RHEUMATOLOGY: HISTORY TAKING Summary Pattern of joint involvement & mode of onset Character of pain - relieving and exacerbating

factors Character of stiffness - early morning and after immobility Extra-articular features Family, social and general medical history 1 GENERAL SYMPTOMS Principle clinical features of rheumatic disease are joint pain, stiffness and swelling, bone pain and muscle weakness. Many rheumatic diseases are easily recognized by the anatomical pattern of involvement of joints and other connective tissues. Pattern recognition combined with observation of 'extra-articular' or systemic Features, forms the basis for formulating a differential diagnosis. Important diagnostic clues may be obtained from the family history and social history, including the patients occupation and personal habits. Since rheumatic symptoms are frequently the presenting complaint of many systemic disorders, a careful general medical history must also be obtained. 2 PATTERNS OF JOINT INVOLVEMENT Establish which joints or groups of joints have been affected, whether monoarticular (single joint), oligoarticular (a few joints) or polyarticular, along with mode of onset i.e. acute, chronic, insidious, migratory etc. (Table 1). 3 CHARACTERISTICS OF THE RHEUMATIC SYMYTOMS Pain should be analysed according to the severity, type of onset (acute or chronic), pattern in time and relation to activities. Stiffness of joints occurs both with inflammatory and degenerative lesions. In inflammatory joint disease, such as rheumatoid arthritis. there is characteristically a diurnal variation in stiffness and pain which is worse on rising in the morning, typically lasts at least 30 minutes, and may return at the end of the day. Such patients also describe marked 'immobility stiffness' or 'gelling' after periods of inactivity Patients with degenerative joint disease similarly may complain of stiffness, but this tends to show much less or no diurnal exacerbation, and may persist even with use of the joint. Typical questions which may be used to elicit the main characteristics of a patients symptoms of pain and stiffness are shown in Table 2. Swelling is also an important feature of joint disease, and although usually identified during the physical examination should be sought from the history where the condition is episodic. Swelling, in the absence of trauma, is highly suggestive, but not

pathognomic of inflammation Conversely, some inflammatory joint disease may be associated with little or no swelling (eg viral arthritis, SLE). Weakness may occur as a result of joint disease, but where weakness is the presenting dominant symptom it is highly suggestive of a myopathy. Table 1. COMMON PATTERNS OF JOINT INVOLVEMENT Joints Symmetrical polyarticular MCP PIP& MTP joints DIP joint(s) Bony swelling of DIP or PIPs or 1st CMC joint (base of thumb) Proximal girdle joints Asymmetrical large joint oligoarticular disease Acute monoarticular disease Chronic monoarticular Axial, sacroiliac & girdle joint Axial joints Dactylitis (sausage digit) Disease RA, SLE & Psoriatic arthritis Psoriasis, OA OA Polymyalgia Rheumatica & RA Reactive arthritis, Psoriasis, AS Infection, psoriasis, gout, pseudogout Psoriasis, RA, AS, OA & chronic infection (e.g. tuberculosis) AS Lumbar & cervical spondylosis/OA Psoriasis, Reactive arthritis, AS, infection

MCP = metacarpophalangeal; PIP = proximal interphalangeal; MTP = metatarsophalangeal; CMC= carpometacarpal joint; RA = rheumatoid arthritis; DIP = distal interphalangeal; SLE = systemic lupus erythematosis; OA = osteoarthritis; AS = ankylosing spondylitis. Table 2. SOME USEFUL QUESTIONS Is your pain or stiffness: Worse or better in the morning? If worse, how long does it take to improve or wear off? Worse or better at the end of the day? Made worse or better by anything? Eased or made worse by sitting? Disturbing your sleep? Interfering with walking? If so, how? EXAMPLES The following examples provide a guide to the features of pain and stiffness encountered in specific conditions. INFLAMMATORY DISEASE

Acute lesions. In acute lesions such as osteomyelitis. septic arthritis or gout the pain is severe and throbbing, increases at rest, disturbs sleep and prevents use of the limb or affected joint. When a joint is involved all movement is inhibited by protective spasm and any attempt at movement causes severe pain. Infection of bone near a joint may also give rise to protective spasm, but in contrast to septic arthritis, gentle examination should reveal a small range of joint movement. Chronic lesions. The local and systemic features are less severe than in acute lesions and often exhibit diurnal variation. For example rheumatoid arthritis often has an insidious onset, with pain and stiffness, which is worse in the morning and eases with gentle activity. In a severe case, the symptoms may return towards the end of the day or persist throughout the day and disturb sleep at night. Similarly in ankylosing spondylitis, back pain and stiffness may be quite severe on rising, last up to several hours, ease with physical activity and disturbs sleep. Inflammatory muscle disease. The dominant symptom of inflammatory muscle disease, such as polymyositis, is progressive weakness. This is predominantly of proximal girdle and truncal muscles, and the patient complains of difficulty getting up from a lying or sitting position, climbing stairs or brushing their hair. Distal and facial muscles are usually spared. DEGENERATlVE LESIONS Degenerative joint disease is often associated with a mild inflammatory reaction. Some immobility stiffness and early morning exacerbation therefore may be present but is usually short lived and much less marked than in inflammatory joint disease. Osteoarthritis. Patients will usually give a history of gradually increasing pain over months or years, with loss of movement of the joint. Hip and knee disease is especially common. Early morning and inactivity stiffness and pain usually settles after gentle use of the joint over about 15 minutes. Prolonged activity is often limited by pain and daily activities such as dressing the lower limb, walking and climbing steps will become progressively impaired. Rest pain and night pain usually indicates advanced disease. Prolapsed intervertebral disc. Acute back pain may occur without prior warning or there may be a several year history of minor back ache associated with physical activity. Usually the acute episode occurs when bending or lifting or on the day after such activities, but sometimes occurs for no discernible reason. The cervical or lumbar spine may be affected. Pain subsides with rest over a period of several weeks, and is often followed by further major or minor episodes. Disc degeneration leads to osteoarthritis of the spine. Spinal stenosis. Narrowing of the spinal canal or neural exit foramina are usually caused by degenerative changes in the intervertebral discs and facet joints and can result in back pain or radicular pain. The back pain is often diffuse, radiates to the buttocks and legs and may be accompanied by tingling and numbness. These symptoms, which the patient may find difficult to describe, increase with standing or walking, and are relieved by sitting or lying down. Leaning forward (e.g. holding a supermarket trolley) may help to ease pain and increase exercise tolerance.

Joint instability. Unstable joints become increasingly painful as the day progresses. As the supporting muscles tire, the related ligaments stretch and pain increases. TUMOURS With the exception of osteoid osteoma, benign bone tumours are painless unless they press on neighboring structures. Pain is a variable feature of malignant tumours of bone (primary or secondary) and when present is not related to activity, is not relieved by rest and may be worse at night. Pathological fractures may occur as a result of trivial trauma and cause sudden pain. PSYCHOGENIC SYMPTOMS Chronic polyarthralgia or myalgia, which is constant day and night, and does not conform to any clear pattern, should raise the suspicion that this may be a somatic presentation of an underlying psychological or psychiatric problem. Closer questioning may result in the presenting symptom evaporating only to he replaced by multiple new symptoms. Other clues include the lack of associated organic symptoms such as stiffness or joint swelling and the presence of features such as tiredness, lack of energy, change in mood and sleep patterns or appetite. Remember though that the pain and disability of chronic joint disease may also result in lowered mood, sleep disturbance and tiredness TRAUMATIC LESIONS Sprained ligaments. Immediately after a sprain, pain may be severe and constant. Subsequently, pain only occurs with movement which stretches the damaged structure and is relieved when the ligament is relaxed With chronic strains, for example of weight bearing ligaments in the back or foot, the patient is most comfortable in the morning. As the day progresses the supporting muscles tire and an aching pain develops which is relieved by rest. Traumatic arthritis. Following severe joint injury there may be immediate swelling due to haemarthrosis as a result of damage to bone or ligaments. Injury may also cause slower onset of swelling due to damage to avascular structures such as the menisci of the knee. However, trauma may also precipitate an underlying 'latent' disorder such as osteoarthritis, rheumatoid arthritis or gout and when symptoms of inflammation persist longer than expected, this possibility must be considered. 4 EXTRA-ARTICULAR OR SYSTEMIC FEATURES Extra articular features are often crucial to making a correct diagnosis of inflammatory joint disease and should be carefully sought. The pattern of joints involved suggests possible diagnoses thus prompting enquiry about particular extra articular features- for example in a patient with an acute lower limb oligoarthritis suggestive of reactive arthritis a careful bowel (& restaurant) history should be taken to identify recent enteric infection. A Sensitive enquiry into sexual contacts should also be made to identify possible exposure to venereal infection. Similarly night sweats and 'flu-like' symptoms in a patient with acute monoarthritis suggests sepsis. Examples of extra-articular features and their disease associations are shown in Table 3.

5 MEDICAL BACKGROUND, FAMILY & SOCIAL HISTORY A careful enquiry into past illnesses, family history, social history and medication often brings out important diagnostic clues. Drugs may precipitate rheumatic disease. For example gout may be precipitated by diuretics. Certain antibiotics may cause hypersensitivity vasculitis, and hydrallazine and procainamide are well known causes of drug induced SLE. Certain ethnic and racial groups are pre-disposed to particular conditions For example, SLE in Afro-Caribbean's and Asians, and gout in Polynesians with a Western lifestyle. Family history. This may be crucial to making a diagnosis. For example, psoriatic arthritis may be diagnosed in a patient who does not have psoriasis but presents with a chronic oligoarthritis with a strong family history of psoriasis. Other conditions in which a family history may be helpful include diseases linked with the HLA-B27 gene such as ankylosing spondylitis, iritis and reactive arthritis. Familial syndromes such as Marfan's and Ehlers Danlos syndrome also cause musculoskeletal symptoms and a family history of gout is occasionally helpful. Social history. A patient's social background or their daily activities may be the cause of their symptoms (Table 4), conversely the development of chronic rheumatic disease may have profound social and economic consequences, particularly for people in manual or unskilled jobs, An assessment Of activities of daily living - ability to dress, wash, use a lavatory, walk, climb steps, perform hard functions (turning taps, writing etc) and do daily chores such as shopping and housework, is of great importance. Simple self assessed questionnaires are available for this purpose leg Health Assessment Questionnaire). Table 3. COMMON EXTRA-ARTICULAR FEATURES IN RHEUMATIC DISEASES Disease Symmetrical polyarthritis RA Extra-articular features Raynaud's, subcutaneous nodules, episcleritis/scleritis, sicca syndrome, pleurisy, pulmonary fibrosis, neuropathies Raynaud's, sicca syndrome, pleurisy, alopecia, photosensitivity, purpuric rash, fever Psoriasis, nail changes urethritis, diarrhoea (preceding) fever, penile ulcers (circinate balanitis), psoriasiform rash, conjunctivitis, intis, mouth ulcers, enthesitis, achilles tendonitis, plantar fasciitis) iritis, enthesitis ulcerative arthritis, Crohn's disease, erythema nodosum, weight loss erythema nodosum & hilar adenopathy

SLE Psoriasis Asymmetrical oligoarthritis Reactive arthritis (including reiters syndrome)

Ankylosing spondylitis Colitic arthritis Sarcoidosis Monoarthritis

Gout Septic arthritis Psoriatic

tophi, obesity, hypertension, renal impairment fever, malaise, source of infection eg skin or throat psoriasis

Table 4. SOCIAL FACTORS RELATING TO RHEUMATIC DISORDERS Social Factor Employment Carpet layers and miners Exposure to vinyl chloride monomer Personal habits Smoking Excess alcohol, obesity Frequent sexual partners IV drug abuse Condition Pre-patellar bursitis Raynauds & acro-osteolysis Lung carcinoma & hypertrophic osteoarthropathy Gout Chlamydial infection & reactive arthritis, gonococcal arthritis Septic arthritis