification and management of rheumatological problems in patients is predicated upon accurate history taking and examination. In this chapter we consider key aspects of history taking, physical examination and investigations in patients in whom rheumatological disease is suspected. For purposes of this chapter, we interpret rheumatological as pertaining to disorders of the musculoskeletal system (Doherty & Woolf 1999).



JOINT PAIN


By far the commonest symptom with which patients with a rheumatological problem present is pain. For such patients, clinical assessment should first be undertaken to establish answers to the following five questions:


1. Does the problem seem musculoskeletal in nature?

2. Is the problem acute or chronic?

3. Is the problem inflammatory or non-inflammatory?

4. What is the pattern of joint involvement?

5. What is the impact of the symptoms on the patient?

Accurate addressing of the above questions should allow the therapist to go a long way in identifying the problem and appreciating the patient’s perspective. Over the next paragraphs, we will briefly expand upon each of these key questions.


1. Does the problem seem musculoskeletal in nature? Patients sometimes present with symptoms they perceive to be arising from their bones or joints when in fact this is not the case. Classic examples are patients with a biliary problem presenting with shoulder pain, patients with angina presenting with left arm pain and/or pins and needles, and patients with intra-abdominal or retro-peritoneal problems presenting with back pain. Careful history taking can often clarify and prevent such confusion.

2. Is the problem acute or chronic? Mode of onset and course is often very helpful in elucidating the nature of a patient’s rheumatological problem. The first issue is whether symptoms were related to any physical trauma which could be relevant in their causation – a fall, a possible sports injury, accident, etc. The second issue is the onset and duration. In the absence of injury, acute onset peripheral joint pains often are inflammatory in causation. Peripheral joint symptoms which fluctuate quite markedly are again, often inflammatory. By contrast, pain arising in association with osteoarthritis is often insidious in onset and gradually progressive.

3. Is the problem inflammatory or non-inflammatory? A key aspect of the assessment of a patient presenting with peripheral or spinal joint pain is deciding whether the problem is arising from underlying inflammation as this often has major implications for the diagnosis and management. Prominent joint stiffness, particularly prolonged morning stiffness of the joints (typically in excess of 30 minutes), is suggestive of an inflammatory problem. By contrast, patients with a non-inflammatory problem often report little stiffness. Knee stiffness which comes on after sitting and lasts a minute or two after standing is quite typical of osteoarthritis. Another pointer towards an inflammatory problem which may be reported by patients is joint swelling, particularly swelling which fluctuates. It must be recognised, however, that patients are sometimes not very accurate in reporting joint swelling. Other features suggesting an inflammatory problem include pains, which improve somewhat with activity (particularly in the case of inflammatory back pain) and the presence of systemic upset, e.g. anorexia, weight loss or fever.

4. What is the pattern of joint involvement? This is another highly relevant question. Is the problem monoarticular (one joint), oligoarticular (fewer than five joints) or polyarticular (more than four joints)? Is the joint involvement essentially symmetrical? Are small and large joints involved? If the hands are involved, are the distal interphalanageal (DIP) joints? Taking the information established from points 1-4, one may be able to summarise patients’ presentations thus: a 40-year-old woman with a chronic (4 month) fluctuating symmetrical inflammatory arthropathy involving the hands (sparing the DIPs), wrists and feet, with a sub-acute onset. This would be characteristic of a primary inflammatory arthropathy such as rheumatoid arthritis. Alternatively, a 60-year-old man with a one day history of an acute inflammatory arthropathy involving the right knee only would raise the likelihood of acute septic arthritis or crystal arthritis.

5. What is the impact of the symptoms on the patient? No assessment of a patient presenting with musculoskeletal symptoms is complete without an assessment of the impact of the symptoms on the patient’s activities and quality of life. Are there specific things the patient can’t do? Some therapists talk of a ‘disability ladder’, starting with inability of the patient to perform certain activities such as sport or hobbies, then prevention of activities more essential to the patient such as work or looking after the household, through to inability to perform essential activities such as self hygiene or sleeping. Part of this evaluation includes some assessment of the patient’s mood. Is the patient depressed? It should be remembered that, as well as joint symptoms resulting in patient depression, there are instances in which joint symptoms can be a physical representation of a patient’s depression or mental state, sometimes called somatisation.


Evaluating regional joint pains


In addition to the above approach for a patient presenting with musculoskeletal pain, there are other specific aspects that require assessment in patients presenting with regional joint pains. Are there aspects of the patient’s activities, occupational or recreational, which may be causally relevant to their symptoms? More obvious examples include the development of heel pain in someone who does unaccustomed exercise or wears inappropriate footwear (possible plantar fasciitis), or lateral elbow pain in someone who has recently resumed racket sports (lateral epicondylitis). Other important questions for patients with a regional pain problem include exacerbating and relieving factors.


Symptoms in certain joints generally require specific questioning. One example is non-inflammatory mono-articular knee pain. In patients presenting with this, it is important to ask about ‘locking’ (an acute inability to extend the knee fully, which subsides spontaneously or with some manipulation by the patient – suggests a loose body within the joint) and ‘giving way’ (the knee acutely letting the patient down). The latter can arise from severe pain but can also be a result of ligamentous instability. In cases of patients presenting with non-inflammatory back pain, it is important to assess for radicular (nerve root compression) or myelopathic (spinal cord compression) problems, by asking about peripheral pins and needles, numbness and weakness, as well as disturbance of control of micturition or bowel evacuation.



MUSCULOSKELETAL RED FLAGS


Red flags are symptoms or signs which raise the possibility of serious underlying disease (Leerar et al 2007, Sizer et al 2007), generally neoplastic (malignant) or infectious. In patients with rheumatological problems, red flags may also reflect inflammatory disease.


Red flags include systemic features such as weight loss and fever, local features of unremitting, boring pain with prominent nocturnal pain, and a past history of cancer. In the case of back pain, the age of presentation can also be a red flag. First onset back pain aged > 50 would itself be deemed a red flag (Leerar et al 2007, Sizer et al 2007). The presence of red flags in a patient presenting with musculoskeletal symptoms generally highlights the necessity for further investigation and evaluation.

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Jul 3, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Initial clinical assessment of patients with possible rheumatic disease

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