What are the key components of taking a rheumatology history?

Key Components of Rheumatology History Taking

A comprehensive rheumatology history must systematically capture joint symptoms, functional impact, disease activity indicators, and risk factors for persistent disease to guide early diagnosis and treatment decisions.

Essential Symptom Characterization

Joint-Specific Inquiry

• Document the pattern of joint involvement including which specific joints are affected (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal, wrists, knees), as symmetric small joint involvement is the most frequent presentation of inflammatory arthritis 1, 2
• Characterize pain and swelling by asking about joint tenderness, swelling duration, and whether symptoms are worse in the morning 2, 3
• Quantify morning stiffness duration specifically asking how long it takes from waking until maximal improvement—stiffness lasting at least 1 hour suggests inflammatory arthritis and correlates with disease activity 2
• Distinguish between pain and stiffness as patients often confuse these symptoms, which provide different diagnostic information 2

Temporal Pattern Assessment

• Establish onset characteristics: insidious versus acute/subacute (occurs in 25% of cases), palindromic (recurrent episodes without residual damage), monoarticular, or polymyalgic-like presentation 2
• Determine symptom duration from onset, as referral to rheumatology ideally should occur within 6 weeks of symptom onset for polyarticular arthritis 1

Functional Impact Documentation

Disability Assessment

• Assess physical function limitations in daily activities, as rheumatologists rank physical function as the second most important element (16% of decision-making weight) after symptoms 4
• Evaluate disability and handicap using structured approaches like the PILS screen to capture prevention needs, independence level, lifestyle impact, and social resource requirements 1, 5
• Document work ability and employment status, as maintenance of work capacity is a key outcome measure 1

Disease Activity Indicators

Inflammatory Markers History

• Inquire about systemic symptoms including fatigue, fever, weight loss, and malaise, which indicate active systemic inflammation 2, 3
• Ask about number of actively painful and swollen joints as joint counts are critical for determining disease activity levels 1

Patient Global Assessment

• Obtain patient/parent global assessment of overall well-being on a 0-10 scale, as this is incorporated into disease activity criteria (low activity requires <2/10, high activity ≥4-5/10) 1

Risk Stratification Elements

Poor Prognosis Features

• Identify high-risk joint involvement specifically asking about hip or cervical spine arthritis, which predicts persistent and erosive disease 1
• Document ankle or wrist involvement combined with marked inflammatory marker elevation, as this combination indicates poor prognosis 1
• Ask about family history of rheumatoid factor positivity or anti-CCP antibodies in relatives, as these predict worse outcomes 1

Differential Diagnosis Screening

Exclusion of Alternative Diagnoses

• Screen for infection history including recent viral illnesses, tick exposures (Lyme disease), or risk factors for hepatitis B/C and tuberculosis, as these can mimic inflammatory arthritis 1, 6
• Ask about crystal arthropathy risk factors including gout triggers (alcohol, purine-rich foods) and pseudogout associations 5
• Inquire about mechanical versus inflammatory back pain characteristics: mechanical pain improves with rest, while inflammatory back pain (spondylitis) improves with activity 1, 5
• Screen for systemic autoimmune features including photosensitivity, oral ulcers, Raynaud's phenomenon, dry eyes/mouth, and rashes to identify lupus or other connective tissue diseases 1, 5

Red Flags for Urgent Conditions

• Ask about fever with monoarthritis to identify septic arthritis, which requires urgent intervention 1, 5
• Screen for spinal cord compression symptoms including bowel/bladder dysfunction, progressive weakness, or saddle anesthesia 1
• Inquire about destructive back pain features such as night pain, progressive pain, or constitutional symptoms suggesting malignancy or infection 1

Periarticular and Extra-Articular Manifestations

Soft Tissue Involvement

• Ask about tendon pain and swelling as tenosynovitis and bursitis are frequent and often clinically dominant in early rheumatoid arthritis 2
• Document enthesopathy symptoms (pain at tendon/ligament insertions) particularly at the Achilles, plantar fascia, and elbow, which suggest spondyloarthropathy 1

Systemic Complications

• Screen for extra-articular manifestations including subcutaneous nodules, vasculitis symptoms, hematologic abnormalities, and visceral involvement 2
• Ask about comorbidities as patients with RA have increased risk for serious infection, respiratory disease, osteoporosis, cardiovascular disease, and cancer 3

Medication and Treatment History

Current and Past Therapies

• Document all prior treatments including NSAIDs, corticosteroids, and disease-modifying antirheumatic drugs (DMARDs), with specific attention to response, duration, and reasons for discontinuation 1
• Assess treatment adherence as this significantly impacts treatment decisions 4
• Review pain management strategies currently employed 4

Contraindications Screening

• Evaluate gastrointestinal, renal, and cardiovascular status before considering NSAIDs 1
• Screen for contraception needs in women of childbearing age, as many DMARDs are teratogenic 1

Common Pitfalls to Avoid

• Failing to use structured approaches like symptom checklists leads to incomplete histories—systematic questioning about all major joint groups prevents missed diagnoses 5
• Underestimating functional impact by focusing only on joint counts without assessing disability and quality of life misses critical treatment targets 5, 4
• Delaying detailed history in suspected septic arthritis—this is an emergency requiring immediate joint aspiration, not prolonged history-taking 5
• Overlooking the "squeeze test" by not asking if the patient has pain with compression of the metacarpophalangeal or metatarsophalangeal joints, which is a simple screening maneuver for synovitis 1