+ What are the relevant components of this patient’s history and physical examination, and why?

Relevant History:

• How did this begin?
• Was there injury/trauma?
• Where exactly is the pain? Quality, duration, aggravating/alleviating factors, radiation?
• Has this ever happened before?
• Is there stiffness, fever, weakness, numbness, or tingling?
• What has she tried so far to alleviate the problem? Medications, therapy, bracing, injections, surgery?
• Has she had any workup already for this problem?
• Is she active?
• Functional history and current functional status?
• Family history?
• Past Medical and Surgical History?
• Medications?

Relevant Physical Examination:

• Vital signs
• Inspection
• Palpation of bilateral shoulders
• Manual muscle testing of bilateral upper limbs (would include rotator cuff isolation testing here)
• Sensory and reflex examination of bilateral upper limbs
• Passive and active range of motion evaluation of the shoulders and neck
• Special testing: Spurling, Neer, Hawkins, Painful Arc, Empty Can, Speed, O’Brien, Scarf

+ Challenge Question #1

• The patient states she has also felt like she has had fevers and shoulder stiffness for 1-2 hours each morning. What else would you like to know?

+ Challenge Answer #1

• I would ask if she has experienced any weight loss, headaches, jaw claudication, fatigue, malaise, or vision changes.

+ Challenge Question #2

• What are you hoping to learn by asking about those signs and symptoms?

+ Challenge Answer #2

• I want to help elucidate if she might be suffering from a rheumatologic condition, such as rheumatoid arthritis, systemic lupus erythematosus, or polymyalgia rheumatica, for example.

+ Challenge Question #3

• Why is it important to ask about headaches or jaw claudication symptoms?

+ Challenge Answer #3

• These symptoms may indicate giant cell arteritis (GCA/temporal arteritis), which can results in blindness if not treated promptly with high-dose corticosteroids.

+ What is your differential diagnosis for this patient?

• Polymyalgia rheumatica, subacromial subdeltoid bursitis, rotator cuff (supraspinatus) impingement or tear, biceps tenosynovitis, glenohumeral osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, giant cell (temporal) arteritis, dermatomyositis, polymyositis, multiple myeloma, fibromyalgia, cervical radiculopathy, cervical spondylosis.

+ What specific workup would you arrange for this patient?

• I would order bloodwork, starting with a basic metabolic panel (BMP), complete blood count (CBC), erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). I would start physical therapy for musculotendinous reconditioning and functional improvement as well. I would advise acetaminophen and over-the-counter NSAIDs such as ibuprofen for pain control. She may try topical heat and/or ice for symptomatic relief. I would like to see her back in the office in 6 weeks to see how she is doing.

+ Her workup returns as follows:

• BMP: within normal limits
• CBC: within normal limits
• ESR: elevated
• CRP: elevated

+ What are your specific management recommendations for this patient?

• I would call the patient or see her in the office, depending on when the lab results returned and how imminent her follow-up appointment with me is. I would discuss the need to start oral corticosteroids (prednisone) and discuss a rheumatologist referral, as I have concerns about rheumatologic disease at this point, namely polymyalgia rheumatica. I would also discuss polymyalgia as a diagnosis and explain what it means and how it is treated. I would ensure all questions are answered to the patient’s satisfaction.

+ How would you make your decision on what dosage of steroids to start this patient on?

• In the immediate term I would review published guidelines from the American College of Rheumatology on corticosteroid dosing in suspected polymyalgia rheumatica. If unsatisfactory, I would reach out to the consulted rheumatologist for recommendations until they are able to evaluate the patient and assume care.

+ Your response?

• “I am so sorry that your condition has led to blindness. That must be so incredibly difficult and life-changing. Unfortunately your condition (PMR) is known to be related to another condition called temporal arteritis (GCA), which itself can lead to blindness. However, at your visit with me, you exhibited no signs or symptoms that would suggest you required urgent treatment or workup for potential GCA. We started you on oral corticosteroids and referred you to a rheumatologist for further management of this rheumatologic condition. I also made certain to follow all of the guidelines exactly as published by the American College of Rheumatology for this condition, as is documented in the electronic medical record. Again, I am so sorry that this condition has led to this life-changing disability for you. I want you to know that I am here for you if there is anything you would like me to assist with in the future, including directing your physical therapy (if needed at this point), or for any other problems that might arise within my expertise. I would also be more than happy to reach out to your rheumatologist to discuss your case personally. Are there any other questions you have that I can help answer today?”

• The key here is to remember to ally yourself with the patient (always “you and the patient vs. the problem”, not “you vs. the patient”, even if the patient appears adversarial. It is ok to politely but firmly re-establish that you followed all proper guidelines, and that unfortunately sometimes we cannot predict how diseases will progress. In all likelihood this patient will not have progressed to full-blown GCA/blindness in the real world, as she exhibited no red flags to warrant aggressive steroids and temporal artery biopsy. Low-dose steroids are the mainstay of treatment for PMR in the absence of signs or symptoms of GCA/temporal arteritis.