History Taking

Question 1

Things to summarise in the history

Answer 1

• Timing - acute, subacute, chronic
• Pattern of symptoms - monoarthropathy, poly, axial involvement? Symmetrical or Asymmetrical?
• History of injury

Question 2

First questions to ask in MSK history

Answer 2

• Timing - acute, subacute, chronic
• Pattern of symptoms - monoarthropathy, poly, axial involvement? Symmetrical or Asymmetrical?
• History of injury
• Associated symptoms - fever, rash, weight loss, bowel disturbances.

Question 3

Most common MSK symptoms

Answer 3

• Joint pain
• Joint swelling
• Joint stiffness
• Muscle pain
• Weakness and loss of function
• Locking and triggering:incomplete range of movement (i.e. broken fragments of cartilage)
• Deformity

Question 4

Extra-articular manifestations

Answer 4

• Head & neck: any headaches? Any scalp tenderness?
• Eyes: any ocular pain? Any red eyes? Any visual changes?
• Chest: any breathing difficulty?
• Heart: any chest pain? Any palpitations?
• Gastrointestinal: any change in bowel habit? Any bleeding? Any swallowing problems?
• Genitourinary: any dysuria? Any haematuria? Any abnormal vaginal bleeding?
• Skin: any skin rashes? Any hair loss?

Question 5

Relevant PMH

Answer 5

When discussing previous MSK problems always establish:

• Age of diagnosis(e.g. lupus at 23 years old)
• Treatment for condition(e.g. hydroxychloroquine)
• Any complications(e.g. alopecia)
• Last follow-up & recommendations(e.g. annual review by rheumatology)
• Pre-existing rheumatological disease
• Other autoimmune conditions
• Previous gastrointestinal bleeding (NSAIDs contraindicated)
• Recent infections including sexually transmitted infections (if considering septic arthritis or reactive arthritis)

Question 6

Relevant Dhx

Answer 6

• Prescribed medications
• Over-the-counter medications
• Herbal remedies
• Current steroid or immunosuppressive regimen(e.g. prednisolone 15 mg once daily)
• Number of steroids courses(e.g. continuous steroids over last year)
• Previous treatments(e.g. azathioprine and methotrexate)
• Side-effects(e.g. Cataracts in both eyes)
• Bone and GI protection(e.g. usually on omeprazole 20 mg once daily and AdCal D3 two tablets once daily)

Question 7

Medications commonly prescribed with rheumatological disease

Answer 7

• Analgesics (e.g. paracetamol, NSAIDs, opiates)
• Corticosteroids (e.g. prednisolone)
• Anti-TNF agents (e.g. infliximab)
• Biologics (e.g. rituximab)

Question 8

Key SHx

Answer 8

A full social history is required, but ensure you take time to focus on activities of daily living (ADLs).

Really talk about impact on their lives!

Question 9

Example systemic review

Answer 9

• Systemic: fevers (e.g. discitis, septic arthritis), weight change (e.g. malignancy)
• Cardiovascular: chest pain (e.g. pericarditis, myocarditis, costochondritis)
• Respiratory: dyspnoea, cough (e.g. interstitial lung disease, sarcoidosis), pleuritic chest pain (e.g. pleuritis)
• Gastrointestinal: nausea, dyspepsia, abdominal pain (SLE)
• Genitourinary: dysuria (urethritis)
• Neurological: seizures (SLE)
• Musculoskeletal: joint pain, reduced range of joint movement (e.g. rheumatoid arthritis, psoriatic arthritis)
• Dermatological: rashes (e.g. psoriasis), butterfly rash (e.g. SLE)

Question 10

Rheumatoid Arthritis History

Answer 10

Pain
Rashes / nail changes
Immune
Stiffness
Malignancy
Swelling and Sweats

Question 11

Systemic Sclerosis History

Answer 11

Calcinosis
Raynauds
Oesophageal Dysmotility
Sclerodactyly
Telangiectasia

Question 12

What to ask about stiffness

Answer 12

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).