History Taking Flashcards
Main symptoms of Rheumatic disease.
Pain
Swelling
Stiffness
Fatigue
Weakness
What should you ask about regarding pain?
What type of pain?
Why is it happening?
When does it happen?
How bad is it?
Where is the pain?
How do patients tell you that they have neuralgic pain?
Burning or pins and needles
Acute pain in rheutmatic disease.
Gout
PMR
Insidious pain in rheumatic disease.
RA
SLE
What to ask about when the pain comes about?
Acute or insidious onset?
Nocturnal pain? (indicates inflammatory or destructive process)
Pain aggravated by rest (inflammatory arthritis) or by activity (OA)?
Pain better with NSAIDs or steroids?
Pain worse on particular movements? (periarticular pathology)
Why is it important to ask the patient how bad the pain is?
To set a baseline against which to measure improvement with treatment.
Impacted daily living?
Support from family and friends?
Aids or adaptations made due to pain?
Where is pain from acromioclavicular joint usually felt?
In the joint itself.
Where is pain from the GHJ and rotator cuff usually felt?
In the upper arm
Where is pain from the hip usually felt?
Groin
Buttock
Thigh
Knee
Where can pain from AAA be felt?
As back pain
Explain pain due to tenosynovitis or tendinitis.
Usually triggered only by certain movements.
Where is tennis elbow pain felt?
Outside of the elbow joint and worse on resisted elbow extension.
Where is achilles tendinitis pain felt?
Above the heel and is worse on active plantar flexion.
Where is De Quervain’s tenosynovitis pain felt?
In the snuffbox area of the wrist and is worse when pinching or using thumb to operate a smart phone.
Common muscular pain in rheumatic disease.
Fibromyalgia
Inflammatory muscle disease
Pain in proximal joints.
PMR
Pain in distal joints only.
OA
Gout
Psoriatic Arthritis
Small joint pain only.
Early stages of RA
Large joints only?
OA
Large and small joint pain.
Late stages of RA
How many joints in monoarticular?
1 joint
What is it called when 2-4 joints are affected?
Oligoarticular or pauciarticular
What is it called when over 4 joints are affected?
Polyarticular
Symmetrical joint involvement.
RA
Asymmetrical joint involvment.
PsA or gout
Causes of acute monoarthritis.
Septic arthritis unless otherwise proven.
Infections - S. aureus and streptococcal most common.
Crystal induced like gout or pseudogout
Trauma -> haemoarthrosis
Causes of chronic monoarthritis.
Infections - TB
Inflammatory - PsA, reactive arthritis, foreign body
Non-inflammatory - OA, meniscal tear, osteonecrosis, neuropathic like Charcot’s
Tumour
Causes of acute polyarthritis
Inflammatory - RA, PsA, reactive arthritis
Autoimmune - SLE and vasculitis e.g.
Viral infection - HIV, Chikungunya, parvovirus
Crystal arthritis - Uncontrolled gout
Causes of chronic polyarthritis.
Inflammatory - RA, PsA, reactive arthritis
Autoimmune - SLE and vasculitis e.g.
Crystal - uncontrolled gout
Causes of arthritis in DIPJs.
PsA accompanied with nail dystrophy on affected digit.
OA with heberden’s nodes.
Explain history of stiffness.
How long it takes the patient to loosen up and get going in the mornings or after resting.
Duration of early morning stiffness?
Stiffness generalised or in a certain place?
Localised stiffness?
Stiffness lasting longer than 30 minutes in the morning.
RA
PsA
Generalised stiffness.
Suggestive of inflammatory disease.
Spinal stiffness in the morning.
Suggestive of ankylosing spondylitis.
Stiffness localised to a joint or brief inactivity gelling.
OA
What to ask about joint swelling?
How rapid did it come about? (gout is rapid)
Preceding injury to swelling and pain?
How long does it last? (if less than 24h then likely not significant)
Swelling parallel to the join line?
Bony swelling?
Soft and tender swelling?
Swelling extrude chalky material?
Swelling extrude hard yellowish lumps?
Bony swelling?
OA
Soft and tender swelling?
Clinical synovitis indicating inflammatory disease
Swelling extrude chalky material?
Tophi in gout
Swelling extrude hard yellowish lumps?
Calcinosis in systemic sclerosis
Why is it important to ask about fatigue?
FIbromyalgia feel tired from moment they wake up and is called “unrefreshed sleep”.
Patients with inflammatory arthritis usually become fatigued several hours into their day’s activities.
It is important to distinguish fatigue from depression and muscle weakness.
What drugs can can cause cutaneous hypersensitivity vasculitis?
Penicillin
What drugs can cause lupus skin rashes?
E.g. minocycline and sulfasalazine
What drugs can worsen Raynaud’s symptoms?
Beta blockers
What drugs can reduce uric acid excretion and lead to gout?
Diuretics
What is seronegative spondyloarthropathy associated with?
Anterior uveitis
Psoriasis
IBD
Why is a sexual history important?
Sexually acquired infection or diarrhoea may indicate reactive arthritis or gonococcal arthritis.
Why is family history important?
Because its presence often influence a patient’s expectations through their knowledge of their family member’s experiences of disease and its treatment.
Why is social history important in rheumatic disease?
Smoking can cause more severe RA and also Raynaud’s
Alcohol -> gout
Methotrexate + alcohol -> cirrhosis
Back pain common in manual workers.
Knee OA in coal miners, hip OA in farmers may be eligible for industrial compensation.
Constitutional symptoms in rheumatic disease.
Fever
Night sweats
Weight loss
Loss of appetite
Suggestive of inflammatory, infection or neoplasia.
