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Table of Contents
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Taking a rheumatological history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a rheumatological history in an OSCE setting.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Use the PRISMS acronym to explore key rheumatological symptoms:
Rashes, skin lesions and nail changes
Swelling and sweats
If a patient has pain, explore it further using the SOCRATES acronym:
Ask about the location of the pain:
“Where is the pain?”
“Can you point to where you experience the pain?”
This can be helpful to differentiate between monoarthritis and polyarthritis.
Clarify how and when the pain developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“How long have you been experiencing the pain?”
Ask about the specificcharacteristics of the pain:
“How would you describe the pain?” (e.g. dull ache, burning, sharp)
“Is the pain constant or does it come and go?”
Ask if the pain movesanywhere else:
“Does the pain spread elsewhere?”
Ask if there are other symptoms which are associated with the pain:
“Are there any other symptoms that seem associated with the pain?”
Joint stiffness, fever and skin rashes are commonly associated with rheumatological joint pain.
Clarify how the pain has changed over time:
“How has the pain changed over time?”
“Is the pain worse at a particular time of day?”
Inflammatory arthritis is typically worse in the mornings with associated stiffness whereas osteoarthritis is typically worse later in the day after activities.
Exacerbating or relieving factors
Ask if anything makes the pain worse or better:
“Does anything make the pain worse?”
“Does anything make the pain better?”
Assess the severity of the pain by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Rashes, skin lesions and nail changes
Ask the patient if they have developed any newrashes or skinlesions:
“Have you noticed any rashes or other changes to your skin recently?”
Ask the patient if they have noticed any changes to their nails:
“Have you noticed any changes to your nails recently?”
The presence of salmon pink plaques on extensor surfaces and nail changes such as onycholysis would suggest a diagnosis of psoriasis, which is closely associated with psoriatic arthritis.
The key clinical features of systemicsclerosis can be remembered using the CReST acronym:
Calcinosis: the formation of calcium deposits in soft tissue.
Raynaud’s phenomenon: stress and cold temperature trigger arterial spasm causing reduced blood flow to the fingers and toes resulting in discolouration.
Oesophageal dysmotility: dysphagia affecting the mid to lower oesophagus.
Sclerodactyly: the progressive thickening of the skin distal to the metacarpophalangeal joints.
Telangiectasia: dilated capillaries which appear on the palms of the hands as well as the face and mucous membranes.
Usefulquestions to identify key features of systemic sclerosis:
“Have you noticed any recent skin changes, such as tightening, thickening or the formation of lumps in the skin?”
“Do you notice that your fingertips change colour, particularly in the cold or during stress?”
“Do you ever find it difficult to swallow food or drink fluids?”
“Does it ever feel like food gets stuck in your gullet?”
“Have you noticed any new blood vessels becoming visible on the skin or your palms or face?”
Systemic lupus erythematosus (SLE)
Key clinical features of systemic lupus erythematosus (SLE) include:
Constitutional symptoms: fatigue, fever and weight loss.
Musculoskeletal symptoms: arthralgia and myalgia.
Dermatological symptoms: malar rash, photosensitivity and discoid lupus.
Renal symptoms: haematuria and oedema (acute nephritic disease).
Neuropsychiatric symptoms: seizures and psychosis.
Respiratory symptoms: shortness of breath, cough and chest pain (e.g. pneumonitis and interstitial lung disease).
Gastrointestinal symptoms: nausea, dyspepsia and abdominal pain.
Cardiac symptoms: chest pain and shortness of breath (e.g. pericarditis, myocarditis).
Haematological symptoms: fatigue, shortness of breath, fevers and bruising (e.g. leukopenia, anaemia, thrombocytopenia).
Usefulquestions to identify key features of SLE:
“Have you recently experienced any fevers or weight loss?”
“Do you have any aching in any of your joints or muscles?”
“Have you noticed any rashes or skin changes recently?”
“Have you noticed any blood or other changes in your urine?”
“Have you noticed any changes in your thoughts or mood?”
“Have you felt more short of breath recently?”
“Have you experienced any chest pain recently?”
“Have you felt more fatigued or found that you are bruising more easily recently?”
Key clinical features of Sjogren’s syndrome include:
Usefulquestions to identify key features of Sjogren’s syndrome:
“Have you experienced dry or sore eyes recently?”
“Have you noticed that your mouth is drier than usual recently, even when well hydrated?”
“Have you had a cough recently?”
Jointstiffness is a common feature of several rheumatological diseases including:
Ask the patient when the joint stiffness is at its worst (e.g. early mornings) and how it impacts on their daily activities (e.g. writing, buttoning up a shirt, brushing hair).
Rheumatological disease can present with similar features to malignancy such as fatigue, malaise and weight loss, therefore it’s important to consider malignancy in your differential diagnosis. Rheumatological disease can also develop secondary to malignancy due to paraneoplastic phenomena.
Usefulquestions to identify features of malignancy:
“Have you noticed any unintentional weight loss recently?”
“Have you experienced any night sweats recently?”
“Have you noticed any change in your appetite?”
“Have you felt more tired recently?”
Swelling and sweats
Jointswelling and sweats are both associated with rheumatological disease (e.g. rheumatoid arthritis).
Usefulquestions to identify and explore joint swelling and night sweats include:
“Have you noticed any swelling of your joints recently?”
“Which joints have become swollen and when did that start?”
“Is the joint swelling painful?”
“Does the joint swelling impact your daily activities?”
“Have you noticed any associated redness of skin overlying the swollen joints?”
The presence of joint swelling and fever requires urgent review and investigation to rule out septic arthritis.
Extra-articular manifestations of rheumatological disease
Rheumatological disease can have a number of extra-articular manifestations such as:
Uveitis (associated with ankylosing spondylitis)
Dry eyes (associated with Sjogren’s syndrome)
Interstitial lung disease (associated with rheumatoid arthritis and SLE)
Urethritis (associated with reactive arthritis)
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. joint replacements):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medical conditions relevant to rheumatologicaldisease include: