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Office evaluation of the patient with musculoskeletal complaints

  [ 36 votes ]   [ Discuss This Article ]
By Barth WF • • January 27, 1997

Many musculoskeletal complaints are accompanied by classic
signs and symptoms that can be readily diagnosed by the
primary care physician. Others are much less obvious and
present a diagnostic challenge. In the office evaluation of
patients with musculoskeletal complaints, the history is the
most informative element. Least helpful are laboratory tests.
Although erythrocyte sedimentation rate (ESR), rheumatoid
factor, and other widely available tests are sensitive to the
presence of rheumatic diseases, they are not specific for any
of them. In the initial office evaluation, helpful points of
differentiation include the number of joints involved, their
location, and, when multiple joints are involved, whether they
are symmetric or asymmetric. An acute monarthritis is
associated mainly with trauma, infection, or a crystal-induced
synovitis such as gout or pseudogout. Patients with
polyarthritis may have symptoms that come and go very quickly,
sometimes in < 24-36 hours. This migratory pattern
characterizes diseases such as gonococcal arthritis, viral
disease, and sarcoidosis. "Rheumatoid variants" such as
Reiter's syndrome, psoriatic arthritis, and spondylitis may
affect no more than a few joints and are accompanied by other
signs, such as nail and skin lesions (psoriasis) or urogenital
and enteric infections (Reiter's). Like erosive
osteoarthritis, the rheumatoid variants may also cause
swelling and inflammation of the distal interphalangeal
joints. The classic example of symmetric joint disease is
rheumatoid arthritis (RA). While RA often occurs in a
progressive and additive pattern, its onset may be followed by
a remission several months later. Patients who present with
the "algias" may have no physical signs but manifest extensive
musculoskeletal pain. Fibromyalgia occurs typically in younger
women; polymyalgia rheumatica rarely occurs in patients < 50
years of age and is usually accompanied by a strikingly high
ESR. Age and gender should be noted in the office evaluation
because they can provide clues not only to these "algias," but
other rheumatic diseases seen more frequently in one age or
gender group than another.

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