the rheumatological history
TRANSCRIPT
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
The rheumatological historyMarwan Adwan
Inam Haq
Abstract
Taking a thorough history is an important part of clinical practice in rheu-matology. The attending doctor should set aside the time necessary to
obtain a detailed history from a patient suspected of having a rheumatic
disease, taking into account the multisystem nature of these conditions. A
thorough history may also help to focus the physical examination and in-
vestigations; testing for every possible autoantibody in the hope of
finding a positive one is neither a sensitive nor an effective use of health-
care resources. The history should cover psychosocial as well as physical
issues and be able to identify significant red or yellow flags that will help
decide the management plan.
Introduction
Taking a rheumatological/musculoskeletal history is little
different to taking a history in any other specialty. If done sys-
tematically, it may reveal the underlying diagnosis in many
cases. However, musculoskeletal (MSK) symptoms may be very
specific (e.g. joint swelling) or rather undifferentiated (e.g.
widespread pain, fatigue) and the challenge is to use the history
to help differentiate inflammatory and autoimmune rheumatic
diseases (ARDs) from mechanical conditions, such as osteoar-
thritis, or pain syndromes such as fibromyalgia. A detailed sys-
tems review is essential as many inflammatory MSK conditions
give rise to systemic manifestations (Table 1) that may follow,
coincide with or precede articular symptoms. On the other hand,
patients may present initially to other specialties before a sys-
temic rheumatic disease is suspected. Thus, taking a detailed,
careful rheumatological history is of paramount importance
whatever one’s specialty.
Presenting complaint
Joint pain
The majority of patients referred to a rheumatologist present with
joint pain (arthralgia). It is important to enquire about the site,
onset, nature, duration and severity of pain. The pattern of joint
involvement is important and can give a clue to the underlying
diagnosis; for example, rheumatoid arthritis (RA) tends to
involve particularly the metacarpophalangeal (MCP) and prox-
imal interphalangeal (PIP) joints in a bilateral and symmetrical
Marwan Adwan MBChBMRCPI MSc is a Specialist Registrar in Rheumatology
in the Thames and Kent, Surrey and Sussex Deaneries, UK. Conflicts of
interest: none.
Inam Haq MD FRCP is Reader in Rheumatology and Medical Education at
Brighton and Sussex Medical School, UK. His research interests are in
technology-enhanced learning and development of clinical reasoning in
medical students and junior doctors. Conflicts of interest: Role in
Arthritis Research UK as Associate Medical Director for Education.
MEDICINE 42:4 193
fashion but to spare the distal interphalangeal (DIP) joints in the
hands, whereas osteoarthritis (OA) and psoriatic arthritis (PsA)
involve the DIP joints. The onset of symptoms may be acute or
insidious. An acute onset may point towards trauma, crystal or
septic arthritis, whereas an insidious onset may indicate an in-
flammatory arthritis. Asymmetrical joint involvement occurs in
seronegative arthropathies, such as ankylosing spondylitis (AS),
PsA and reactive arthritis (ReA).
Another aspect of pain that should be enquired about is its
relationship to rest and activity. Pain due to inflammatory con-
ditions improves with activity and worsens with rest, whereas
the opposite is true of pain due to mechanical and degenerative
conditions.
Joint stiffness
Stiffness that is most marked on walking in the morning and after
a period of inactivity, and which lasts longer than 30 minutes,
may indicate inflammatory conditions. Patients may find it
difficult to wash, open jars and turn door handles in the morning
due to stiff hands. Patients with OA and other mechanical or pain
syndromes may also report stiffness, but this generally lasts less
than 30 minutes.
Joint swelling
Patients may present with joints that look or feel swollen, and the
swelling may be persistent or intermittent. The pattern of joint
swelling may give a clue, together with the pattern of pain, to the
underlying diagnosis.
Systematic enquiry
Skin manifestations
Many rheumatic conditions may be associated with a rash. It is
important to obtain a detailed description of the rash, as this may
be intermittent and absent at the time of the consultation. Pho-
tographs taken of the rash with a mobile phone camera may
provide useful information.
Nail changes or scaly skin lesions should make one think of
PsA in a patient with joint or back pain. Raynaud’s phenomenon
is a common complaint. It may be primary or secondary to
various non-rheumatic as well as rheumatic diseases, including
scleroderma, systemic lupus erythematosus (SLE), undifferenti-
ated connective tissue disease (UCTD), dermatomyositis/poly-
myositis or Sj€ogren’s syndrome.1
A facial rash associated with photosensitivity may be a clue to
SLE or dermatomyositis, whereas an evanescent salmon pink
rash may indicate adult-onset Still’s disease. A rash over the MCP
and PIP joints (Gottron’s papules) occurs in dermatomyositis.
The latter may also cause a lilac (heliotrope) rash over the eye-
lids. Erythema nodosum can be caused by many conditions,
including sarcoidosis, Behc‚et’s disease, inflammatory bowel
disease (IBD) or infection.2 Pyoderma gangrenosum may indicate
RA, granulomatosis with polyangiitis (GPA, formerly known as
Wegener’s granulomatosis), inflammatory bowel disease (IBD)
or a plasma cell dyscrasia. An extensive list of the various skin
manifestations is shown in Table 2.
Respiratory system
Breathlessness may indicate pulmonary hypertension, pulmo-
nary embolism, interstitial lung disease, drug-induced lung
� 2014 Elsevier Ltd. All rights reserved.
Systemic manifestations of rheumatic conditions
Symptom Disease association
Fever Septic arthritis, CTDs, PMR, GCA, vasculitis
Raynaud’s phenomenon Scleroderma, SLE, dermatomyositis, MCTD
Muscle weakness Polymyositis, dermatomyositis, steroid
myopathy
Swallowing problems Scleroderma, dermatomyositis
Pericarditis RA, SLE
Pleurisy RA, SLE
Seizures SLE
Stroke SLE, APS, vasculitis
Visual loss GCA, vasculitis
Mouth ulcers SLE, Behc‚et’s
Diarrhoea ReA, enteropathic arthritis
Miscarriages APS
Genital ulcers Behc‚et’s
Dysuria ReA
Thrombotic event APS, Behc‚et’s
Photosensitivity SLE, dermatomyositis
Butterfly rash SLE
APS, antiphospholipid syndrome; CTD, connective tissue disease; GCA, giant
cell arteritis; MCTD, mixed connective tissue disease; PMR, polymyalgia rheu-
matica; RA, rheumatoid arthritis; ReA, reactive arthritis; SLE, systemic lupus
erythematosus.
Table 1
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
disease or chest infection. Tumour necrosis factor (TNF) in-
hibitors are being used increasingly to treat rheumatic condi-
tions. Their use predisposes to mycobacterial infections, so it is
important to think of tuberculosis in a patient taking these drugs
Dermatological manifestations of rheumatic diseases
Skin lesion Association
Acne Behc‚et’s, SAPHO syndrome
Alopecia SLE
Digital infarcts Vasculitis
Discoid rash SLE
Erythema chronicum migrans Lyme disease
Erythema nodosum Sarcoidosis, Behc‚et’s
Heliotrope rash Dermatomyositis
Livedo reticularis APS, PAN
Lupus pernio Sarcoidosis
Malar rash SLE
Photosensitivity SLE
Psoriasis Psoriatic arthritis
Purpura Vasculitis
Salmon pink rash Adult-onset Still’s disease
Skin ulcers Vasculitis, RA
Telangiectasia Scleroderma
APS, antiphospholipid syndrome; PAN, polyarteritis nodosa; SAPHO, synovitis,
acne, pustulosis, hyperostosis, osteitis; SLE, systemic lupus erythematosus;
RA, rheumatoid arthritis.
Table 2
MEDICINE 42:4 194
who presents with a persistent cough that does not improve with
antibiotics. Pleuritic chest pain may be due to pleurisy, which
occurs in RA and SLE, or pulmonary embolism, which may
develop in antiphospholipid syndrome (APS). It is particularly
important to think of the latter diagnosis in young patients pre-
senting with thromboembolic disease who have no other pre-
disposing factors for thromboembolism.
Cough can be a manifestation of gastro-oesophageal reflux
due to scleroderma. In patients taking methotrexate a cough may
be an indication of methotrexate-induced lung disease. Hae-
moptysis may indicate a pulmonary embolism, which may occur
in APS. It may also be caused by a pulmonary haemorrhage in
SLE or a systemic vasculitis.
Cardiovascular system
Many rheumatic diseases affect the heart. Pericarditis can be a
manifestation of RA, SLE and other ARDs. ARDs can also cause
myocarditis. The incidence of ischaemic heart disease is
increased in RA, SLE, vasculitis and gout.3 The inflammatory
process in inflammatory myositis can involve the heart muscle as
well as skeletal muscle. Sarcoidosis, on the other hand, can affect
the conducting system of the heart. It is therefore important to
enquire about cardiovascular symptoms such as angina, peri-
cardial chest pain and palpitations in all patients suspected of
having an inflammatory arthritis or an ARD. Hypertension,
recent measurements of cholesterol concentration, diet and
medication such as corticosteroids should also be asked about.
Gastrointestinal system
Heartburn may be caused by oesophagitis due to the use of non-
steroidal anti-inflammatory drugs (NSAIDs), or it may be due to
oesophageal involvement in scleroderma. The latter may also
cause dysphagia and lower gastrointestinal tract symptoms with
diarrhoea and malabsorption.
Abdominal pain in patients with ARDs may be due to gut
involvement (intestinal ischaemia). SLE may also cause auto-
immune pancreatitis (AIP), which may present with abdominal
pain and vomiting.
Neurological system
Numerous neurological syndromes can result from a wide vari-
ety of rheumatic diseases, including RA, AS, SLE, Sj€ogren’s, APS,
vasculitis and sarcoidosis. These include peripheral neuropathy,
entrapment neuropathy, mononeuritis multiplex, encephalopa-
thy, myelopathy and stroke,4 and may cause various neurolog-
ical symptoms including paraesthesia, focal weakness, diplopia,
hemiplegia, dysphasia, quadriplegia, seizures or reduced
conscious level and coma. Unilateral severe headache in an
elderly patient may herald giant cell arteritis (GCA).
RA can cause myelopathy if there is involvement of the cer-
vical spine with atlanto-axial subluxation.
Neurological symptoms should be taken seriously and inter-
preted in light of a neurological examination. Any symptoms
suggestive of spinal cord compromise should be investigated
urgently.
Ophthalmological and ENT systems
The eyes can be affected in many ways in rheumatic diseases.
Eye dryness is the cardinal symptom of Sj€ogren’s syndrome.
Patients report grittiness and a foreign body sensation. A history
� 2014 Elsevier Ltd. All rights reserved.
Drug-induced rheumatic conditions
Drug Rheumatologic manifestation
Anti-TNF biologics Drug-induced lupus
b-Adrenoceptor blockers Raynaud’s phenomenon
Bleomycin Scleroderma-like illness
Colchicine Myopathy
Corticosteroids Osteoporosis
Hydralazine Drug-induced lupus
Propylthiouracil Small vessel vasculitis
Thiazides Gout, SLE
Tryptophan Scleroderma-like illness
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
of painful red eyes may be due to conjunctivitis, scleritis or
uveitis. Conjunctivitis in a patient with joint pain may be a clue
to the diagnosis of ReA. Scleritis may occur in RA, SLE, vasculitis
or relapsing polychondritis. Uveitis, on the other hand, may
occur in seronegative arthropathies, sarcoidosis, and Behc‚et’s
disease.
Unilateralvisual loss inapatientwithheadache is astrongclue to the
diagnosis of GCA. Diplopia may be due to third nerve palsy as part of a
mononeuritis multiplex and should lead one to suspect vasculitis.
A history of epistaxis, nasal crusting or ear discharge may
suggest systemic vasculitis. Nasal bridge collapse occurs in GPA
and relapsing polychondritis, which is also associated with
recurrent painful swelling of the ears.
Statins Myositis
Zidovudine Myositis
Renal and genito-urinarySLE, systemic lupus erythematosus; TNF, tumour necrosis factor.
Table 3
It is important to enquire about dysuria and urethral discharge,
which may indicate ReA or gonococcal arthritis. In such patients
one should also enquire about genital ulcers, which may also
occur in Behc‚et’s syndrome. A history of frothy urine, haemat-
uria or oliguria may be a clue to the presence of nephritis in a
patient with a connective tissue disease.
Obstetric history
Antiphospholipid syndrome can cause various pregnancy
complications, including miscarriage, premature birth, pre-
eclampsia, eclampsia and placental insufficiency.5 Moreover,
SLE itself can have deleterious obstetric effects, particularly if
conception occurs during periods of active disease.
Past medical history
Red flags for musculoskeletal pain
Age of onset <20 or >55 years
Violent trauma (fracture)
It is always essential to ask about past medical history, which
may provide clues to the underlying diagnosis. For example, a
history of iritis, IBD or psoriasis in a patient presenting with back
pain is a clue to the diagnosis of spondyloarthropathy.
Moreover, ARDs may present sequentially over a period of
time, so that the whole picture can be envisaged only if past
medical history is taken into context. For example, the possibility
of Behc‚et’s disease becomes much clearer when a patient pre-
senting with arthralgia and oral ulcers mentions a past history of
deep vein thrombosis (DVT) or uveitis.
Rheumatic symptoms may also be a manifestation of many
other conditions, including infection with EpsteineBarr virus,
hepatitis B and C, and HIV. It can also be a manifestation of
hypothyroidism, diabetes mellitus, hyperparathyroidism, hae-
mophilia, renal dialysis, haemochromatosis and malignancy.
Previous surgery and interaction with the multidisciplinary
team should not be forgotten. The impact/success of any of these
interventions/procedures should be asked about.
Unrelenting pain (not positional, increasing with time, day and night)
Muscle wasting or weakness, bladder or bowel control affected
Drug historyGeneral ill health: weight loss, fever, night sweats
Neurological symptoms or signs
Thoracic pain
Past history of cancer
Structural deformity
Lumbar flexion consistently restricted
HIV, IV drug abuse
Systemic corticosteroids
Table 4
It is important to take a detailed drug history in patients with sus-
pected rheumatic diseases, as many drugsmay be implicated in the
causation of various disease states.6 Table 3 lists some of these
associations. Drugs may also aggravate an already established
disease (diuretics/gout, sulfonamide antibiotics, contraceptive pill/
SLE). Use of paracetamol and NSAIDs is widespread. A detailed
record of the pattern of use and the clinical effectiveness of NSAIDs
should be obtained, as their long-term use can lead to a number of
important adverse events. Complementary/alternative therapies
are widely used by patients and should also be asked about.
MEDICINE 42:4 195
Lifestyle and family history
Social history, including smoking, alcohol and drug consump-
tion, occupation and hobbies, is an essential part of the rheu-
matological history. Cigarette smoking is a risk factor for
developing rheumatoid arthritis and cocaine use can cause
vasculitis. Certain occupations may predispose to developing
particular diseases. Working with vibrating tools may be a cause
of Raynaud’s phenomenon and alcohol consumption may pre-
cipitate an attack of gout.
One should always enquire about family history in patients
presenting with rheumatic symptoms. Whereas some conditions,
such as EhlerseDanlos syndrome, display a simple Mendelian
inheritance, the aetiology of the majority of conditions is multi-
factorial. However, a family history of a rheumatological condi-
tion increases the likelihood of its presence in a patient
presenting to the rheumatologist.
Effect of symptoms on the patient’s life
This is the main reason why the patient has sought help and
should not be missed. It is important to go into detail about ac-
tivities of daily living and which of these has become more
difficult since the onset of symptoms, at home, during leisure
� 2014 Elsevier Ltd. All rights reserved.
Yellow flags for musculoskeletal pain
Self-rated health poor
Psychological stress and depression
Disproportionate illness behaviour
Low job satisfaction
Personal problems: alcohol, marital, financial
Adversarial medico-legal proceedings
Low educational attainment
Heavy physical occupational work
Table 5
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
and, if appropriate, at work. An occupational history is vital as
work may be a significant contributor to MSK symptoms. The
exact nature of work should be elucidated, as well as enquiring
about the level of support at work and job satisfaction. The
impact of co-morbid chronic conditions such as chronic
obstructive pulmonary disease (COPD) and diabetes upon the
MSK symptoms should also be assessed. Support levels at home
are important, especially in patients with caring roles. The
impact of the symptoms on psychological wellbeing should also
be addressed sensitively. Poor sleep and fatigue are common in
MSK conditions and understanding the effects of these symptoms
on mood and daily life is important.
Red flags and yellow flags
Many MSK symptoms are self-limiting or may require a multi-
disciplinary approach with no need for specific pharmacolog-
ical treatment. However it is important to be able to identify
MEDICINE 42:4 196
serious MSK conditions such as ARDs, inflammatory arthritis,
joint sepsis, fracture, malignancy or spinal cord compression
early. Red flag symptoms (Table 4) should alert the person
taking the history to the possible presence of significant
disease.
Yellow flags indicating psychosocial morbidity (Table 5) are
also important to detect as they may have an effect on the
outcome of any treatment if they are not tackled at the same
time, where possible.
Summary
The rheumatological history is a key part of the diagnostic pro-
cess. A detailed history taking into account physical symptoms
and psychosocial issues put the patient at the centre of care and
will help to plan appropriate management. A
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� 2014 Elsevier Ltd. All rights reserved.