Editors: Isenberg, David A

Editors: Isenberg, David A.; Maddison, Peter J.; Woo, Patricia; Glass, David; Breedveld, Ferdinand C.

Title: Oxford Textbook of Rheumatology, 3rd Edition

> Table of Contents > Section 1 - Clinical Presentation of Rheumatic Disease > 1.1 - Clinical presentations in different age groups > 1.1.1 - The adult patient > Before the history and physical examination

Before the history and physical examination

Part of "1.1.1 - The adult patient"

The process of evaluation begins even before the patients begin to give their history. After reading the physician's referral letter and any accompanying documentation, our own initial assessment begins in the waiting room (Table 1).

Table 1 Pre-consultation intuitive observations
Clinical problem / Possible diagnosis
Painful foot, elderly woman on diuretics / Gout
Young, sexually active; hot swollen joint / Gonococcal arthritis
Headache with diffuse aches and pains in an elderly person / Polymyalgia rheumatica
Antinuclear antibody-positive, but no symptoms / Referring physician's dilemma, not the patient's
On allopurinol with high uric acid but no arthritis / Not gout
Post-pubertal male with low back pain / Ankylosing spondylitis
Woman, 6 weeks post-partum; small joint arthritis / Rubella vaccination; rheumatoid arthritis
Note: Intuitive diagnoses must be constantly subject to reflection and reassessment.

Many important signs may be noticed when asking for the patient. An accompanying friend or relative may respond, leading a disabled or reluctant patient forward and apparently wishing to take charge of the proceedings. Observation of such interpersonal reactions forms a significant part of the assessment. We also see whether the patient rises from a chair with difficulty, owing to weakness or stiffness, and how he or she walks towards us. Is a walking aid being used? If so, does it seem to be needed? On introduction, with a normal handshake, is there a flinch? Does the gait change in the walk from the waiting to the examining room? What is the patient's general demeanour? Even before the history taking begins, areas of focus will have already been intuitively defined. These will subsequently be organized in a systematic manner.

Editors: Isenberg, David A.; Maddison, Peter J.; Woo, Patricia; Glass, David; Breedveld, Ferdinand C.

Title: Oxford Textbook of Rheumatology, 3rd Edition

> Table of Contents > Section 1 - Clinical Presentation of Rheumatic Disease > 1.1 - Clinical presentations in different age groups > 1.1.1 - The adult patient > History

History

Part of "1.1.1 - The adult patient"

When taking the history, the physician should, in due course, attempt to focus the patient's complaints into a differential diagnostic scheme. It is obviously important to determine where the complaints are situated. Are they localized or generalized, episodic, constant, or progressive? Is there any

P.4

diurnal variation and what, if any, are the aggravating or alleviating factors? In many conditions it is often possible to establish a fairly firm diagnosis from the history alone and, when symptoms are episodic, such a working diagnosis will have to suffice until the patient is seen during a symptomatic period. A ‘wait and see’ approach is not uncommon in rheumatology but the rationale must be carefully explained to the patient. Thus, the described pattern of joint involvement and characteristic symptoms will often allow the diagnosis of acute gout or palindromic rheumatism to be made with confidence, awaiting objective confirmation during the next episode.

Specific symptoms to be asked for include arthralgias, myalgias, joint swelling, morning stiffness, Raynaud's phenomenon, and skin rashes and paraesthesias.

If there is suspicion of a systemic disease, a full systematic medical inquiry must be embarked upon and any significant symptoms noted. Figure 1 shows what we believe to be the key points in our own intuitive diagnostic process. This becomes modified by the statistics of disease likelihood in our practice. Even if the problem appears to be localized, one must be conscious of the fact that systemic diseases (rheumatic and non-rheumatic) often present with local symptoms, for example, carpal tunnel syndrome in rheumatoid arthritis and hypothyroidism (Table 2).

Fig. 1 Aspects of differential diagnosis in rheumatology.
Table 2 Primarily non-rheumatic illnesses presenting in the rheumatology clinic
Symptom/sign / Illness
Weight loss/bone pain / Multiple myeloma
Carpal tunnel syndrome / Acromegaly
Hypothyroidism / Amyloid
Bone pain / Secondary tumour
Vasculitis (polyarteritis nodosa) / Hepatitis
Stiffness and difficulty in walking / Parkinson's disease
Chronic synovitis with bowel problems / Inflammatory bowel disease
Stiff fingers, shoulder pain / Diabetic cheiroarthropathy

Pain and stiffness

The majority of adult patients seeking a rheumatological consultation complain of pain and/or stiffness. The pain is usually localized descriptively to their joints, muscles, or bones and the clinician has to determine whether this localization is correct.

It is important to bear in mind that patients are not usually familiar with anatomy and physiology, and that it is often impossible, for example, to elucidate an anatomically correct description of pain and paraesthesias due to compression of the median nerve from a patient with pain in the hand and forearm. Similarly, patients may complain of pain in the hip ‘right in the joint’ and when asked to indicate the site of the pain, they will point to the greater trochanter or gluteal region, not the groin.

Nevertheless, if a patient presents with a somewhat localized problem (e.g. forearm pain with use), close attention to the anatomical peculiarities of the region and the relevant symptoms and signs will generally provide a clear diagnosis. Localized problems may be multifocal, suggesting a generalized disorder, but a careful examination (e.g. for bursitis and for tendinitis) after the history will help in this distinction. It is important to be wary of the diagnosis of diffuse or even focal osteoarthritis as the cause of symptoms, even when there may be supporting radiographic evidence. Although this condition may be present, it may not be the predominant cause of symptoms (Table 3).

Table 3 Clinical pointers in syndromes where pain is poorly localized
Diagnosis / Clinical pointer
Periarticular shoulder pain / Referred to deltoid insertion
Tennis and golfer's elbow / Diffuse forearm pain on gripping
Carpal tunnel / Nocturnal paraesthesiae, often diffuse
Flexor tenosynovitis / Triggering and/or finger pain on gripping (pulp-pinch sign positive)
de Quervain's tenosynovitis / Positive Finkelstein test
Mechanical back pain / Tenderness over gluteals and sacroiliac ligaments frequent
Spondylitic back pain / Minimal sacroiliac or gluteal tenderness; morning stiffness marked
Trochanteric bursitis / Nocturnal pain when lying on that side; focal, point tenderness
Hip synovitis / Usually groin and outer-thigh pain, occasionally elsewhere
Anserine bursitis / Often nocturnal medial knee pain if knees are touching; localized tenderness
Note: Other, better localized syndromes, e.g. calcaneal bursitis, plantar fasciitis, infrapatellar bursitis should be immediately apparent on examination of the painful area.

Pain is defined by the patient's subjective description. The clinician's task is to characterize this in terms that are in common medical usage. As indicated, the starting point is to describe localization. The quality, intensity, duration, and type of onset, as well as provoking, aggravating, or alleviating factors must be determined, together with the presence of a diurnal variation. However, such technical terms are usually best avoided with the patient. Important and revealing questions are ‘What brings on the pain?’, ‘What can you do to relieve it?’. Having become familiar with the customary responses to such questions the rheumatologist is more alert to the patient who seems unable or even unwilling to describe the problem clearly. It is often helpful to try and reproduce the symptoms by manipulation or pressure, particularly when the patient appears unable to pinpoint the location without help. Thus, forearm pain on gripping tightly may help

P.5

distinguish the tender origin of the common extensor in a patient with tennis elbow from a similarly tender trigger point found in fibromyalgia.

While the spread of pain outside the usual limits may reflect intensity, this rarely proves a problem with a superficial pain, which is commonly well localized; thus gout or septic arthritis may be associated with severe pain but the origin is obvious. A glomus tumour of the nail bed may cause considerable proximal radiation of pain but examination should localize the source. To locate the source of pain of deeper or visceral origin may be much more difficult because of the phenomenon of ‘referral’. Some patterns of referred pain are precise and well known, for example, shoulder pain from a diaphragmatic lesion or gallbladder; arm and/or neck pain from myocardial ischaemia. Others are more variable. Thus, the presence of sciatica may reflect nerve-root compression from a lumbar disc but much more commonly represents a referred distribution of pain from one or more regions around the lumbar spine. Experiments involving threads left temporarily after surgery around painful sensory structures or involving injection of hypertonic saline into ligaments and facetal joint structures have shown referral of pain from the lumbar spine into gluteal areas, to the posterior thigh, and even down the calf (Kellgren 1977). Involvement of the upper half of the lumbar spine tends to be referred to the anterior thigh. The only way to distinguish clearly true sciatica from such referred pain is on the basis of neurological signs, as associated symptoms (e.g. a cough or sneeze impulse) may be found with either. Sometimes, the pain may be remarkably well localized but again at a point distant from the exciting lesion; thus interscapular pain may be seen with postural/mechanical problems in the cervical spine, and anterior chest pain in relation to inflammation involving the mid-dorsal spine. Sometimes, relatively focal or diffuse tenderness may be associated with such referred pain syndromes. Pain referral may prove confusing to the physician but it is also often difficult to explain to a patient with, for example, pain well localized to the deltoid insertion that it is coming from a pericapsular lesion of the shoulder joint. Equally, deep visceral pain, such as a penetrating duodenal ulcer, may of course be referred to skeletal structures. Because of potentially similar patterns of pain referral a differentiation between skeletal and true visceral pain may have to be made on grounds other than the location of the discomfort.

Quality of pain

Skeletal pain may be caused by a variety of problems ranging from ischaemia, inflammation, and nerve entrapment to central factors that lead to a perception of pain where no evident peripheral causes exist. Quite apart from aggravating or relieving factors, the quality of the pain may provide diagnostic pointers. Thus, a burning pain in the feet, especially at night, may suggest a neuropathy. The pain of rheumatoid arthritis is usually steady and aching, not agonizing, excruciating, or terrifying. Such descriptions in a patient with rheumatoid arthritis would suggest an alternative explanation, for example sepsis, fracture, nerve entrapment, or non-organic causes. Chronic pain syndromes are well recognized but their underlying nature remains controversial. Because of overlapping and insufficient criteria a single individual may be designated by one physician as having a myofascial pain, by another as referred pain with secondary depression, and by a third as a (non-organic, i.e.) central, pain syndrome. The descriptions used by patients with central pain tend to be extreme and we find that to have patients complete instruments such as the McGill pain questionnaire is helpful as a teaching aid in illustrating to students the range of terms used. Some of the terms from that questionnaire, which distinguish between central or non-organic pain include flickering, shooting, lancinating, lacerating, crushing, seating, placing, unbearable, exhausting, terrifying, tearing and peripheral or organic pain syndromes include pounding, jumping, pricking, sharp, pinching, hot, tender, nagging, spreading, annoying, tiring, fearful, and tight. Similar expressions are chosen by patients with fibromyalgia, which is one reason for its earlier name of ‘pain magnification syndrome’, but also by those with causalgia, reflex sympathetic dystrophy, and occasionally even periarticular shoulder pain. In addition, some individuals or groups of individuals tend to use these extreme terms out of a sense of frustration or anxiety, or because of ethnic convention (Zborowski 1952), and risk being labelled as neurotic because of them, when the presence of organic disease may be missed. The reality of such pain of central origin has often been dramatically demonstrated by the stage hypnotist with a variety of forms of post-hypnotic suggestion. The severe quality of the rare thalamic pain syndrome is also well recognized. It is notable that Mark et al. (1960) observed, with stereotactic thalamic surgery, that in some, pain sensation could be abolished without loss of the unpleasant emotional effect and in others the emotional effect may disappear and yet the pain remain without its unpleasant qualities. Some of our current pharmacotherapeutic approaches reflect these findings. Therapy that is less conventional may have even more dramatic affects. Organic pain—for example, hot metal or hand immersion at 4°C for 45 min—can be blocked both from consciousness and from detection by electroencephalography during some forms of meditation. The block appears to be below the level of the cortex (Davidson and Goleman 1977). While the various central pain syndromes may respond to narcotic analgesics, this is for us an inappropriate approach both because it decreases the production of endorphins and because it is likely to cement the abnormal pain-behaviour patterns. Furthermore, no clearcut improvements in function have been demonstrated as a result of narcotic use. Some of these patients have post-traumatic pain syndromes with associated medicolegal implications. In any event, as a group they form a large proportion of patients in many rheumatological practices. It is clear that we still need better criteria both for diagnosis and classification of pain syndromes, as well as better approaches to treatment.

Stiffness

Stiffness is an important symptom in rheumatological disease. Typically, patients with rheumatoid arthritis complain of peripheral joint stiffness present for more than 30 min after awakening and recurring after periods of immobility. Patients with peripheral joint osteoarthritis may alsohave

P.6

morning stiffness. This is usually of shorter duration but may also recur after rest. Peripheral stiffness may reflect non-articular inflammation and can be marked, as in plantar fasciitis, but is unusual with lesions around the shoulder. Stiffness for less than 5 min is generally of minor significance but could represent, for example, flat feet. Mechanical disorders of the lumbar spine may be associated with morning stiffness of short duration (less than 15 min) whereas patients with ankylosing spondylitis may say that their stiffness persists for several hours. Stiffness present for many hours, and even ‘all day’, in the absence of gross physical findings usually points to a functional condition such as fibromyalgia.

Is there a history of joint swelling or not?

The cardinal observation made by rheumatologists is that of joint swelling but patients can be amazingly unreliable, in being able to describe joint swelling. This is most notorious in fibromyalgia and it is critical to be able to distinguish arthralgias, which may include a variety of lesions of bursas, tendons, and tendon sheaths, from true arthritis (i.e. a swollen joint observed by a physician). It is, therefore, a critical part of the subsequent examination to confirm the presence or absence of joint swelling (see below).

Comment

In addition to focusing on differential diagnosis, the history and presentation of symptoms should give the first indication of how patients should be given advice. Some people will often make light of severe rheumatoid arthritis whereas in another circumstance a patient with fibromyalgia will say that they cannot carry out mundane tasks because of ‘knives twisting in the muscles’. The physician's task is to ameliorate disease and to provide advice that will allow both types of patient to carry on with normal lives. The stoical patient may elicit a more sympathetic response from the physician but complaints from a medically trivial condition are no less valid or worthy of attention.

Editors: Isenberg, David A.; Maddison, Peter J.; Woo, Patricia; Glass, David; Breedveld, Ferdinand C.

Title: Oxford Textbook of Rheumatology, 3rd Edition

> Table of Contents > Section 1 - Clinical Presentation of Rheumatic Disease > 1.1 - Clinical presentations in different age groups > 1.1.1 - The adult patient > History

History

Part of "1.1.1 - The adult patient"

P.4

Specific symptoms to be asked for include arthralgias, myalgias, joint swelling, morning stiffness, Raynaud's phenomenon, and skin rashes and paraesthesias.