Rheumatoid: History
  1. Presenting complaint
  2. Pain: joints, limbs, elsewhere
  3. Stiffness, swelling
  4. Deformity, Raynaud's
  5. Eyes, mouth
  6. Systemic
  7. Past medical, surgical history
  8. Family, social, disability, drug history
Presenting complaint
  • What is the problem lately.
Pain: joints
  • See SOCRATES.
  • Site: number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
  • Timing: acute/ chronic.
  • Exacerbating factors: rest, exercise.
Pain: limbs
  • See SOCRATES.
  • Bone pain.
  • Severe pain of sudden onset (vascular dz).
  • Nerve entrapment.
  • In amputated limb (phantom pain).
Pain: elsewhere
  • See SOCRATES.
  • Back is common.
  • Spinal cord: localize to dermatome.
Stiffness
  • Generalized or specific to certain joints.
  • Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
  • Worse in morning (RA, other inflammatory).
  • Duration before wears off (severity).
Swelling
  • Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
  • When first noticed.
  • Getting larger or smaller.
Deformity
  • Misshapen joints.
  • Time course of the deformity.
Raynaud's
  • Assess Raynaud's phenomenon (scleroderma).
Eyes, mouth
  • Dry eyes, mouth (Sjogren's).
  • Red eyes,  painful eyes (seronegatives).
  • Unilateral loss of visual acuity (seronegatives).
Systemic
  • Rash (SLE).
  • Fatigue, breathlessness.
  • Fever (connective tissue dz).
  • Weight loss (dyspagia or malabsoption 2 to scleroderma).
  • Abdominal pain, GI bleeding (NSAID s/e).
Past medical, surgical history
  • Time of menopause [if applicable].
  • Current problem in past.
  • Trauma in past.
  • Fractures, sprains.
  • Infections:
    Gonorrhea [esp. if monoarticular, young].
    Staphylococcus
    Streptococcus
    Hepatitis
    TB
    Dysentery
  • Gout (gouty arthritis).
  • IBD (IBD-associated arthritis).
  • Psoriasis (psoriatic arthritis).
  • Thyroid problems (osteoporosis).
  • Tick bites (Lyme dz) [usu. USA only].
  • Arthritis as a child.
  • Depression [common in chronic disability].
  • Seen a rheumatologist before?.
  • Physiotherapy, occupational therapy.
  • Joint surgery, bone surgery.
Family history
  • The current complaint in parents/ siblings/ children: health, cause of death, age of onset, age of death.
  • Hereditary dz suspected: do a family tree.
  • IBD.
  • Gout.
  • Rheumatoid arthritis.
  • Osteoarthritis.
  • Seronegatives: PAIR:
    Psoriasis
    Anklyosing
    IBD-associated
    Reiter's 
Social history
  • Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew] (increases NSAID risk).
  • Alcohol: do you drink. If yes: type, how much, how often (fall risk, increases NSAID risk).
  • Present occupation.
  • Any other factors that you wish to mention?
Disability
  • Who is with you there at home [important for managing daily activities].
  • Describe your home: stairs, if apartment what floor, handles (fall risk).
  • Difficulties with cooking, dressing, bathing.
  • How interrupts life.
  • Home aids, utensils, appliances.
Drug history
  • Prescriptions currently on [gold, etc], noting side effects.
  • Over-the-counters, esp. NSAIDs.
  • Steroids.
  • Recreational drugs [most rheumatoid pt's are older than this, but may use for pain escape].
  • Estrogen replacements [if menopausal], other hormones.
  • Calcium supplements.
  • Allergies: if allergic to drug, make sure not an allergy, not just a common side-effect.

Rheumatoid Exam