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Rheumatology History Taking and Differential Diagnoses

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Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Onset:
    • Did it come on suddenly or gradually?
    • What were they doing when it came on?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Joint problems 

A general structure that may help includes:

  • Pain – Use SOCRATES
  • Pattern
  • Function and appearance
  • Red flags
  • Extra-articular features

Pain – use SOCRATES:

  • Site:
    • Where is the pain?
  • Onset:
    • Did it come on gradually or suddenly?
    • Generally, >6 weeks is considered chronic
  • Character:
    • What is the pain like (e.g. dull, stabbing, burning, stinging)?
  • Radiation:
    • Does the pain spread anywhere?
  • Associated symptoms:
    • Ask about extra-articular features
    • Is there any muscle pain?
    • Stiffness is a key feature to ask about:
    • >30 minutes to an hour suggests an inflammatory cause
  • Timeline:
    • Is it continuous or intermittent?
    • Has it been getting better, worse, or stayed the same?
  • Exacerbating/relieving factors:
    • Does anything make it better or worse?
    • Does it improve with movement? – suggests inflammatory cause
  • Scale:
    • On a scale of 0-10, with 0 being no pain and 10 being the worst, how would you rate the pain?

Pattern – what joints are affected:

  • Is it just one joint? (monoarthropathy)
  • Is it multiple joints? (polyarthropathy)
  • Are the joints affected symmetrically?

Function and appearance – is there any weakness, loss of function, or changes in appearance?:

  • Is there any weakness?
    • Is it because of the pain?
  • Are they still able to use the joint?
    • E.g. can they weight-bear? – if they cannot use the joint, this is a red flag
  • Is there any joint locking?
  • Is there any deformity?
  • Have there been any problems with movement or sensation?
  • Is the joint red, hot, or swollen?

Red flags

Red flags for septic arthritis:

If it came on acutely (within 2 weeks)

  • Any fever?
  • Any history of trauma or injury?
  • Is the joint swollen, red, and/or hot to the touch?
  • Are they unable to move the joint or put weight on it?

Other general red flags:

  • Is the pain constant?
  • Does the pain continue during the night?
  • Is there any unexplained weight loss?
  • Is there any fever?
  • Do they get night sweats?
  • Is there any unexplained bruising?

Extra-articular features

  • A head-to-toe approach helps:
  • Skin:
    • Skin rashes?
    • Photosensitivity?
    • Does sunlight exacerbate symptoms? – suggests SLE
    • Hair loss?
    • Skin tightness?
    • Nail changes?
    • Swollen fingers (dactylitis)?
  • Head and neck:
    • Headaches?
    • Scalp tenderness?
    • Jaw pain?
    • Mouth dryness?
    • Lumps around the neck?
  • Eyes:
    • Eye pain?
    • Visual changes?
    • Red eyes?
    • Dry eyes?
  • Face:
    • Skin rashes? – e.g. the ‘butterfly’ rash in systemic lupus erythematosus (SLE)
    • Mouth ulcers?
    • Skin tightening?
  • Chest:
  • Gastrointestinal:
  • Genitourinary:

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
    • Full blood count (FBC):
      • May show derangements which can be associated with rheumatological diseases
    • Urea and electrolytes (U&Es):
      • Some rheumatological diseases can have renal manifestations (e.g. SLE) leading to derangements
    • Urinalysis:
      • To look for derangements
    • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR):
      • Non-specific markers of inflammation
    • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR):
      • Non-specific markers of inflammation
    • Coagulation screen:
    • Creatine kinase:
    • Rheumatoid arthritis autoantibodies:
      • Rheumatoid factor – high sensitivity, good rule-out test
      • Anti-CCP antibodies – high specificity, good rule in test
    • Systemic connective tissue disease (e.g. systemic lupus erythematosus, SLE) autoantibodies:
      • ANA – high sensitivity
      • SS-A and SS-B – may be seen in SLE and Sjögren’s syndrome
      • More antibodies with higher specificity may need testing depending on clinical features, e.g. anti-dsDNA for SLE
    • Vasculitides autoantibodies:
      • c-ANCA and p-ANCA
    • Bone profile:
      • Calcium
      • Phosphate
      • Albumin
      • Alkaline phosphatase (ALP)
  • Orifice tests:
    • Urinalysis:
      • To look for derangements
  • X-rays:
    • X-ray of the affected joint
      • May show abnormal features (e.g. loss of joint space in osteoarthritis and rheumatoid arthritis)
  • Special tests:
    • Joint aspiration and synovial fluid analysis:
    • Helpful in gout/pseudogout, septic arthritis, or patients with monoarthritis

Differential Diagnoses: Joint Disorders

Osteoarthritis

  • Non-inflammatory pain and stiffness
    • Pain and stiffness worse on exertion
    • Pain worse at the end of the day
  • Usually >45 years old
  • Unilateral symptoms
  • Heberden’s/Bouchard’s nodes
  • Joints affected: hip, knee, CMCs, DIPs, PIPs

Rheumatoid arthritis

  • Inflammatory pain and stiffness:
    • Pain and stiffness improve on exertion
    • Morning stiffness >30 minutes – 1 hour
  • Joint deformities may be seen:
    • Swan neck deformity
    • Boutonnière’s deformity
  • Bilateral distal polyarthropathy
  • Features of systemic upset may be seen
  • Joints affected include MCPs and PIPs, but any can be affected
  • RF may be positive, anti-CCP may be positive

Psoriatic arthritis

  • Presents similarly to RA
  • Asymmetrical oligoarthritis (<5 joints)
  • Dactylitis may be present
  • Psoriatic skin rashes may be seen
  • Nail changes (e.g. pitting and onycholysis) may be seen
  • Autoantibodies negative

Reactive arthritis

  • Usually 1-6 weeks after an STI or GI infection
  • Usually lower limb joints affected
  • “Can’t see, pee, or climb a tree”:

Septic arthritis

  • Acute (<2 weeks) swollen and tender monoarticular joint
    • Always regarded as septic arthritis until proven otherwise, even if there is no fever and blood tests are normal
  • Restricted joint movement/reluctance to weight bear
  • Fever
  • History of diabetes, joint surgery, injury, intravenous drug use, or immunodeficiency may be present
  • Most commonly affects the knee in adults
  • Synovial fluid analysis:
    • May appear yellow, green, cloudy, or opaque
    • Gram stain may be positive

Gout/pseudogout

  • Acute onset, reaches maximum intensity within 12 hours
  • May present similarly to septic arthritis
  • No fever
  • Usually mono/oligo-arthropathy
  • Gout most commonly affects the first MTP joint
  • Pseudogout most commonly affects the wrist and knee joints
  • In gout, there may be gouty tophi
  • Synovial fluid analysis:
    • Gout – negatively birefringent needle-shaped crystals
    • Pseudogout – weakly positive birefringent rhomboid-shaped crystals

Ankylosing spondylitis

  • Classically young man with inflammatory lower back pain and stiffness
  • Pain may occur at night
  • Reduced lateral and/or forward flexion
  • Reduced chest expansion
  • There may be a history of Achilles tendonitis or anterior uveitis

IBD-associated arthritis (enteropathic arthritis)

  • History of IBD or its features
  • Axial arthritis (spondylitis and/or sacroiliitis)
  • Peripheral arthritis
    • Inflammatory asymmetric oligoarthritis usually affecting the lower limbs
  • Enthesopathy
    • Severe localised pain at the site of insertion of the Achilles tendon

Differential Diagnoses: Systemic Connective Tissue Disorders

Systemic lupus erythematosus (SLE)

  • Classically affects young women
  • Photosensitive rash may be present
    • Such as the malar ‘butterfly-shaped’ rash on the face sparing the nasolabial folds
  • Generalised myalgia
  • Mouth ulcers
  • Pleurisy
  • Hair loss
  • ANA positive, anti-dsDNA and/or anti-Sm may be positive

Polymyalgia rheumatica

  • Classically affects older people (>60 years), particularly women
  • Causes inflammatory-type pain and stiffness in proximal limb muscles
  • There is no true muscle weakness in PMR
  • Systemic features include low-grade fever, night sweats, and lethargy
  • Mild joint pain may be present
  • CRP/ESR generally elevated
  • Creatine kinase normal
  • Responds well to corticosteroids (by around 3-4 weeks)
  • Other conditions need ruling out (e.g. cancer, infection, and giant cell arteritis)

Polymyositis

  • Symmetrical proximal muscle weakness
  • Associated with malignancy
  • Dyspnoea
  • Dysphagia
  • Dysphonia
  • Raynaud’s phenomenon
  • Muscle atrophy
  • Elevated serum creatine kinase
  • Anti-Jo-1 may be positive

Dermatomyositis

  • Features of polymyositis
  • Gottron’s papules – red papules over finger extensor surfaces
  • ‘Mechanic’s hands’ – extremely dry and scaly hands
  • Nail fold capillary dilatation
  • Violaceous heliotrope periorbital rash
  • Photosensitivity
  • Many patients are ANA positive
  • Anti-Jo-1 and anti-Mi-2 may be positive

Systemic sclerosis (SSc)

  • Skin thickening and tightening are predominant
  • Limited cutaneous SSc:
    • Face and distal limbs mainly affected
    • CREST syndrome (Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia)
    • Associated with anti-centromere antibodies
  • Diffuse cutaneous SSc:
    • Trunk and proximal limbs mainly affected
    • Associated with interstitial lung disease
    • Associated with anti-Scl-70 antibodies

Behçet’s syndrome

  • Recurrent oral and genital ulcers without the presence of sexually-transmitted infections
  • Anterior uveitis
  • Erythema nodosum
  • More common in men
  • More common in people aged 20-30 years

Sjögren’s syndrome

  • Dry eyes, dry mouth, and vaginal dryness are predominant features
  • Arthralgia
  • Increased risk of lymphoma
  • Associated with anti-Ro and anti-La antibodies
    • These backward spells (ORAL)
  • Anti-nuclear antibodies (ANA) are positive in around 70% of cases

Antiphospholipid syndrome

  • Recurrent arterial/venous thrombosis
  • Recurrent miscarriage
  • Livedo reticularis (mottled, net-like discolouration of the skin, usually on the legs)
  • Blood tests may show:
    • Thrombocytopenia
    • Prolonged APTT
    • Auto antibodies (anti-cardiolipin, lupus anticoagulant, anti-beta2 glycoprotein I)

Differential Diagnoses: Vasculitides

Giant cell arteritis

  • Seen in older patients (>50 years)
  • Headache
  • Scalp pain/tenderness
  • Jaw pain and claudication
  • May have associated polymyalgia rheumatica
  • Associated with anterior ischaemic optic neuropathy and visual loss
  • High-dose corticosteroids should be given if suspected, even before investigations

Takayasu’s arteritis

  • More common in women <40 years old
  • Upper and lower limb claudication on exertion
  • Constitutional features (e.g. malaise, headaches, low-grade fever, and weight loss)
  • Carotid bruits may be present
  • Unequal blood pressure in the upper limbs
  • Absent or weak peripheral pulses (‘can’t Takaya pulse’)
  • CT/MRI angiography is used for diagnosis

Granulomatosis with polyangiitis

  • Affects the:
  • A saddle-shaped nose may be present
  • Associated with c-ANCA

Eosinophilic granulomatosis with polyangiitis

  • Affects the:
    • Upper respiratory tract – sinusitis
    • Lower respiratory tract – difficult-to-treat asthma, haemoptysis (less common)
    • Kidneys – rapidly progressing glomerulonephritis
  • Blood tests show eosinophilia
  • Some drugs may precipitate the disease (e.g. macrolides and leukotriene receptor antagonists such as montelukast)
  • Associated with p-ANCA

Henoch Schönlein Purpura (HSP, IgA vasculitis)

  • Purpuric rash over the extensor surfaces of the arms and legs and buttocks
  • Polyarthritis
  • Abdominal pain
  • IgA nephropathy (recurrent episodes of haematuria and slight proteinuria)
  • A renal biopsy shows mesangial IgA deposition

Differential Diagnoses: Bone Disorders

Osteomalacia

  • Most commonly caused by vitamin D deficiency
  • Presents with diffuse bone pain
  • Bone and muscle tenderness may be present
  • Proximal muscle weakness may be seen
  • There may be a history of limited sunlight exposure or nutritional deficiency
  • Blood tests show:
    • Low vitamin D
    • Raised alkaline phosphatase (ALP)
    • Low calcium and phosphate

Osteoporosis

  • Painless and insidious until a fracture occurs
  • Fractures are usually fragility fractures (e.g. vertebral compression fractures or neck of femur fractures after a fall)
  • Risk factors such as corticosteroid use, increasing age, and low BMI may be present
  • Bone profile tests are normal (normal calcium, phosphate, ALP, and parathyroid hormone (PTH))

Paget’s disease of bone

  • Most patients are asymptomatic
  • Seen in older patients (>50 years)
  • Localised bone pain in the proximal long bones, spine, and pelvis
  • A bone profile shows an isolated raised ALP

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