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Taking a rheumatological history is an important skill that can be assessed in the OSCE setting. It usually involves taking a history of a joint problem, with the patient also mentioning other systemic features of rheumatological disease. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough history of rheumatological pathology.


Introduction

Introduce yourself – name/role

Confirm patient details – name/DOB

Explain the need to take a history

Gain consent

Ensure the patient is comfortable


Presenting complaint

It’s important to use open questioning to elicit the patient’s presenting complaint

“So what’s brought you in today?”  or  “Tell me about your symptoms”

Allow the patient time to answer, trying not to interrupt or direct the conversation

Facilitate the patient to expand on their presenting complaint if required

“Ok, so tell me more about your joint pain”


History of presenting complaint

Key rheumatological complaints

PRISMS

  • Pain
  • Rashes and skin lesions
  • Immune
  • Stiffness
  • Malignancy
  • Swelling and Sweats

 

Pain

If pain is a symptom, clarify the details of the pain using SOCRATES

  • Site – where is the pain? (e.g. monoarthritis vs polyarthritis)
  • Onset – when did it start? / sudden vs gradual? / associated with trauma?
  • Character – how would you describe the pain? (e.g. sharp/dull ache/burning)
  • Radiation – does the pain move anywhere else?
  • Associations – other symptoms associated with the pain? (e.g. stiffness)
  • Time course – worsening/improving/fluctuating/time of day dependent? (e.g. rheumatoid arthritis worse in mornings vs osteoarthritis worst during/after activity)
  • Exacerbating / Relieving factors – does anything make the pain worse or better?
  • Severity – on a scale of 0-10, how severe is the pain?

 

Rashes and skin lesions

 

Immune

Systemic sclerosis: CREST

  • Calcinosis – “Have you noticed any skin changes?”
  • Raynaud’s – “Do you notice that your fingertips change colour, particularly in the cold or during stress?”
  • Esophageal dysmotility – “Do you ever find it difficult to swallow?”
  • Sclerodactyly – “Have you noticed any thickening/tightening of the skin of your fingers?”
  • Telangiectasia – “Do you notice small spider-like red lines on your face or elsewhere?”

 

Systemic Lupus Erythematosus (SLE)

  • Constitutional symptoms (fatigue, fever, weight changes)
  • Musculoskeletal symptoms (arthralgia, myalgia) – “Do you have any aching in any of your joints or muscles currently?”
  • Dermatological symptoms (malar rash/butterfly rash), photosensitivity, discoid lupus) – “Have you noticed any rashes or skin changes recently?”
  • Renal (acute nephritic disease) – “Have you noticed any blood or other changes in your urine?”
  • Neuropsychiatric (seizure, psychosis) – “Have you noticed any changes in your thoughts or mood?” 
  • Pulmonary (pneumonitis, interstitial lung disease) – “Have you felt more short of breath recently?”
  • Gastrointestinal (nausea, dyspepsia, abdominal pain)
  • Cardiac (pericarditis, myocarditis) – “Have you experienced any chest pain recently?”
  • Haematological (leukopenia, anaemia, thrombocytopenia) – “Have you felt more fatigued or found that you are bruising more easily recently?”

 

Sjogren’s syndrome

  • Dry eyes
  • Dry mouth
  • Chronic cough

Stiffness

  • Reduced range of movement
  • Locking of the joint
  • Functional difficulties (e.g. writing, buttoning up shirt, brushing hair)

 

Malignancy

 Ask about B symptoms to rule out malignancy:

  • Fever
  • Night sweats
  • Weight loss

 

Swelling and Sweats

  • Joint swelling – confirm which joints are affected and timescale for onset
  • If joint swelling is present, is there associated erythema? –  gout/septic arthritis

 

Ask about extra-articular manifestations of rheumatological joint disease: 

  • Red/painful eyes – uveitis –  ankylosing spondylitis
  • Dry eyes – Sjogren’s syndrome
  • Breathing difficulties – interstitial lung disease – RA/SLE
  • Urethritis – reactive arthritis
  • Fever – inflammatory arthropathies/septic arthritis

 

Ask about history of recent infections

  • Septic arthritis (often the causative organism is from another source e.g. urine)
  • Reiter’s syndrome (STIs)

 

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?

Concerns – explore any worries the patient may have regarding their symptoms

Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

 

Summarising

Summarise what the patient has told you about their presenting complaint.

This allows you to check your understanding regarding everything the patient has told you.

It also allows the patient to correct any inaccurate information and expand further on certain aspects.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.

Continue to periodically summarise as you move through the rest of the history.

 

Signposting

Signposting involves explaining to the patient:

  • What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
  • What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history

Rheumatological disease 

Autoimmune conditions

Peptic ulcers/duodenal ulcers/ischaemic heart disease/ischaemic stroke (NSAIDS would be contraindicated)

ALLERGIES


Past surgical history

Joint surgery/replacements


Drug history

Analgesics

Immunosuppressants:

  • Corticosteroids – e.g. prednisolone
  • anti-TNF – e.g. infliximab
  • Biologics – e.g. rituximab

Family history

Ask about any history of rheumatological disease in first-degree relatives.


Social history

Occupation:

  • Are they currently working?
  • Are their joint problems impacting their ability to work?

Mobility – How does the patient mobilise? – e.g. wheelchair/stick/zimmer frame/independent

Smoking – How many cigarettes a day? How many years have they smoked for?

Alcohol – How many units a week? – type/volume/strength of alcohol

Recreational drug use – IV drug use is a potential source of joint sepsis

 

Living situation:

  • Own home/care home – adaptations/stairs?
  • Who lives with the patient? – is the patient supported at home?
  • Any children?
  • Any carer input? –what level of care do they receive?

 

Activities of daily living:

  • Is the patient independent and able to fully care for themselves?
  • Can they manage self-hygiene/housework/food shopping?

Systemic enquiry

Involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. arthralgia in psoriatic arthritis).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

Cardiovascular – Chest pain / Palpitations  / Dyspnoea /  Syncope / Orthopnoea  / Peripheral oedema 

Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit 

Urinary –  Volume of urine passed / Frequency / Dysuria  / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Musculoskeletal – Bone and joint pain / Muscular pain 


Closing the consultation

Thank the patient

Summarise the history