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-urinary

SLE, 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 history

General 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.