Primary care needs better physical exam skills

by Joseph Biundo, MD

Not long ago, primary care physician Rob Lamberts did a blog post about the economics of seeing Medicare and Medicaid patients, stating that doing so was bad business. While I agree with most of his points, I have a quarrel with his statement that primary care physicians keep down the cost of care by keeping people healthy, away from specialists, and out of the hospital.

That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests, and x-ray and MRI reports but are diagnosed in my office by a simple history and physical exam.

Those expensive tests certainly did nothing to hold down the cost of care. But, a primary care physician with good diagnostic skills can, indeed, keep patients out of a specialist’s office.

And, perhaps more importantly, they can spare the patient some unnecessary and expensive tests.

Speaking from the rheumatologist’s perspective, it takes just a few minutes to do a brief but meaningful joint examination. Yet, too often, I find the primary care physician’s physical examination of the joints and extremities consists only of recording the mantra, “no clubbing, cyanosis, or edema.”

That notation allows a physician to justify the coding requirements for extremities, but use of this shortcut makes it too easy not to look any further for more common and more important problems.

Everyone would agree that edema is common and noting it is important. But, clubbing, even though it might be important if present, is very rare in the typical primary care office. Cyanosis is also important, but it, too, is not a common finding.

What then, besides edema, should a primary care doctor record in the physical examination of the extremities?

It would be more valuable to describe that there is no swelling, tenderness, or loss of motion of the joints, if that is the case. Otherwise, a short list of the abnormal findings would be of value.

Extremity strength of both arms and legs is also much more significant to record than clubbing or cyanosis.

That is not to say one should ignore clubbing or cyanosis, if present. The issue here is the mindless notation of highly unlikely physical findings while overlooking disease that is much more common and relevant.

A quick assessment of joints can begin by inspection and palpation of the hands, which can confirm the presence of osteoarthritis in identifying Heberden’s nodes in the distal interphalangeal (DIP) joints and Bouchard’s nodes in the proximal interphalangeal (PIP) joints and bony swelling of the first carpometacarpal (CMC) joint.

These nodes are due to bony swelling and not synovial swelling that is seen in rheumatoid arthritis primarily in the metacarpophalangeal (MCP) and PIP joints of the hand.

Often, the appearance of the hands is so clear cut that OA can be diagnosed without need of an x-ray or ordering a rheumatoid factor.

A very common but often overlooked problem in the hands is volar flexor tenosynovitis, in which pain, tenderness on palpation, and tendon sheath swelling occurs. Progression to triggering or locking of the digit on flexion at the PIP can occur.

Again, an x-ray is unnecessary to make this diagnosis, and a local corticosteroid injection into the tendon sheath is often helpful.

In the wrist one may note the presence of a ganglion over the dorsal area, which is an outpouching of the synovium of the wrist joint or extensor tendons.

A complaint of pain over the medial aspect of the wrist could be due to de Quervain’s tenosynovitis, which is manifested as swelling and tenderness over the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons.

When the complaint is tingling or numbness of the fingers, then carpal tunnel syndrome might be the cause of the symptoms. A positive Tinel sign helps with the diagnosis.

In the elbow region swelling of the olecranon area can be seen and palpated due to bursitis, rheumatoid nodules, or gouty tophi.

A quick assessment of shoulder motion and presence of pain on motion might detect rotator cuff tendinitis, rotator cuff tears, or adhesive capsulitis.

Pain on hip flexion or loss of motion on flexion, internal or external, could signify OA of the hip. A Trendelenburg gait is also associated with the condition. Remember, we must see the patient walking to detect this. Often, in a busy office the physician may not see the patient walk into or out of the office.

With the knees, effusions and increased temperature can be palpated, and genu valgus or genu varus can be observed.

In the ankles and feet, pes planus, hallux valgus, and hammer toes are noteworthy in patients complaining of foot pain.

Additionally, in the patient who complains of generalized pain, palpation of the various muscle groups, including chest wall, trapezius and cervical spine muscles should be done to help identity the presence of tenderness which can be related to fibromyalgia.

In summary, instead of writing “no clubbing, cyanosis or edema,” it is much more valuable to do a practical musculoskeletal examination and describe the abnormalities.

If the exam is unremarkable, then one could record the following summary statement for the extremity exam: “The joint examination reveals no swelling, tenderness, or loss of motion. Muscle strength is adequate, and no peripheral edema is present.”

Primary care physicians who do that kind of exam can communicate more clearly if they do need to refer to a rheumatologist, and the patient may be able to forgo expensive tests entirely.

In this day of rising healthcare costs, it’s my firm belief that one of a physician’s most important assets is the ability to do an excellent physical exam.

Joseph J. Biundo is a rheumatologist and physiatrist.

Originally published in MedPage Today. Visit MedPageToday.com for more rheumatology news.

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