11/13/24, 8\:12 PM Guide | Rheumatological history

Rheumatological history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Open vs closed questions
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History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Use the PRISMS acronym to explore key rheumatological symptoms\:
Pain
Rashes, skin lesions and nail changes
Immune
Sti
Malignancy
Swelling and sweats

Pain

If a patient has pain, explore it further using the SOCRATES acronym\:
Site
Ask about the location of the pain\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
This can be helpful to di
Onset
Clarify how and when the pain developed\:
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h e n d i d t h e p a i n
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g t h e p a i n ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. dull ache, burning, sharp)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Radiation
Ask if the pain moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Associations
Ask if there are other symptoms which are associated with the pain\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?"
Joint sti
Time course
Clarify how the pain has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
" I s t h e p a i n w o r s e a t a p a r t i c u l a r t i m e o f d a y ?"
In
in the day after activities.
Exacerbating or relieving factors
Ask if anything makes the pain worse or better\:
https\://app.geekymedics.com/osce-guides/history/rheumatological-history/ 2/711/13/24, 8\:12 PM Guide | Rheumatological history
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?"
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?"
Severity
Assess the severity of the pain by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"

Rashes, skin lesions and nail changes

Ask the patient if they have developed any new rashes or skin lesions\:
" H a v e y o u n o t i c e d a n y r a s h e s o r o t h e r c h a n ge s t o y o u r s k i n r e c e n t l y ?"
Ask the patient if they have noticed any changes to their nails\:
" H a v e y o u n o t i c e d a n y c h a n g e s t o y o u r n a i l s r e c e n t l y ?"
The presence of salmon pink plaques on extensor surfaces and nail changes such as onycholysis would suggest a diagnosis of
psoriasis, which is closely associated with psoriatic arthritis.
See our dermatological history taking guide for more details.

Immune

Systemic sclerosis
The key clinical features of systemic sclerosis can be remembered using the CReST acronym\:
Calcinosis\: the formation of calcium deposits in soft tissue.
Raynaud’s phenomenon\: stress and cold temperature trigger arterial spasm causing reduced blood
toes resulting in discolouration.
Oesophageal dysmotility\: dysphagia a
Sclerodactyly\: the progressive thickening of the skin distal to the metacarpophalangeal joints.
Telangiectasia\: dilated capillaries which appear on the palms of the hands as well as the face and mucous membranes.
Useful questions to identify key features of systemic sclerosis\:
" H a v e y o u n o t i c e d a n y r e c e n t s k i n c h a n g e s , s u c h a s t i g h t e n i n g , t h i c k e n i n g o r t h e f o r m a t i o n o f l u m p s i n t h e s k i n ?"
" D o y o u n o t i c e t h a t y o u r
" D o y o u e v e r
" D o e s i t e v e r f e e l l i k e f o o d g e t s s t u c k i n y o u r g u l l e t ?"
" H a v e y o u n o t i c e d a n y n e w b l o o d v e s s e l s b e c o m i n g v i s i b l e o n t h e s k i n o r y o u r p a l m s o r f a c e ?"
Systemic lupus erythematosus (SLE)
Key clinical features of systemic lupus erythematosus (SLE) include\:
Constitutional symptoms\: fatigue, fever and weight loss.
Musculoskeletal symptoms\: arthralgia and myalgia.
Dermatological symptoms\: malar rash, photosensitivity and discoid lupus.
Renal symptoms\: haematuria and oedema (acute nephritic disease).
Neuropsychiatric symptoms\: seizures and psychosis.
Respiratory symptoms\: shortness of breath, cough and chest pain (e.g. pneumonitis and interstitial lung disease).
Gastrointestinal symptoms\: nausea, dyspepsia and abdominal pain.
Cardiac symptoms\: chest pain and shortness of breath (e.g. pericarditis, myocarditis).
Haematological symptoms\: fatigue, shortness of breath, fevers and bruising (e.g. leukopenia, anaemia, thrombocytopenia).
Useful questions to identify key features of SLE\:
" H a v e y o u r e c e n t l y e x p e r i e n c e d a n y f e v e r s o r w e i g h t l o s s ?"
" D o y o u h a v e a n y a c h i n g i n a n y o f y o u r j o i n t s o r m u s c l e s ?"
" H a v e y o u n o t i c e d a n y r a s h e s o r s k i n c h a n ge s r e c e n t l y ?"
" H a v e y o u n o t i c e d a n y b l o o d o r o t h e r c h a n g e s i n y o u r u r i n e ?"
" H a v e y o u n o t i c e d a n y c h a n g e s i n y o u r t h o u g h t s o r m o o d ?"
" H a v e y o u f e l t m o r e s h o r t o f b r e a t h r e c e n t l y ?"
https\://app.geekymedics.com/osce-guides/history/rheumatological-history/ 3/711/13/24, 8\:12 PM Guide | Rheumatological history
" H a v e y o u e x p e r i e n c e d a n y c h e s t p a i n r e c e n t l y ?"
" H a v e y o u f e l t m o r e f a t i g u e d o r f o u n d t h a t y o u a r e b r u i s i n g m o r e e a s i l y r e c e n t l y ?"
Sjogren’s syndrome
Key clinical features of Sjogren’s syndrome include\:
Dry eyes
Dry mouth
Chronic cough
Useful questions to identify key features of Sjogren's syndrome\:
" H a v e y o u e x p e r i e n c e d d r y o r s o r e e y e s r e c e n t l y ?"
" H a v e y o u n o t i c e d t h a t y o u r m o u t h i s d r i e r t h a n u s u a l r e c e n t l y , " H a v e y o u h a d a c o u g h r e c e n t l y ?"
e v e n w h e n w e l l h y d r a t e d ?"

Sti

Joint sti
Rheumatoid arthritis
Ankylosing spondylitis
SLE
Reactive arthritis
Ask the patient when the joint sti
buttoning up a shirt, brushing hair).

Malignancy

Rheumatological disease can present with similar features to malignancy such as fatigue, malaise and weight loss, therefore
it's important to consider malignancy in your di
malignancy due to paraneoplastic phenomena.
Useful questions to identify features of malignancy\:
" H a v e y o u n o t i c e d a n y u n i n t e n t i o n a l w e i g h t l o s s r e c e n t l y ?"
" H a v e y o u e x p e r i e n c e d a n y n i g h t s w e a t s r e c e n t l y ?"
" H a v e y o u n o t i c e d a n y c h a n g e i n y o u r a p p e t i t e ?"
" H a v e y o u f e l t m o r e t i r e d r e c e n t l y ?"

Swelling and sweats

Joint swelling and sweats are both associated with rheumatological disease (e.g. rheumatoid arthritis).
Useful questions to identify and explore joint swelling and night sweats include\:
" H a v e y o u n o t i c e d a n y s w e l l i n g o f y o u r j o i n t s r e c e n t l y ?"
" W h i c h j o i n t s h a v e b e c o m e s w o l l e n a n d w h e n d i d t h a t s t a r t ?"
" I s t h e j o i n t s w e l l i n g p a i n f u l ?"
" D o e s t h e j o i n t s w e l l i n g i m p a c t y o u r d a i l y a c t i v i t i e s ?"
" H a v e y o u n o t i c e d a n y a s s o c i a t e d r e d n e s s o f s k i n o v e r l y i n g t h e s w o l l e n j o i n t s ?"
The presence of joint swelling and fever requires urgent review and investigation to rule out septic arthritis.
Extra-articular manifestations of rheumatological disease
Rheumatological disease can have a number of extra-articular manifestations such as\:
Uveitis (associated with ankylosing spondylitis)
Dry eyes (associated with Sjogren’s syndrome)
Interstitial lung disease (associated with rheumatoid arthritis and SLE)
Urethritis (associated with reactive arthritis)
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Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers (e.g. discitis, septic arthritis), weight change (e.g. malignancy)
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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), butter

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. joint replacements)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
Medical conditions relevant to rheumatological disease include\:
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)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications prescribed to patients with rheumatological disease include\:
Analgesics (e.g. paracetamol, NSAIDs, opiates)
Corticosteroids (e.g. prednisolone)
Anti-TNF agents (e.g. in
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Biologics (e.g. rituximab)

Family history

Ask the patient if there is any family history of rheumatological disease in
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e r h e u m a t o l o gi c a l d i s e a s e s s u c h a s r h e u m a t o i d a r t h r i t i s ?"

Social history

Explore the patient's social history to both understand their social context.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for septic arthritis.
Occupation
Ask about the patient’s current occupation\:
Assess the impact of the patient's symptoms on their ability to work.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Source\: geekymedics.com
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