Stepwise Medical History in Rheumatoid Arthritis

Severe advanced RA: ulnar deviation at MCPs, swan-neck deformity, dorsal tendon swelling, and thenar wasting

Step 1 — Demographic Profile (Biodata)

• Age: Peak onset is 40-60 years; RA can occur at any age including juvenile form (<16 years = JIA)
• Sex: Female predominance (F:M = 3:1); sex hormones influence disease onset and severity
• Occupation: Ask about repetitive joint use (manual labour, typing); disability impacting work is common
• Marital status / living alone: Relevant for functional assessment and support

Step 2 — Chief Complaints

1. Joint pain (arthralgia/arthritis) - most common presenting complaint
2. Joint swelling
3. Morning stiffness
4. Difficulty using hands / reduced grip
5. Fatigue and generalized weakness
6. Deformity (in chronic/advanced disease)

Step 3 — History of Presenting Illness (HOPI)

A. Joint Pain

• Site: Which joints are involved first? Classic RA starts in the small joints of the hands (PIP and MCP joints) and toes (MTP joints). Importantly, DIP joints are typically spared - their involvement suggests psoriatic arthritis or OA
• Onset: Insidious (most common in RA) vs. acute; some patients have a palindromic pattern (migratory, episodic attacks)
• Character: Dull aching; throbbing pain suggests acute inflammation
• Radiation: Does it radiate? Cervical spine involvement can cause neck pain radiating to arms (C1-C2 subluxation)
• Aggravating / Relieving factors: Pain worsens with activity, improves with warmth and gentle movement; pain is also reportedly aggravated during rainy seasons and at full/new moon
• Severity: Score on a 0-10 numerical rating scale
• Progression: Which joints were involved first? How did disease spread (additive vs. migratory vs. simultaneous)?
• Symmetry: RA is characteristically bilateral and symmetric - involvement of both wrists, both MCPs, both PIPs

B. Joint Swelling

• Which joints? Symmetrical involvement of small joints of hands and feet is characteristic
• Is swelling soft (synovial effusion) or boggy (synovial proliferation/pannus)?
• Is it persistent or intermittent?

C. Morning Stiffness - The Key Diagnostic Feature

• Duration of morning stiffness - must be elicited precisely; in RA it lasts >1 hour (often hours) and is a hallmark feature
• Distinguishes RA from OA (where stiffness lasts <30 minutes)
• Ask: "When you wake up, how long does it take before your joints are as loose as they'll be for the rest of the day?"
• Stiffness is relieved by warmth and activity

D. Functional Impairment

• Difficulty gripping objects, opening jars, buttoning clothes
• Difficulty walking, climbing stairs
• Activities of daily living (ADL) assessment

E. Extra-articular Symptoms (Review of Systems Pertaining to RA)

Step 4 — Past Medical History

1. Previous episodes of joint pain/swelling - RA may have a palindromic prodrome
2. History of tuberculosis, gonorrhoea, syphilis, typhoid or pneumonia - relevant to differential diagnosis of infective/reactive arthritis
3. Previous trauma to joints - can precipitate or complicate OA
4. Previous investigations - prior RF testing, X-rays, any previous diagnosis
5. Previous treatment - steroids, NSAIDs, DMARDs; response to treatment helps confirm diagnosis
6. Cardiovascular disease, diabetes, osteoporosis - important comorbidities and treatment considerations
7. Thyroid disease - hypothyroidism commonly co-exists with RA and causes rheumatic symptoms

Step 5 — Treatment History

• Current medications: NSAIDs, glucocorticoids (dose, duration), conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide), biologic DMARDs (TNF inhibitors, IL-6 inhibitors, abatacept, rituximab), targeted synthetic DMARDs (JAK inhibitors - tofacitinib, baricitinib)
• Response to treatment: Any improvement? Side effects?
• Steroid history: Long-term use raises risk of osteoporosis, infections, adrenal suppression
• NSAID use: GI bleeding risk, renal function monitoring required
• Vaccinations: Ask about hepatitis B, pneumococcal, influenza status (essential before starting biologics)

Step 6 — Family History

• Rheumatoid arthritis or autoimmune diseases in first-degree relatives - RA has a significant heritable component (~60% genetic contribution); risk in first-degree relatives is 3-5x higher
• Haemophilia, gout, tuberculosis, rheumatic fever - relevant to differentials
• Cardiovascular disease - RA patients have increased cardiovascular mortality; family history adds further risk
• Family history of periodontal disease is also emerging as relevant (shared microbiome and citrullination pathways)

Step 7 — Personal / Social History

• Smoking: A major environmental risk factor for seropositive RA; smoking promotes citrullination via PAD2 enzyme induction in alveolar macrophages; smokers have much higher ACPA levels (57% vs 7% in non-smokers)
• Alcohol: Interacts with methotrexate (hepatotoxicity)
• Diet: Mediterranean-style diet is protective; obesity worsens inflammation
• Occupation: Joint stress; disability and work absence are early features even in pre-clinical disease
• Physical activity level
• Living situation: Support at home; ability to carry out ADLs independently
• Stress / mental health: Psychological stress is a potential trigger; depression is a common comorbidity

Step 8 — Menstrual and Obstetric History (in women)

• Pregnancy: RA classically improves during pregnancy (especially 2nd and 3rd trimester) and often flares postpartum
• Oral contraceptive use: May be protective against developing RA
• Menarche/menopause: Onset around or after menopause is common; hormonal influence on autoimmunity
• Breastfeeding: Associated with postpartum flares

Step 9 — Systemic Review (remaining systems)

• GI: nausea, diarrhoea (NSAID/DMARD side effects; GI amyloidosis in chronic RA)
• Genitourinary: proteinuria, oedema (amyloidosis, gold-induced membranous nephropathy)
• CNS: memory, mood (depression in chronic pain)

Putting it Together: ACR/EULAR 2010 Classification Criteria (Diagnostic Aid)

Summary: Red Flags in History Suggesting Poor Prognosis

• High-titer RF or ACPA positivity
• Many small joints involved at onset (score ≥5 joint domain)
• Persistent elevated CRP/ESR
• Early functional limitation
• Extra-articular features
• Erosions on imaging at presentation