Although the Rheumatology Speciality is
expanding, and the latest blood tests like anti-CCP for rheumatoid arthritis or ANCA for vasculitis, are increasingly helpful in diagnosing rheumatic, connective tissue or auto immune disorders, we are still left with a few conditions in rheumatology, which are diagnosed only clinically at the bed side. The following are the examples:

1. Patient having frozen shoulder may not show any abnormality in the investigations. Fortunately, the disease can be easily treated by simple physiotherapy.
2. RSD (Reflex sympathetic dystrophy) is a very important disease, which can make a young man/woman invalid. For example, the right arm may be involved, and could be extremely painful in the arm/hand areas with severe swelling, vasomotor changes of skin, painful oedema and masked muscular weakness mimicking paralysis. There is no clinical test to confirm this disease. Unfortunately there is nothing specific in allopathic medicine to offer these patients.
3. Patients, who complain of cramps, which 99% of the times, are not due to any organic disease, but are idiopathic. There is no investigation to confirm this diagnosis and history taking is the only method. The therapeutic test with oral quinine, with/without tranquilliser, can be used to confirm the diagnosis.
4. Raynaud’s phenomenon is a clinical diagnosis and no test can confirm this. Although there are families where females have this disorder, unfortunately it can occur in illnesses like SLE and scleroderma.
5. Sero-negative rheumatoid arthritis: Since the rheumatoid factor, even the one done by latest method of nephelometry, may be negative, the diagnosis of this illness can only be made on clinical grounds, supported by a raised ESR. The disease may last for a lifetime. With big new pathological laboratories using methods like nephelometry and not Rose Waaler test or latex fixation test and with the coming of new anti CCP test, the number of such so called sero-negative rheumatoid arthritis cases is likely to fall.
6. Behcet’s Disease can be diagnosed only by clinical examination and good history taking. It has to be remembered that 30% of patients, who may be getting aphthous ulcers in the mouth, will not show ulcers on the genitals. What should draw the attention of the doctor to the diagnosis is that this patient having aphthous ulcers, is a very sick person with bodyache, joint pains, skin rashes or erythema nodosum with loss of appetite, loss of weight, fever, and possibly having additional systemic involvement.
7. Finally, although scleroderma can be confirmed by tissue biopsy, it is mainly diagnosed by clinical examination.
   Thus even in modern days, with so many advances in laboratory diagnosis and imaging, there are certain illnesses like tetanus or a few other rheumatological conditions, where we need more tests to confirm the diagnosis.