For crying out loud: musculoskeletal assessment of inpatients referred to rheumatology

R. W. Marshall and R. G. Hull

Rheumatology Department, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY, UK

Correspondence to: R. Marshall. E-mail: R.W.Marshall{at}doctors.org.uk

SIR, It has recently been shown that, even 10 yr after the development of the GALS (gait, arms, legs, spine) system, musculoskeletal examination of general medical admissions may be seriously deficient [1]. It could be argued that in many cases musculoskeletal problems are not the most immediate issue. However, it has also been shown that, after the acute problem has resolved, arthritis accounts for a significant proportion of delayed discharges [2]. We therefore postulated that all hospital in-patients who are referred for a rheumatological opinion should have had their joints examined adequately by the referring clinician, and we aimed to determine whether this is the case in practice.

We prospectively analysed the medical records of all rheumatological referrals seen by one specialist registrar over a 6-month period between October 2003 and March 2004 inclusive. Notes were graded according to whether the recorded musculoskeletal examination was ‘none’, ‘minimal’ (i.e. confined to the individual joint or joints in question), ‘GALS or equivalent’ or ‘comprehensive’ (i.e. appropriate records of swollen joints, synovitis, skin changes such as psoriasis, and a complete examination of the joints). Demographic details, along with the patient's overall diagnosis, were also recorded.

Thirty-five patients were seen over the 6-month period. All patients were referred from the Departments of Medicine or Elderly Care. Twelve patients (34%) had inflammatory arthritis, seven patients (20%) crystal arthritis, seven patients (20%) vasculitis or a connective tissue disease, and the remainder soft tissue problems, osteoarthritis, osteoporosis, septic arthritis or a pyrexia of unknown origin/other multisystem disease (Table 1).


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TABLE 1. Diagnoses of rheumatological referrals seen

 
Fifteen of the patients (43%) had no musculoskeletal examination whatsoever recorded. A further 15 had an examination that was confined to one or a small number of joints. Three patients (9%) had a GALS examination recorded and two patients (5%) had a comprehensive examination recorded. The latter two patients had been referred by senior house officers who had completed a rheumatology attachment in our hospital.

This small study confirms the work of Doherty et al. [3] and the more recent work of Lillicrap et al. [1], which showed that musculoskeletal assessment of medical inpatients is often deficient. However, this survey goes further in that it analyses specifically patients who have a suspected rheumatological problem. Seventy-six per cent of the patients in our study had only a limited or no musculoskeletal examination recorded, despite the fact that the overwhelming majority had multisystem rheumatic disease. The best examinations were recorded by junior doctors with previous experience of rheumatology. With the advent of foundation years training, rheumatologists must ensure that the acquisition of clinical skills in musculoskeletal examination are a mandatory requirement.

The authors have declared no conflicts of interest.

References

  1. Lillicrap MS, Byrne E, Speed CA. Musculoskeletal assessment of general medical in-patients—joints still crying out for attention. Rheumatology 2003;42:951–4.[Abstract/Free Full Text]
  2. Keough A, Kirwan J. Arthritis as a cause of prolonged in-patient admission in acute medical beds. Rheumatology 2003;42:810–1.[Free Full Text]
  3. Doherty M, Abawi J, Pattrick M. Audit of medical inpatient examination: a cry from the joint. J R Coll Physicians Lond 1990;24:115–8.[ISI][Medline]
Accepted 29 June 2004





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