History-Taking Skills in Rheumatology

Abstract

History taking in rheumatology is the most important skill needed for proper handling of a patient with a rheumatological complaint. Obtaining a good history will help you to reach almost 90% of your diagnosis. However, history taking is mostly depending on experience and practice rather than theoretical recall. Here in this section, we provide you with the most important points in history taking you should use while dealing with rheumatological patients. There is an approach to history taking in rheumatology started as with the classical approach in history taking like any other disease. There is much focus on rheumatological aspects related to the onset of joints pains, patterns, symmetry of joints involvement, number of joints involved, and ultimately rheumatology review of systems. We summarized the classic symptomatic correlations with certain rheumatological diseases. We present briefly a suggested approach to your presentation of the entire case.

1 Introduction

History taking in rheumatology is the most important skill needed for proper handling of a patient with a rheumatological complaint. Obtaining a good history will help you to reach almost 90% of your diagnosis. However, history taking is mostly depending on experience and practice rather than theoretical recall. Here in this section, we provide you with the most important points in history taking you should use while dealing with rheumatological patients. There is an approach to history taking in rheumatology started as with the classical approach in history taking like any other disease. There is much focus on rheumatological aspects related to the onset of joints pains, patterns, symmetry of joints involvement, number of joints involved, and ultimately rheumatology review of systems. We summarized the classic symptomatic correlations with certain rheumatological diseases. We present briefly a suggested approach to your presentation of the entire case.

1.1 Objectives

• 1. To compose a comprehensive and organize history for patients with rheumatological problems.

• 2. To recall the most important points in eliciting history for certain rheumatological diseases.

• 3. To construct a differential diagnosis in rheumatology.

• 4. To develop an approach for monitoring patients with arthritis.

2 Approach to History Taking in Rheumatology

This approach is based on the assumption that majority of patients with rheumatological diseases present at the beginning with joint(s) pain. Rheumatological diseases are systemic diseases affecting almost all body systems with no system that is preserved. You may have patients with neurological complaints (like hemiplegia because of ischemic stroke) end up with the diagnosis of a rheumatological disease like systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS). Here the initial presentation was not joints pain, but yet the final diagnosis was rheumatological. This concept emphasizes the point that good foundations in general internal medicine is essential to the rheumatology practice.

The approach to joints pain for any new patient should establish two basic issues: the personal data and then full analysis of the presenting illness. The latter includes the followings (Fig. 1.1).

• 1. Onset.

• 2. Duration.

• 3. Patterns of joints affected.

• 4. Symmetry.

• 5. Number of joints affected.

• 6. Associated symptoms.

• 7. Constitutional symptoms.

• 8. Functional impairment.

• 9. Relieving and aggravating factors.

• 10. Rheumatology review of systems.

Fig. 1.1

Approach to history taking in rheumatology

This should be followed by the classical components in any history taking in internal medicine (past medical and surgical history, family history, drug and allergy, and social history).

Here is a brief description about each one of the above.

• 1. Onset: The patient should determine whether joint(s) pain have started suddenly or gradually. This is essential as the top differential diagnoses that should be ruled out for sudden onset of joints pains are septic arthritis and crystal-induced arthritis (after excluding trauma as a possible cause for joints pains) (Fig. 1.2). Gradual onset joint pains have long list of differential diagnoses including the classic rheumatological diseases like rheumatoid arthritis (RA) and SLE (see Fig. 1.2).

• 2. Duration: It is essential to determine whether the joint pains have been present for less or more than 6 weeks. Classically, arthritis caused by acute viral illnesses like parvovirus B19 infection can cause RA-like arthritis in distribution but with less than 6 weeks duration. Duration more than 6 weeks is an essential criteria to diagnose RA based on 2010 classification criteria of RA (see Chap. 25).

• 3. Patterns of joints affected: Each rheumatological disease has a pattern of presentation that should be recognized from this early stage. Each pattern has a differential diagnosis (Figs. 1.3 and 1.4).

  Predominant small joints involvement (like in pattern A) particularly the wrists, metacarpophalangeal (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) joints is a classical presentation for RA. Other disorders like SLE, psoriatic arthritis (PsA), polyarticular gout, and reactive arthritis (ReA) can present in a similar way. The commonest joints involved in RA, for example, are wrists and MCP (2nd and 3rd). It has to be noted that distal interphalangeal (DIP) joints involvement is rarely ever involved in RA. These joints (DIP) are predominantly involved in patients with PsA and inflammatory osteoarthritis (OA) of the hands. Classical presentation of inflammatory OA of the hands (pattern E) involves DIPs, PIPs, and first carpometacarpal joint just at the base of the anatomical snuff. It has to be noted as a physical examination caveat that the swellings of the joints in inflammatory OA of the hands are bony! It represents the degenerative changes happening in the cartilage with osteophyte formation. Predominant large joints involvement in the lower limbs (pattern B) is a classical presentation for ReA. A group of disorders called spondyloarthritis (SpA) (include ankylosing spondylitis (AS), PsA, ReA, and arthritis associated with inflammatory bowel diseases (IBD-related arthritis) and undifferentiated spondyloarthritis) (see Chap. 23 for detailed classification criteria) has particular predilection of large joints of the lower limb. Sacroiliac joints can be involved in an asymmetrical fashion (pattern B) in ReA or can be symmetrically involved (pattern C) with inflammation of all the insertions of tendons and ligaments to the bones of the back (this is called enthesitis, and such inflammatory process in the back is called spondylitis). Therefore, (pattern C) is a classical presentation for AS. Spondylitis per say can be a manifestation of any disease of the SpA group of disorders. Large joints like proximal girdle joints (shoulders and hips) can be involved predominantly in diseases like polymyalgia rheumatica and RA. There is one feature that is quite classical for PsA and crystal induced arthritis. It is the inflammation of all articular and periarticular structures in one digit (dactylitis). This is not a feature for RA. It has to be noted then, involvement of small joints like in (pattern D) with predominance of DIPs, dactylitis, and asymmetrical sacroiliac joint involvement is classical for PsA.

  For acute sudden monoarticular joint involvement, a septic process and/or crystal-induced arthritis should be ruled out. The knee joint is the commonest joint involved in septic arthritis, while the first metatarsophalangeal joints are the commonest joint involved in gout. For chronic monoarticular joint involvement, a chronic infectious process should be ruled out like tuberculosis or brucellosis. However, systemic rheumatic diseases like RA can rarely present with a monoarticular joint only.

• 4. Symmetry: This might have been covered partly in the above section. It has been included here to help the evaluator remember it all the time and consider it while composing the differential diagnosis. There are diseases like PsA that can present in several different ways including symmetrical arthritis like RA and asymmetrical arthritis involving only few joints like the DIPs. Symmetrical arthritis does not include in the differential diagnosis only known rheumatological diseases like RA and SLE. There are less common diseases like sarcoidosis, and paraneoplastic syndromes can present with arthritis (Fig. 1.5).

• 5. Number of joints involvement (How many joints affected?): Again, this feature has been covered partially above (Figs. 1.6 and 1.7). The emphasis is on a monoarticular single joint involvement when it should be considered a medical emergency. If a septic monoarticular joint was not diagnosed and treated properly, it will lead unfortunately to irreversible damage and lifelong disability if not death from disseminated infection [1]. It is hard clinically to separate between oligoarticular and polyarticular in the initial workup as will be shown in Chap. 3. A list of possible differential diagnosis is provided for you just to give a knowledge background base to proceed further in the history from patients with joints pains.

• 6. Associated symptoms: Obtaining history of redness, swelling, and morning stiffness is essential in any patient with joints pains. Any severely inflamed joint will cause obvious swelling observed by the patient. Keep in mind that sometimes, swellings of the small joints can be detected by physical examination only as the patient did not notice any because of its small size. Redness is one of the cardinal signs of inflammation. Active RA does not cause redness usually unless there is a superimposed infection in that joint that it is red. Therefore red and swollen joints are caused classically by septic arthritis and/or crystal induced arthritis (Fig. 1.8).

• 7. Constitutional symptoms: Obtaining these symptoms in any history obtained from patients for whatever symptoms presented is essential. Fever and arthritis are common clinical association. Again, septic arthritis whether in a monoarticular or polyarticular presentation should be ruled out. There is a full outline for this combination: fever and arthritis in Chap. 11. Apart from fever, the following symptoms should be obtained: weight loss, loss of appetite, night sweat, and fatigue. It has to be noted that patients with inflammatory arthritis often feel a general malaise. Fibromyalgia patients often report feeling ill (if I go shopping I am wiped out for the next 3 days). On the other hand, OA patients may be a bit tired but not really unwell.

• 8. Functional impairment: any inflamed joint will affect the functionality of the patient. The followings should be obtained:

  • How has the arthritis affected your daily ability to self-care?

  • How has the arthritis affected your ability to sleep well and to do things at home, work, and leisure?

• 9. Relieving and aggravating factors: Here the focus should be mainly on the effect of activity on the symptoms. Activity tends to aggravate joint pains caused by a degenerative process of the interarticular cartilage, i.e., OA, to be a reliving factor for inflammatory back pain as going to be shown in Chap. 6 about low-back pain. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) tends to relive symptoms in a remarkable way in patients with inflammatory arthritis in comparison with patients with degenerative arthritis (OA) (Fig. 1.9).

• 10. Rheumatology review of systems: After your full analysis of the joints pain(s), now it is time to think which rheumatological diseases might be the top in your differential diagnosis. All rheumatological diseases are systemic diseases with significant involvements of other body parts (Fig. 1.10). Some patients may not correlate the relationship between numbness, tingling sensations, and joints pain(s) (some patients may present with arthritis and mononeuritis multiplex like in vasculitis or RA). Others may not remember to mention history of skin disease like psoriasis. Obtaining obstetric history is extremely important for any childbearing female patient as there are many complications in pregnancy related to SLE and/or APS (see Chap. 17). For all of these reasons, it is your rule to review all possible symptoms that might be present and help you in composing your differential diagnosis. All possible symptoms are complied in an approach from head to toe just to help you mastering this part of the history.

  • Past medical history:

    • History of any rheumatic disease (RA, SLE, gout, psoriasis, etc.).

    • History of recent infections (think of ReA!).

    • History of chronic diseases. There are some rheumatological associations with diabetes mellitus (see Chap. 21).

  • Family history:

    • Ask if similar condition happened in the family.

    • Any family history of RA, SLE, psoriasis, etc.

  • Medications and allergy:

    • Detailed medication history.

    • Any allergy from food and/or drugs?

  • Past surgical history:

    • History of any previous operations.

    • History of blood transfusion.

  • Social history:

    • Marital status and occupation (tendinitis in typist!). How many children? Where do they live?

    • History of contact with TB or jaundiced patients: essential prior to start of disease modifying anti-rheumatic drugs (DMARDs) and biological therapy.

Fig. 1.2

Identifying the site of the pain

Fig. 1.3

Patterns of joints affected

Fig. 1.4

Each rheumatological disease has a pattern. (a) Rheumatoid arthritis. (b) Reactive arthritis. (c) Ankylosing spondylitis. (d) Psoriatic arthritis. (e) Inflammatory osteoarthritis of the hand

Fig. 1.5

Symmetry of the joints

Fig. 1.6

Number of joints involvement (How many joints affected)

Fig. 1.7

Alarming presentation of arthritis in RA and SLE

Fig. 1.8

Associated symptoms

Fig. 1.9

Relieving and aggravating factors

Fig. 1.10

Rheumatological review of systems

3 Historical Correlation

Some patients may present initially with symptoms suspected for a certain disease. Then you need to check other symptoms related to this disease that might help you to make your diagnosis from historical grounds only! This is different than rheumatology review of systems mentioned above. Actually, as your skills in obtaining history from patients with joints pain grow, you will notice yourself combing this step with rheumatology review. For example, you are evaluating a young female patient with joint pains. You have a suspicion for SLE as you are proceeding in your history; then during your history taking, you should cover all common presentation of SLE! The common symptoms for some diseases have been complied for you (Figure 1.11 a, b, c historic correlation). Some of the questions may not be related to symptomatology! It might just address risk factors. If you are assessing a patient with pain in the first MTP and/or with a red swollen knee joint and you are suspecting gout as a possible diagnosis, then you need to check for risk factors for gout: prior history of uric acid renal stones, alcohol intake and use of diuretics, etc.

Fig. 1.11

Historical correlation

4 Physical Examination

This is just to remind you about the particular approach of physical exam techniques that should be performed and then presented (Fig. 1.12). A comprehensive approach to joints examination is presented in Chap. 2.

Fig. 1.12

Physical examination

5 How to Present your Case

You are ready now to present your case! You have built an organized approach to history taking from patients with joints pain(s). You have performed a comprehensive physical examination focusing on evaluation of these joints and whether there is true articular process like arthritis or periarticular process like tendinitis (see Chap. 22). Simply you need to present your history and physical examination in the same manner mentioned above with focusing on positive findings and important negatives. After your history and physical examination presentation, it is required from you to sum up all your information together. It is better to start with your impression (summary of the case) and then your problem list and differential diagnosis.

5.1 Impression

This (age) who is (known to have (chronic diseases)) presents with:

• History (usually presenting complain).

• Physical exam(mention obvious findings).

• Lab results (mention the important results related to the case) (if it is known to you).

5.2 Problem List

In this section you have to make a list with all your patient’s problems or complains starting with the most serious and important one. This should guide you to reach the diagnosis easily.

This is a suggested approach on how to write a problem list:

Regarding the first problem:

• 1. Write your differential diagnosis for this issue and mention which diagnosis is more relevant with your case and why.

• 2. Write your management plan, if further investigations and/or referral are needed.

See the diagram below for more details (Fig. 1.13).

Fig. 1.13

Problem lists

6 Follow-Up Patient

Established patients with rheumatological diseases have frequent visits to outpatient clinics. They come for routine visits for assessing the progress of their disease and review the management plan of their chronic disease. Here are suggested tips for you to help you deal with these patients.

You should ask about:

• 1. Pain (how he/she is doing since last visit).

• 2. Which joints are particularly affecting you today?

• 3. Associated symptoms (morning stiffens (mins), swelling).

• 4. How well controlled do you feel the arthritis is?

• 5. What drugs are you taking? Your adherence? Do you get any benefit?

• 6. Any functional impairment?

  You should not forget to:

• 7. Do not forget to examine his/her all joints.

• 8. Do not forget to review all his/her medications.

• 9. Do not forget to review his/her previous investigations (Fig. 1.14).

Fig. 1.14

Outcome measures of the disease activity

7 The 2011 ACR/EULAR Definitions of Remission in Rheumatoid Arthritis Clinical Trials

7.1 Boolean-Based Definition [2]

At any time point, patient must satisfy all of the following:

• Tender joint count ≤1⁺

• Swollen joint count ≤1⁺

• C-reactive protein ≤1 mg/dl

• Patient global assessment ≤1 (on a 0-10 scale)⁺.

7.2 Index-Based Definition

Simplified Disease Activity Index score of ≤3 [3].

Definitions for some of the outcome measures in rheumatology are compiled in Fig. 1.15. Further reading is required from you to know more about the implications of its use in the management of patients with RA (Fig. 1.15 outcome measures of disease activity in RA and their interpretations).

Fig. 1.15

Outcome measures of disease activity in RA and their interpretation