Rheumatology History Taking

1. Classification Framework (Know Before You Ask)

2. Presenting Complaint

Joint Pain (Arthralgia / Arthritis)

• Onset - sudden (gout, septic arthritis, reactive arthritis) vs. gradual (RA, OA)
• Number of joints - monoarthritis (1), oligoarthritis (2-4), polyarthritis (5+)
• Pattern - which joints? Symmetrical vs. asymmetrical?
  • Small peripheral joints (MCPs, PIPs, MTPs) - RA
  • DIP joints - psoriatic arthritis, OA
  • Large lower limb joints - spondyloarthropathy, reactive arthritis
  • Axial skeleton (spine, sacroiliac) - ankylosing spondylitis
• Migratory vs. additive - gonococcal/reactive arthritis tends to migrate; RA is additive
• Duration - acute (< 6 weeks) vs. chronic (> 6 weeks)

Morning Stiffness

• Duration is key: > 1 hour strongly suggests inflammatory arthritis (RA)
• OA typically produces stiffness lasting < 30 minutes
• Ask about "gel phenomenon" - stiffness after any period of rest

Swelling

• Distinguish joint effusion (fluctuant, intra-articular) from periarticular swelling (bursitis, tendinitis) or bony enlargement (OA osteophytes)

3. Pain Characterization

• Location - joint line, periarticular, diffuse
• Character - aching, burning, sharp, throbbing
• Severity - visual analogue or numeric rating scale
• Radiation - nerve root involvement? Carpal tunnel syndrome?
• Aggravating/relieving factors
  • Rest relieves mechanical/OA pain; inflammatory pain often improves with activity
  • Inflammatory back pain classically improves with exercise and worsens with rest (key for ankylosing spondylitis)
• Nocturnal pain - inflammatory disease, malignancy (red flag)

4. Constitutional / Systemic Symptoms

• Fever - pattern matters:
  • Evening spiking fevers: systemic JIA / Adult-onset Still disease
  • Episodic fevers: periodic fever syndromes
  • Chaotic fever: SLE, macrophage activation syndrome
• Fatigue and lethargy - common in all chronic inflammatory diseases; often underreported
• Weight loss / anorexia - systemic inflammation, malignancy (red flag)
• Weakness - proximal muscle weakness suggests inflammatory myopathy (polymyositis, dermatomyositis); absent weakness with pain suggests fibromyalgia or pain syndrome
• Impaired linear growth (in children) - systemic inflammation marker

5. Extra-Articular Features by System

Skin

• Butterfly (malar) rash - SLE (spares nasolabial folds)
• Psoriatic plaques - behind ears, scalp, extensor surfaces, umbilicus, nails - psoriatic arthritis
• Nodules over extensor surfaces - rheumatoid nodules vs. gouty tophi
• Skin tightness - hallmark of systemic sclerosis (scleroderma); starts with digit swelling, then hand tightness
• Telangiectasias, digital ulcers - systemic sclerosis
• Gottron's papules, heliotrope rash - dermatomyositis
• Palpable purpura - vasculitis

Vascular

• Raynaud's phenomenon - color changes (white-blue-red) in fingers/toes with cold; frequently precedes systemic sclerosis by years; also seen in SLE, mixed connective tissue disease
• Ask about color change sequence and triggers

Eyes

• Dry eyes (xerophthalmia) - Sjogren's syndrome (sicca symptoms)
• Eye redness, pain, photophobia - uveitis/iritis - strongly associated with spondyloarthropathies (HLA-B27-related)
• Scleritis - RA, vasculitis

Mouth / Mucosa

• Dry mouth (xerostomia) - Sjogren's syndrome; ask about difficulty swallowing dry food
• Oral ulcers - SLE, Behcet's disease, reactive arthritis
• Dental caries - secondary to xerostomia in Sjogren's

Respiratory

• Shortness of breath, dry cough - interstitial lung disease (especially systemic sclerosis, RA, myositis)
• Pleuritis - SLE, RA

Cardiac

• Chest pain (pericarditis) - SLE, RA
• Dysphagia - systemic sclerosis (esophageal dysmotility)

Renal

• Haematuria, frothy urine, oedema - glomerulonephritis (SLE is a major cause)

Neurological

• Headache, cognitive change, psychosis - neuropsychiatric SLE
• Peripheral neuropathy - vasculitis, RA
• Carpal tunnel syndrome - RA, hypothyroidism (mimic), amyloidosis

Gastrointestinal

• Chronic diarrhea, bloody stools - enteropathic arthritis (Crohn's, UC)
• Genital ulcers - Behcet's disease

6. Disease-Specific Questions

For Spondyloarthropathy (Ankylosing Spondylitis / Psoriatic Arthritis)

• Lower back pain < 45 years of age, duration > 3 months
• Inflammatory back pain: insidious onset, worse with rest, better with exercise, nocturnal pain
• Alternating buttock pain (sacroiliitis)
• History of psoriasis (personal or family)
• History of uveitis, Crohn's, or UC
• Heel pain (plantar fasciitis / Achilles enthesitis - an enthesopathy is characteristic)

For Gout

• Sudden, severe monoarthritis (especially 1st MTP joint - podagra)
• Nocturnal onset
• Dietary history: alcohol, red meat, seafood, fructose
• Medications: diuretics (thiazides), low-dose aspirin (raise uric acid)
• Previous attacks - frequency and resolution
• Tophi

For SLE

• Young woman; multi-system involvement
• Photosensitivity
• Alopecia (hair loss)
• Oral ulcers
• Serositis (pleuritis, pericarditis)
• History of thrombosis or pregnancy loss (antiphospholipid syndrome)
• Renal symptoms

For Vasculitis

• Headache, jaw claudication, scalp tenderness, visual changes (temporal arteritis/GCA) - in elderly
• Haematuria, haemoptysis (ANCA-vasculitis)
• Palpable purpura, peripheral neuropathy
• Constitutional symptoms

7. Past Medical History

• Previous episodes of joint problems
• Prior diagnoses of rheumatic disease or autoimmune conditions
• Psoriasis, inflammatory bowel disease, uveitis
• Infections preceding arthritis (reactive arthritis: urethritis, diarrhea 1-4 weeks prior)
• Malignancy (paraneoplastic arthropathy)
• Hypothyroidism, hyperparathyroidism (mimic rheumatic disease)

8. Drug History

• NSAIDs - already self-treating?
• Drugs causing lupus-like syndrome: hydralazine, procainamide, isoniazid, minocycline, anti-TNF agents
• Drugs raising uric acid: thiazide diuretics, loop diuretics, low-dose aspirin, ciclosporin
• Statins / fibrates - drug-induced myopathy (mimic myositis)
• Steroids (current or recent) - avascular necrosis, osteoporosis
• Hydroxychloroquine, methotrexate, biologics - already being managed

9. Family History

• Rheumatoid arthritis, SLE, psoriasis, ankylosing spondylitis
• Gout (polygenic component)
• HLA-B27-related diseases run in families

10. Social History

• Occupation - repetitive strain, vibration exposure, physical demands (OA, carpal tunnel, tendinopathies)
• Alcohol - gout trigger; liver disease affects drug choices (methotrexate)
• Smoking - strongly associated with RA (particularly seropositive RA) and worsens disease course; also associated with SLE
• Sexual history - gonococcal arthritis, reactive arthritis (Chlamydia)
• Travel history - Lyme disease (tick bite), viral arthritis (chikungunya, Ross River virus)
• Pets / animal exposure - Lyme, rat-bite fever
• Functional impact - activities of daily living, work, mobility, sleep quality

11. Red Flags in Rheumatology History

12. Special Considerations in Pediatric Rheumatology

• History should be age-appropriate; involve the child directly (especially adolescents)
• Adolescents should be seen alone at some point (confidential history)
• Disparity between parent and child accounts may signal abuse
• Child abuse can present as musculoskeletal or rheumatic complaints
• Constitutional features (lethargy, irritability, reduced appetite, impaired growth) are more prominent markers of systemic disease in children
• Evening spiking fevers are characteristic of systemic JIA

Summary Mnemonic for Joint History

• Site - which joint(s)?
• Onset - sudden or gradual?
• Character - aching, burning?
• Radiation - nerve involvement?
• Associated symptoms - swelling, stiffness, rash, fever?
• Time course - acute, chronic, episodic?
• Exacerbating/relieving factors - rest or exercise?
• Severity + Stiffness duration (morning stiffness > 1 hr = inflammatory)