What review of systems and history questions should I ask a patient with chief complaint of joint pain?

Review of Systems and History for Joint Pain

When evaluating a patient with joint pain, conduct a structured assessment focusing on six critical clinical factors: disease chronology, presence of inflammation, joint distribution pattern, extra-articular manifestations, disease course, and patient demographics. 1

Essential History Components

Pain Characteristics

• Timing details: Document onset (acute vs. insidious), duration, and periodicity of symptoms 2, 1
• Location and distribution: Determine if pain is monoarticular, oligoarticular (2-4 joints), or polyarticular (≥5 joints), and whether symmetric or asymmetric 1
• Quality and severity: Characterize the pain type and intensity using validated scales 2
• Morning stiffness duration: Stiffness exceeding 30 minutes strongly suggests inflammatory rather than non-inflammatory arthritis 3, 4

Inflammatory Features

• Presence of joint swelling, warmth, or erythema: These indicate inflammatory synovitis rather than mechanical pain 2, 1
• Fever, weight loss, or fatigue: Systemic symptoms suggest inflammatory or infectious etiology 2, 1
• Pattern of joint involvement: Migratory, additive, or symmetric patterns help narrow differential diagnosis 4

Aggravating and Relieving Factors

• Activity-related changes: Pain worsening with use suggests mechanical/degenerative causes; pain improving with movement suggests inflammatory arthritis 2, 5
• Response to rest: Inflammatory conditions typically worsen with prolonged rest 5
• Effect of weather, physical activity, posture, stress, and tiredness 2

Extra-Articular Manifestations

• Skin changes: Document any rashes, their distribution, morphology, and timing relative to joint symptoms 4
• Eye symptoms: Uveitis, conjunctivitis, or dry eyes may indicate spondyloarthropathy or Sjögren's syndrome 2
• Oral/nasal symptoms: Ulcers suggest systemic lupus or Behçet's disease 2
• Gastrointestinal symptoms: Diarrhea may precede reactive arthritis 2
• Genitourinary symptoms: Urethritis suggests reactive arthritis 2
• Neurological symptoms: Altered sensation or weakness may indicate nerve involvement 2

Previous Treatments and Response

• Current and past pain medications: Include prescribed, over-the-counter, and homeopathic remedies 2
• Previous therapies tried: Physical therapy, injections, or other interventions and their efficacy 2
• Frequency and safety of medication use: Assess for potential overdosing 2

Functional Impact Assessment

• Effect on activities of daily living: Determine limitations in self-care, instrumental activities, work, and hobbies 2
• Sleep disturbance: Inquire about causes (pain, worrying, poor sleep habits) 2
• Impact on mood and concentration: Screen for depression and anxiety 2
• Patient's valued life goals: What activities they cannot currently perform 2

Contextual and Psychosocial Factors

• Patient beliefs and concerns: Their understanding of pain cause and perceived control over symptoms 2
• Fear of movement or catastrophizing: These psychological factors influence treatment selection 2
• Coping strategies and self-efficacy: Assess patient's confidence in managing symptoms 2
• Social support and work status: Impact on ability to participate in treatment 2

Medical and Family History

• Comorbidities: Diabetes, cardiovascular disease, obesity, immunosuppression 2, 1
• Family history: Genetic predisposition to rheumatologic conditions 2, 1
• Recent infections: Viral illnesses, tick exposure (Lyme), sexually transmitted infections, or gastrointestinal infections preceding arthritis 1
• Trauma history: Previous joint injuries predispose to secondary osteoarthritis 6
• Medication history: Drugs that may cause arthralgia or lupus-like syndromes 1

Lifestyle and Behavioral Factors

• Tobacco, alcohol, or drug use: May influence pain or treatment options 2
• Physical activity level: Sedentary lifestyle versus high-demand activities 2
• Obesity status: Contributes to pain and disability, particularly in weight-bearing joints 2
• Occupational exposures: Repetitive movements or joint stress 2

Physical Examination Priorities

Joint-Specific Assessment

• Complete examination of all peripheral joints: Assess for tenderness, swelling, warmth, erythema, and range of motion 2, 3, 4
• 28-joint count assessment: Include PIPs, MCPs, wrists, elbows, shoulders, and knees 3
• Spine examination: Assess for sacroiliitis if symptoms suggest spondyloarthropathy 2, 4
• Distinguish synovitis from bony hypertrophy: Palpable synovitis indicates inflammation; bony changes and crepitus suggest osteoarthritis 1

Functional Movement Assessment

• Observe gait pattern: Antalgic gait or hesitance suggests fear avoidance or severe pain 2
• Single-leg squat or functional tasks: Assess movement patterns and pain provocation 2
• Muscle strength testing: Hip and knee muscle weakness may guide treatment 2

Extra-Articular Examination

• Skin inspection: Look for rashes, nodules, psoriatic plaques, or vasculitic lesions 4, 1
• Eye examination: Check for conjunctivitis, uveitis, or dry eyes 2
• Oral cavity: Assess for ulcers or dry mucosa 2
• Lymph node palpation: Generalized lymphadenopathy may suggest systemic disease 1

Critical Red Flags Requiring Urgent Evaluation

• Fever with joint pain: Consider septic arthritis or systemic inflammatory disease 2, 1
• Severe unilateral joint pain with effusion: Septic arthritis until proven otherwise 2
• Constitutional symptoms: Weight loss, night sweats, or profound fatigue may indicate malignancy or serious systemic disease 2, 1
• Neurological deficits: May indicate spinal involvement or nerve compression 2
• Recent immunosuppression or checkpoint inhibitor therapy: Increased risk of infection or immune-related adverse events 2