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Rheumatology History Taking

"History taking is the most important skill in rheumatology." - Rheumatology 2022, Elsevier, p.260

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Structure of the Consultation

1. Patient-centered phase - let the patient tell their story uninterrupted
2. Physician-centered phase - directed questioning to clarify and characterize
3. Interactive phase - discuss findings, address concerns, shared decision-making

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1. Presenting Complaint and Symptom Characterization

Pain (Most Common Symptom)

• Ask the patient to point to where pain is felt - they are often inaccurate ("my hip" usually means any part of the hindquarter)
• Is it localized or generalized?
• Know referred pain patterns:

• Acute (hours-days) vs. subacute (weeks) vs. chronic (months-years)?
• Any precipitating event - trauma, infection, new drug, overuse?
• Pattern of evolution: improving, worsening, relapsing-remitting, fluctuating?

• Aching, throbbing, burning, stabbing, deep?
• Score 0-10 at rest and with movement
• Effect on sleep (a key rheumatology marker - inflammatory pain often wakes patients at night)

• Worse with activity, better with rest = mechanical/OA
• Worse with rest/early morning, better with activity = inflammatory
• Response to NSAIDs (good response suggests inflammatory etiology)

• Does it travel? - suggests nerve root involvement or referred pain

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Stiffness

• Morning stiffness duration (key differentiator):

  • 1 hour = inflammatory arthritis (RA, SpA, polymyalgia rheumatica)

  • <30 minutes = osteoarthritis, mechanical
  • "Gelling" - stiffness after prolonged rest but easing quickly = OA
• After inactivity ("post-rest stiffness") vs. morning
• Does stiffness affect specific joints or is it generalized?

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Swelling

• Joint swelling vs. soft tissue vs. bony swelling
• Distribution - monoarticular, oligoarticular (≤4 joints), polyarticular (≥5)?
• Symmetry - symmetric (RA) vs. asymmetric (SpA, reactive, PsA)?
• Migratory/additive/intermittent pattern?
• Fluctuant (effusion) vs. boggy (synovial thickening) vs. hard (bony)

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Joint Pattern - Critical in Rheumatology

• Small joints of hands (MCPs, PIPs, DIPs, wrists) vs. large joints (knees, shoulders, hips)
• DIPs involved? - Think OA, psoriatic arthritis, reactive arthritis
• MCPs/PIPs + wrist + symmetric? - Think RA
• Axial involvement (spine, sacroiliac joints)? - Think seronegative SpA (AS, PsA, IBD-arthropathy, reactive)
• First MTP? - Think gout

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Other Musculoskeletal Symptoms

• Weakness - proximal (myopathy, PMR) vs. distal (neuropathy)?
• Functional limitation - use two sensitive screening questions:
  • "Do you have difficulty washing and dressing yourself, including putting on socks and shoes?"
  • "Do you have difficulty going up or down stairs?"
• Fatigue - prominent in RA, SLE, fibromyalgia, inflammatory myopathy
• Locking, clicking, giving way - mechanical joint pathology
• Trigger phenomena - in Raynaud's, ask about cold/stress triggering color changes

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2. Systemic Review - Mandatory in Rheumatology

Constitutional

• Fever, night sweats, weight loss ("B symptoms" - think vasculitis, malignancy, infection)
• Fatigue, anorexia

Skin and Mucous Membranes

• Rashes: butterfly/malar rash (SLE), photosensitive, discoid, heliotrope (DM), psoriatic plaques (PsA), Gottron's papules
• Raynaud's phenomenon (SLE, SSc, MCTD, PM/DM)
• Oral ulcers (SLE, Behcet's, reactive arthritis)
• Genital ulcers (Behcet's)
• Dry eyes/mouth (Sjogren's)
• Skin tightening, puffy fingers (SSc)
• Nodules (RA, gout tophi)
• Nail changes - pitting, onycholysis (psoriasis/PsA)

Eyes

• Red eye, pain, photophobia: uveitis (SpA, JIA, sarcoid), episcleritis, scleritis (RA, vasculitis)
• Dry eyes (Sjogren's)
• Visual changes (SLE-related retinopathy, hydroxychloroquine toxicity, GCA - amaurosis fugax)

Cardiovascular

• Chest pain - pleuritis/pericarditis (SLE, RA), ischemic (accelerated CVD in RA/SLE)
• Palpitations (SLE with cardiac involvement)
• Limb claudication (vasculitis)

Respiratory

• Dyspnea - ILD (RA, SSc, PM/DM, SLE), pulmonary hypertension (SSc)
• Dry cough
• Pleuritis

Gastrointestinal

• Dysphagia - oesophageal dysmotility (SSc), myositis
• Diarrhea, bloody stool - IBD-associated arthropathy
• Reflux, bloating, constipation (SSc)
• Abdominal pain - vasculitis, FMF/periodic fever syndromes

Genitourinary

• Urethritis, cervicitis - reactive arthritis (Reiter's)
• Hematuria, proteinuria - lupus nephritis, vasculitis
• Menstrual irregularity (SLE activity)

Neurological

• Headache - GCA, CNS vasculitis
• Seizures, cognitive change, psychosis (neuropsychiatric SLE)
• Peripheral neuropathy (vasculitis, RA)
• Muscle weakness (myositis, neuropathy)

ENT

• Oral/nasal ulcers (GPA/Wegener's, SLE)
• Nasal discharge, saddle-nose deformity (GPA, relapsing polychondritis)
• Hearing loss (relapsing polychondritis)

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3. Past Medical History

• Prior episodes of arthritis or similar symptoms
• Previous infections (streptococcal pharyngitis → reactive arthritis, rheumatic fever)
• Previous STIs (reactive arthritis)
• IBD, psoriasis, uveitis (often precede or co-occur with SpA)
• Malignancy (paraneoplastic arthritis, DM)
• Thyroid disease, diabetes (mimic or associate with MSK conditions)
• Recurrent miscarriages / DVT / PE (antiphospholipid syndrome - ask specifically)
• Renal disease (SLE, vasculitis, gout)
• TB exposure (before starting biologics - critical)

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4. Drug History

• NSAIDs and COX-2 inhibitors (how long, response?)
• Steroids - doses, duration, tapering
• DMARDs - MTX, leflunomide, hydroxychloroquine, sulfasalazine (doses, duration, side effects, monitoring)
• Biologics - TNF inhibitors, IL-6 inhibitors, JAK inhibitors
• Drug-induced lupus triggers: hydralazine, procainamide, isoniazid, minocycline
• Drugs causing hyperuricemia/gout: diuretics (thiazide, loop), ciclosporin, pyrazinamide, low-dose aspirin
• Contraception and HRT (SLE is estrogen-sensitive)
• Statins (drug-induced myopathy)
• Bisphosphonates (in context of osteoporosis)
• Vaccinations status (before starting immunosuppression)
• Complementary/herbal medications

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5. Family History

• RA, psoriasis, SLE, SpA/AS, gout - strong familial patterns
• HLA-B27 associated diseases run in families
• Premature CVD (relevant to SLE, RA risk)
• Hemochromatosis (arthropathy, DM, liver disease)
• Periodic fever syndromes (FMF - ethnic background, TRAPS, etc.)

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6. Social History

• Occupation - repetitive strain, heavy physical work, chemical exposures (silica → systemic sclerosis, scleroderma)
• Smoking - strong risk factor for RA seropositive disease and ILD; accelerates AS
• Alcohol - gout trigger, drug interactions (MTX hepatotoxicity)
• Recreational drugs
• Living situation - who provides support at home?
• Functional status - work, driving, hobbies, ADLs
• Sexual history - relevant for reactive arthritis (STI-triggered), gonococcal arthritis
• Travel history - Lyme disease, brucellosis, viral arthritis (chikungunya, dengue, Ross River)
• Animal contact - Lyme (ticks), brucellosis
• Diet - purine-rich food, alcohol (gout)
• Psychological and social impact - anxiety, depression are common and bidirectional

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7. Reproductive History (Women)

• Pregnancy - many autoimmune diseases flare postpartum (RA, SLE); some improve in pregnancy (RA)
• Miscarriages → antiphospholipid syndrome
• Contraception - COCP may exacerbate SLE
• Lactation (affects drug choices)
• Menopause - PMR incidence peaks post-menopause

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8. Red Flags to Actively Exclude

• Fever + joint swelling = septic arthritis until proven otherwise
• Night pain, weight loss, progressive weakness = malignancy / myeloma
• Bilateral hip girdle pain + raised ESR + elderly = polymyalgia rheumatica / GCA
• Visual symptoms + headache + temporal tenderness = GCA (ophthalmic emergency)
• Acute monoarthritis + hyperuricemia + risk factors = gout vs. septic arthritis
• Widespread skin tightening + Raynaud's + dysphagia = SSc
• Neurological symptoms + rash + ANA+ = SLE
• Uveitis + chronic back pain + young man = ankylosing spondylitis

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9. Impact Assessment (Mandatory)

• Pain scores (NRS 0-10 at rest and activity)
• Functional limitations - use HAQ (Health Assessment Questionnaire) or similar
• Work - time off, job modification, risk of job loss
• Sleep - disrupted by pain?
• Mood - depression and anxiety screening (PHQ-2/GAD-2 at minimum)
• Relationships and social participation
• Patient's own goals and expectations - "What matters most to you?" "What do you want to be able to do?"

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Key Diagnostic Patterns to Synthesize from the History

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