Rheumatology Resources for Physicians

If you feel your patient needs to be seen immediately, denote “urgent” on the rheumatology referral form. All referrals marked “urgent” are triaged to help make sure patients are seen in a timely fashion. If you wish to speak to the on-call pediatric rheumatologist, call 404 785 DOCS (3627).

Generally, conditions that may warrant an urgent initial outpatient visit include, but are not limited to:

• Persistent joint swelling (chronic arthritis is defined as ≥6 weeks) without antecedent trauma. Starting an NSAID such as ibuprofen or naproxen may be warranted. We do not advocate giving these patients oral steroids prior to the initial consultation visit, as they may obscure alternative diagnoses and signs of arthritis.
• Significant joint contractures affecting function.
• Joint pain and swelling with persistent fevers (>101° F) without infectious or oncologic etiology.
• A persistent malar rash with mild cytopenias, signs of serositis (pleural effusion on X-ray or pericardial effusion on ECHO) or mild proteinuria (send first morning urine protein: creatinine).
• A dermatomyositis rash (i.e., persistent pink scaly papular rash over MCPs, PIPs, elbows, and/or knees, or malar rash) with signs of weakness or elevated muscle enzymes (i.e., AST, ALT, CK or LDH).

There are several conditions we see that may not warrant an urgent evaluation given the available resources. These may include the following:

• Chronic pain with sleep disturbances, fatigue, diffuse joint or muscle pain with normal exam, and normal CBC and acute phase reactants do not require an urgent appointment. These patients can be managed by the primary care provider with counseling or by the pain service if severe. A positive ANA test without other symptoms, exam findings or abnormal labs (i.e., CBC, ESR, CRP, CMP, urinalysis, muscle enzymes, TSH or free T4) does not change this recommendation.
• Children with musculoskeletal pain but no signs of inflammation (i.e., swelling, warmth or decreased range of motion) seldom have a chronic rheumatic condition, even if they have a positive ANA test. Consider X[1]ray to evaluate for fracture, cancer, physical therapy and increased physical activity. Children with prolonged episodes of intermittent leg pain at night with normal daytime activities and normal studies (i.e., CBC, ESR, CRP or X-ray) usually have “growing pains” and do not necessarily need a rheumatologic evaluation.
• Raynaud’s phenomenon is a common complaint in tall, thin teenage girls in winter months. Most of these patients—as long as they do not have other concerning symptoms or exam abnormalities—have primary Raynaud’s phenomenon and no underlying rheumatic disease. Labs that are helpful in evaluating these patients and could be obtained prior to referral include: CBC with differential, ESR, CRP, CMP, ANA IFA and anti-phospholipid antibodies. Make sure patients keep core and extremities warm by wearing warm gloves and socks, and by using heat packs.
• Abnormal lab findings, such as a positive ANA or positive rheumatic factor at a low titer, in the absence of objective clinical findings usually do not require rheumatologic evaluation.

For non-urgent medical requests, we offer e-consult via accessCHOA. E-consult offers physicians the opportunity to receive timely guidance on lower-complexity and data-oriented clinical questions that may not require an in-person evaluation. One of our specialists will typically respond within three business days. Patient family consent is required.

There are some conditions that may warrant the expertise of other specialties, even though joint pain might be one of their manifestations.

• Fibromyalgia/amplified musculoskeletal pain syndrome: For patients with chronic widespread pain where you suspect fibromyalgia, make a referral to the Chronic Pain Clinic as well. The wait is often long for these patients. If they wait to see rheumatology before a referral to the Chronic Pain Clinic is made, they will wait even longer to be seen in the Chronic Pain Clinic. Our primary role is to exclude a rheumatic disease that might be present concomitantly.
• Non-inflammatory connective tissue disorders (i.e., Ehlers Danlos syndrome or Marfan’s syndrome): Refer to the Genetics Clinic. Also consider a cardiology evaluation to screen for cardiac manifestations of connective tissue disease.