Clinicians have often regarded musculoskeletal problems as requiring a physical, hands-on approach. We have developed examination routines that focus on the palpation and movement of joints. How do we assess a patient if we can’t do this?
However, remote consultations can be effective if a logical and structured approach is taken – beginning with a careful history, thinking about the information needed to narrow a differential diagnosis, and early awareness of potential pitfalls and red flags. Also, GPs can support other clinicians to consult remotely, including extended-scope nurses and practice-based physiotherapists. Well-established processes will facilitate this.
Here, we will examine this approach through two clinical scenarios. For each, we will adopt a structured approach. Preparing for a consultation in this way need not be time consuming and will facilitate an objective assessment and reduce the risk of an unstructured, low-quality conversation.
Preparation for the consultation
The process starts with a review of the information obtained from the patient’s initial contact with the practice. This could be a phone call, but ideally it would be a structured written electronic consultation – perhaps asking the patient to complete a questionnaire beforehand – that will allow you to identify their key concerns, needs and expectations.
Your preparation will depend on the quality of information available, but ideally will include:
• Reviewing the submission from the patient and their background.
• Considering a wide differential diagnosis based on this.
• Identifying potential serious diagnoses.
• Identifying potential red flags based on the above.
• Formulating questions or an examination to fill the information gap.
• Considering likely endpoints of the consultation: medication, imaging, referral or admission.
It may feel counterintuitive to sketch in potential diagnoses and endpoints early on, but a key benefit of this kind of consultation is the opportunity to think and reflect beforehand.
Case 1: Buttock and leg pain
A 58-year-old female reports the worsening of buttock and groin pain, which is radiating down the leg towards the knee. She says the symptoms have been present for two to three weeks, but have worsened over the previous 48 hours, with more intense pain in the leg itself.
Structured approach to buttock and leg pain
At first glance, the case has a diagnostic conundrum, mainly between hip and back pathology. A remote consultation may feel uncomfortable, but the following structured approach may help:
• Background – look for any relevant history, such as an MSK issue or serious underlying health issue, for instance prior malignancy.
• Differential diagnosis includes hip joint pain, possible OA, mechanical back pain, prolapsed disc (PID), or a rare underlying cause, including malignancy.
• Potential serious diagnoses include significant PID, undisplaced hip fracture, or occult malignancy.
• Potential red flags are symptoms of cauda equina syndrome (CES), history of trauma, or systemic upset, including weight loss.
• It is important to ask about bladder or bowel problems, any falls and whether the patient is systemically well. Is there any weight loss? Are there any constitutional symptoms?
• Possible endpoints: a face-to-face assessment; admission if you suspect CES; referral if you suspect a progressive disc lesion or have concerns about the underlying cause; medical management; physiotherapy.
The patient’s background is important in this case. Comorbidities such as autoimmune disease, a prior history of MSK problems or malignancy will be very relevant. Any history of similar episodes should be noted as well as any prior specialist assessment or imaging.
The sketched differential diagnosis is likely to steer the consultation, considering the common differential of back or hip pathology, but it is important to consider more serious diagnoses, perhaps in this case significant disc prolapse or underlying malignancy.
Following this a structure for the consultation can be developed. One of the advantages of remote consultations is that you can jot down questions as an aide memoire.
Finally, it is worth thinking of the end of the consultation and likely outcomes. The intention is not to make assumptions about the endpoint, but to create a more efficient consultation with less thinking on the hoof. This will help ensure that possible significant outcomes have been tackled and excluded. If, for example, you do not consider the possibility of a major disc prolapse necessitating immediate hospital admission, you may miss the opportunity to ask key questions that will inform this, for example about bladder and bowel function.
Safe process for converting a remote consultation to a face-to-face one
• Agree with colleagues the process for seeing patients face to face.
This may include referral to a ‘practice team’ if you are working remotely yourself, or referral to a central ‘hot hub’ if a patient is potentially Covid positive.
• There should be no perceived barriers to arranging a face-to-face assessment. Escalate any concerns.
• Be clear before starting the remote consultation what information you need to establish to safely assess the patient. If you find you cannot obtain this, the patient should be seen in person.
• Stay objective in your assessment. This is where a planned approach is helpful.
• Do not accept unmitigated risk because you are consulting remotely. A degree of uncertainty can be acceptable, provided this is carefully safety netted and shared with the patient.
• If you have ‘gut feelings’ of concern, pay heed to them, and ask the patient to attend in person.
Decide on the format
When initiating the remote consultation, decide whether this will be conducted by phone or video, remembering that telephone connections may be more reliable but lack the functionality of video. Video can be especially useful in musculoskeletal problems and if you initiate the call by phone you may wish to switch to video after completing the history element.
As discussed before, when taking a history remember to check that the patient is able to talk freely with appropriate confidentiality. Bear in mind the other pitfalls discussed in last month’s article, such as the need to check the patient’s identity and location, and to strike an appropriate tone.
When speaking with the patient you will confirm details of the presenting problem, and if necessary widen the drafted differential diagnosis. And do be prepared to deviate from your initial plans, especially if time has elapsed since the patient booked the appointment. Open questions are recommended. Invite the patient to speak freely with questions such as ‘can you tell me what has been bothering you?’ or ‘how are you in yourself?’ These are likely to be a better place to start than focused, closed questions and should open up the opportunity to explore any constitutional illness, weight loss or other systemic concerns.
More focused questions can follow, guided by the sketch drafted before the consultation, allowing you to narrow the differential diagnosis.
The examination phase of the consultation may require a move to video. It is worth reflecting that even in the surgery, much of our examination is conducted through observation rather than palpation, with the latter often having a limited input into actual decision making.
The potential examination findings of the patient with buttock and leg pain can include:
• Patient appearance – whether they are well or unwell, cachectic or in pain.
• Any asymmetry, including joint swelling or muscle wasting.
• Mobility, use of walking aids (which you’d see automatically face to face, but will need to be solicited on video).
• Weight, temperature and pulse rate.
• Ability to bend or flex, or to sit with legs extended (which is a proxy of the straight leg raise).
• Ability to actively flex and rotate the hip and knee. Think of simple instructions to give the patient. For testing hip rotation, try: ‘While sitting with your legs straight, keep your heel on the ground, then roll your toes over to the right, then left.’
• Note any reported neurological findings, including power and sensation.
Recognise the limitations of remote consulting
Of course, remote consultation has obvious limitations. There is no opportunity to palpate the patient, to stress ligaments or to carry out direct neurological examination. You might still have an information gap.
If you cannot form a diagnosis or make a decision without physical examination of the patient, this indicates the patient should be seen face to face. If you have an information gap but consider that physical examination would have no effect on the management plan, record the information gap in the notes. It is important to have clear arrangements to convert a remote consultation to a face-to-face one (see box, above).
It is worth remembering that a lack of diagnostic clarity also exists when assessing patients face to face, and we simply accept this and manage the patient on pragmatic grounds. The same can be true when consulting remotely but detachment from the patient can increase clinician anxiety.
If you assume that in the above example the patient has no red flags, you may conclude that the main differential is between hip OA and an early PID.
Early imaging is not indicated in either early OA or PID, so a conservative approach might be appropriate, with analgesia, exercise advice suitable for both possible diagnoses and consideration of physiotherapy. It is worth recapping the patient’s concerns, ideas and expectations at this point to ensure these have been addressed, especially if they were wondering about investigations such as imaging. It is important to explain the rationale of this pragmatic approach and give appropriate safety-netting advice. This can be reinforced through text messaging, including a reminder to report potential red-flag symptoms. Follow-up after an appropriate interval can then be arranged.
If the consultation identifies potential red flags, care escalation is indicated. Consider arranging a face-to-face consultation. However, red flags may indicate direct hospital admission, and a face-to-face consultation should not be arranged where this would not influence the outcome.
Case 2 – Swollen knee joint
Our second case is a 70-year-old man who reports an acutely swollen knee joint. This has developed rapidly over the previous 48 hours and is painful.
Structured approach to patient with acute knee pain
Once again it is important to follow a structured approach.
• Background – relevant history, especially of knee injury, gout or other inflammatory disease. Check for prior sepsis, or any long-term condition, especially those involving immune deficiency.
• Differential includes acute soft-tissue injury, exacerbation of OA, inflammatory arthropathy, septic arthritis and trauma.
• Potential serious diagnoses include septic arthritis and trauma.
• Potential red flags are acute knee swelling with systemic upset, pyrexia, and clinical signs of localised sepsis.
• It is important to ask if the patient is systemically well and if they have any weight loss or constitutional symptoms.
• Possible endpoints: admit if you suspect septic arthritis; investigate or refer if inflammatory arthritis is suspected. Manage conservatively if minor.
In this second example there is a single potentially serious diagnosis, with associated red flags, a wider differential of other significant pathology, and a further possibility of a minor and likely self-resolving disease.
This kind of presentation can be challenging to address using a remote-consultation model as sepsis is the diagnosis that should not be missed. Once again, though, it is worth reflecting on the assessment process that would occur if the patient were to be seen face to face, and to recognise the potential information gap through remote consultation.
In this case a careful history should allow you to identify the likelihood of serious potential diagnoses, and to narrow the wider differential.
You can then perform an examination based on observation. Remotely it should be possible to obtain metrics such as temperature and pulse rate; if necessary, you can offer the loan of near-patient testing equipment from the practice. The examination should indicate the patient’s likely level of constitutional upset, mobility, joint swelling and overlying erythema.
The key element that will be missing from the remote consultation is the ability to assess the presence or absence of significant joint tenderness and heat, which are considered classic signs of septic arthritis. However, these signs are not always present, and their absence will not exclude the diagnosis.
If it is not possible to make a decision without palpation of the knee, the patient should be seen face to face. A patient who clearly is unwell with constitutional upset, a fever and an obviously swollen and red joint needs hospital assessment; asking them to attend the surgery for a face-to-face assessment will introduce delay. Conversely, a patient with a history of pyrophosphate arthropathy who presents with a syndrome entirely consistent with previous episodes may be considered lower risk and managed accordingly.
In summary, MSK problems can seem challenging to manage remotely. As with all such consultations, arrangements for when face-to-face assessment of patients is needed should be clear. However, a structured and logical approach can allow the clinician to offer a high-quality, safe and convenient service.
Dr Jonathan Inglesfield is a GP partner in Surrey