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Musculoskeletal Exam

Contributor: Alan Erickson, MD

+ Case 1

A previously healthy 45 year old female presents with complaints of joint pain in her hands. She notes that her wedding ring won’t fit over her finger any more. She tells you that when she is doing her job as a butcher her hand pain worsens. She has also noted times when her hands feel numb, especially in the morning. She thinks that her hands are starting to look like that of her grandmother’s. She tells you that as she was reading about her problems on the internet and wonders if she may have gout. On physical examination, she has bony enlargement of her PIP and DIP joints.

What are the key features of her history and physical that will help to make her diagnosis?
The history is essential in determining the etiology of musculoskeletal complaints. Inflammatory joint pain is usually worse in the mornings or after periods of inactivity, with improvement with activity. It also commonly will present with warm and swollen joints. Non-inflammatory joint pain is worse with activity and rarely is there synovitis, though you can see joint effusions at times. Pattern recognition is also essential, and the distribution of involved joints can help guide your differential diagnosis. In this case, she describes non-inflammatory sounding pain, in a typical OA distribution and her clinical picture is most consistent with OA of the hand.

Patient Care

  1. Discuss historical features and physical findings that distinguish inflammatory from non-inflammatory arthritis, include appropriate radiographic, laboratory and serologic testing that is indicated
  2. Recognize physical examination findings in common rheumatic diseases
  3. Recognize clues to multi-system inflammatory diseases, and develop a plan for evaluation
  4. Demonstrate an appropriate joint examination and describe common joint injection techniques
  5. Recommend appropriate management and follow-up based on the final diagnosis

Medical Knowledge

  1. Discuss effector mechanisms in autoimmunity and inflammation to include genetics
  2. Recognize the economic burden of musculoskeletal diseases
  3. Identify the risks and benefits of pharmacotherapy
  4. Select instances when non-pharmacological therapies are appropriate
  5. Interpret auto-immune laboratories to include antinuclear antibodies and acute phase reactants
  6. Recommend when appropriate to use steroid sparing agents
  7. Generate a differential diagnosis for different regional pain syndromes

Interpersonal Communications

  1. Explain the patient’s diagnosis, evaluation, and treatment
  2. Discuss both pharmacological and non-pharmacological therapy for a variety of musculoskeletal conditions
  3. Explain infusion therapy
  4. Explain risks and benefits for office procedures such as injection therapy
  5. Direct patients to web-based resources where they can learn more about their disease and medications
  6. Discuss treatment decisions with referring physician involved in your patient’s care

Professionalism

  1. Recognize the importance of patient privacy, informed consent, and equal care
  2. Demonstrate integrity and honesty in discussing patient care issues and management with the patient and family

Practice Based Learning

  1. Set learning goals for the understanding of the evaluation of patients with musculoskeletal complaints
  2. Effectively demonstrate your ability to evaluate and treat a patient’s complaints
  3. Integrate and apply the knowledge gained from the history, physical, laboratory, and radiographic assessment to make informed decisions about patient care
  4. Demonstrate your ability to complete office based procedures
  5. Develop a willingness to learn from errors and use errors in a constructive way to learn and improve the system for patient care
  6. Utilize web based resources for the assessment and education of patients

Systems-based Practice

  1. Identify barriers to the delivery of optimal patient care for patients with musculoskeletal complaints
  2. Demonstrate the ability to collaborate with other health care providers delivering specialized arthritis care
  3. Mount a project to determine cost-effective management of patients with musculoskeletal complaints then implement the project
  4. Specify items that are used by patients that are consider complimentary or alternative care
  5. Inventory items that impact costs to the patient, physician, and the health industry

Keywords: Musculoskeletal complaints, inflammatory arthritis, non-inflammatory arthritis, pharmacological therapy, non-pharmacological therapy.

Key References