History Taking in a Patient with Polyarthralgia

1. Chief Complaint and Presenting Symptoms

2. History of Presenting Illness (HOPI)

A. Pain Characterization (SOCRATES)

• Ask the patient to point to the area of pain with one finger - patients often say "hip" when they mean the buttock, low back, or thigh. Pain in the distribution of joints = articular; pain over bursae/tendons = periarticular.
• Pain described as "excruciating/intolerable" in a patient who is otherwise functional suggests psychosocial amplification ("pain catastrophizing").
• Widespread, vaguely described pain that does not respect anatomic distributions suggests fibromyalgia or a chronic pain syndrome.

"Aching in a joint area suggests an arthritic disorder, whereas burning or numbness in an extremity may indicate a neuropathy." - Firestein & Kelley's Textbook of Rheumatology

B. Joint Pattern - The Most Diagnostically Critical Section

• Oligoarthritis: 2-4 joints (reactive arthritis, psoriatic arthritis, gout)
• Polyarthritis: ≥5 joints (RA, SLE, viral arthritis)

• Symmetric small joint involvement (MCPs, PIPs, wrists) → RA
• Asymmetric large joint involvement → reactive/psoriatic arthritis
• DIP joint involvement → osteoarthritis, psoriatic arthritis
• Axial involvement (spine, sacroiliac joints) → spondyloarthropathies

• Additive: new joints involved while old ones remain affected → RA, SLE
• Migratory/flitting: one joint resolves before another is involved → rheumatic fever, gonococcal arthritis
• Palindromic: recurrent episodic attacks with complete resolution → palindromic RA, crystal arthropathy

• Small peripheral joint pain is more focal and well-localised
• Large proximal joint pain (shoulder, hip) is poorly localised and diffuse

C. Morning Stiffness

• Ask: "In the morning, how long does it take for your joints to 'limber up' to as good as they are going to get for the day?"
• >1 hour (often several hours) → strongly suggests inflammatory arthritis (RA, polymyalgia rheumatica)
• <30 minutes → more consistent with non-inflammatory/degenerative disease (OA)
• The "gel phenomenon" - stiffness after any prolonged inactivity (not just morning) - also points to inflammation
• Note: morning stiffness is not specific; fibromyalgia, Parkinson's disease, and sleep disorders can also cause it

D. Swelling

• True joint swelling (synovitis) significantly narrows the differential compared to arthralgia alone
• Clarify: is the swelling intra-articular vs. diffuse soft tissue swelling (the latter may be venous/lymphatic obstruction)?
• A joint that swells rapidly and is acutely painful (hours) suggests crystal arthropathy (gout, pseudogout) or septic arthritis
• Swelling developing slowly (days-weeks) is more typical of inflammatory arthritis

E. Limitation of Motion

• Abrupt-onset restriction → structural derangement (tendon rupture, torn meniscus)
• Insidious restriction → inflammatory joint disease
• Duration of restriction predicts reversibility (short duration = better prognosis with steroids/PT)

F. Associated Joint Symptoms

• Crepitus (clicking, grinding) → cartilage loss, OA
• Locking or giving way → internal derangement, loose bodies
• Warmth and redness → crystal arthritis, septic arthritis, reactive arthritis

3. Morning vs. Evening Pattern

4. Systemic/Constitutional Symptoms

• Fever - Evening fevers → systemic JIA; episodic fevers → periodic fever syndromes; low-grade fever → RA, SLE, viral arthritis
• Fatigue and lethargy - Common in all inflammatory diseases
• Weight loss and night sweats → malignancy, TB, or severe systemic inflammation
• Anorexia → systemic disease, malignancy
• Myalgia (muscle pain) and proximal muscle weakness → inflammatory myopathy (polymyositis/dermatomyositis), PMR
• Impaired growth (in children) → systemic JIA

5. Extra-articular Features (Review of Systems)

Skin and Mucous Membranes

• Butterfly (malar) rash → SLE
• Photosensitive rash → SLE, dermatomyositis
• Psoriatic plaques (scalp, ears, umbilicus, nails - onycholysis, pitting) → psoriatic arthritis
• Heliotrope rash, Gottron's papules → dermatomyositis
• Oral/genital ulcers → Behcet's disease, SLE, reactive arthritis (Reiter's)
• Keratoderma blennorrhagica, circinate balanitis → reactive arthritis
• Erythema chronicum migrans → Lyme disease
• Raynaud's phenomenon → connective tissue disease (SLE, scleroderma, mixed CTD)
• Subcutaneous nodules → RA, gout (tophi), rheumatic fever

Eyes

• Uveitis/iritis → spondyloarthropathies (AS, reactive arthritis), sarcoidosis, JIA
• Sicca symptoms (dry eyes, dry mouth) → Sjogren's syndrome
• Episcleritis/scleritis → RA, vasculitis

Cardiorespiratory

• Pleuritis, pericarditis → SLE, RA
• Dyspnoea → ILD (RA, polymyositis, scleroderma), pulmonary hypertension (SLE, scleroderma)
• Migratory pleuritis → rheumatic fever
• Cardiac murmur → SLE (Libman-Sacks), rheumatic fever

Gastrointestinal

• Diarrhoea (bloody or mucous) → inflammatory bowel disease-associated arthritis (enteropathic arthritis)
• Dysphagia, GERD → scleroderma
• Oral ulcers → SLE, Behcet's
• Abdominal pain with rash → HSP/IgA vasculitis

Genitourinary

• Urethritis, dysuria → reactive arthritis (Reiter's syndrome: urethritis + conjunctivitis + arthritis)
• Haematuria, proteinuria → SLE nephritis
• Cervicitis/urethral discharge → gonococcal arthritis

Neurological

• Headache, seizures → SLE (CNS involvement)
• Peripheral neuropathy → vasculitis, SLE, heavy metal toxicity
• Paresthesias → neuropathy vs. cervical/lumbar radiculopathy

Haematological

• Recurrent thrombosis, miscarriages → antiphospholipid syndrome

6. Past Medical History

• Previous episodes of joint pain: frequency, duration, triggers, complete vs. incomplete resolution
• Psoriasis (even mild scalp disease) → psoriatic arthritis
• IBD (Crohn's, ulcerative colitis) → enteropathic arthritis
• Previous infections: recent pharyngitis (rheumatic fever), STI (reactive/gonococcal), tick exposure (Lyme), viral illness (hepatitis B/C, parvovirus B19, rubella, chikungunya, COVID-19)
• Trauma or surgery to joints
• Thyroid disease → hypothyroidism causes a non-inflammatory arthropathy
• Diabetes → Charcot arthropathy, adhesive capsulitis
• Renal/hepatic disease → gout (impaired uric acid excretion), hepatitis B/C arthritis
• Malignancy → paraneoplastic arthritis, hypertrophic osteoarthropathy
• Previous joint replacements or procedures

7. Drug History

• Current medications: NSAIDs, DMARDs, biologics, steroids
• Drug-induced lupus: hydralazine, procainamide, isoniazid, minocycline, anti-TNF agents
• Drug-induced myopathy: statins, corticosteroids, colchicine
• Drug-induced arthralgia: quinolones, aromatase inhibitors, checkpoint inhibitors
• Drug-induced gout: diuretics (thiazides, loop), low-dose aspirin, cyclosporine, pyrazinamide
• Response to previous therapy - improvement with NSAIDs/steroids suggests an inflammatory process
• Compliance with current regimens must be assessed and differentiated from true treatment failure

8. Family History

• RA, SLE, psoriasis, ankylosing spondylitis → strong genetic component (HLA associations)
• Gout → familial hyperuricaemia
• Haemochromatosis → chondrocalcinosis, destructive arthropathy
• Muscular dystrophy, familial neuropathy → relevant if weakness is prominent

9. Social History

• Occupation: repetitive motion tasks → OA, tendinopathy; heavy manual work; workplace toxic exposures
• Smoking: associated with RA (especially seropositive) and its severity
• Alcohol: gout (increases uric acid), myopathy, neuropathy
• Sexual history → gonococcal arthritis, reactive arthritis (Reiter's)
• Travel history: endemic areas for Lyme disease, brucellosis, viral arthritides (chikungunya, Ross River)
• Animal exposure: brucellosis (cattle/goat contact), rat-bite fever
• Tick bites: Lyme disease
• Recreational activities: sports injuries, hiking in Lyme-endemic areas

10. Dietary History

• Purine-rich diet (red meat, shellfish, organ meats), high-fructose corn syrup → gout
• Undercooked pork → trichinosis (causes myositis/arthralgia)
• Alcohol (especially beer) → gout

11. Birth/Developmental History (Paediatric Patients)

• Source of history should be primarily the child (especially adolescents) while noting discrepancies with parents
• Adolescents should be interviewed alone at some point
• Disparity in history between child and parent may suggest psychosocial issues or abuse (which can present as musculoskeletal pain)

Summary: Key Differentiating Questions at a Glance