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Office evaluation of the patient with musculoskeletal complaints

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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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