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The rheumatological history
HISTORY TAKING AND EXAMINATION
'When did this start? Did anything trigger it? What happened then?’ Work towards the present: ‘How is it affecting you now? Is it better, worse or the same?’ A useful technique is reiteration of the important points to check your understanding; for example: ‘So this episode of joint swelling has been present for 6 weeks now, is that correct?’ It is also helpful to give patients time to collect their thoughts – do not worry about long silences, and encourage them to take their time over the details that you consider important. Some areas require less detail, however, so do not be afraid to change the subject. The phrase ‘Can we move on to... now?’ may be useful. It is important to show empathy, using phrases such as: ‘I can see that it must be very difficult for you to manage on your own’. Rheumatology patients, particularly those with disabling inflammatory arthritis, often struggle to maintain their independence. The recording of a rheumatological history follows the same format as a general history. It is helpful to summarize the salient points and to record your impressions.
The rheumatological history Jane E Dacre Jennifer G Worrall
A wide range of diseases may affect the musculoskeletal system, from minor regional soft tissue conditions (e.g. tennis elbow), to life-threatening systemic connective tissue diseases (e.g. systemic lupus erythematosus, SLE). The taking of a rheumatological history must therefore be flexible. Appropriate information must be gathered to make a quick diagnostic hypothesis, and time and understanding must be given to patients with severe disability. History-taking is an essential part of any consultation. It is important to recognize that several processes are occurring while you talk – you are gathering sufficient information to make an appropriate diagnosis, in addition to putting the patient at ease and developing a good relationship with him or her. An effective consultation is one in which a rapport is established with the patient. Patients generally feel better after talking to a doctor who listens to their problems and appears to be taking them seriously, and are also more likely to comply with proposed treatments. This is particularly important in patients with inflammatory arthritides or connective tissue diseases. These are chronic diseases requiring long-term follow-up. Patients need education and support, and may need to take toxic drugs under the doctor’s supervision. Patients with degenerative and overuse syndromes also need education and advice on how they can manage their symptoms for themselves.
Presenting complaints The cardinal symptoms of joint disease are pain, stiffness, swelling and deformity. Systemic illness may be present. The degree of disability and handicap must also be assessed. The combination of these symptoms with the pattern of joint involvement often leads to diagnosis of the rheumatic condition. Questions should be asked about the frequency of the symptoms, whether they are constant or intermittent and their duration. Recurrent episodes of acute pain and swelling in a single joint (often the joint at the base of the big toe) suggests gout. Pain in the hip or knee worsening slowly over several years suggests osteoarthritis. The mode of onset may be important; for example, a minor injury may precipitate shoulder capsulitis, or an episode of diarrhoea or influenza may be the first symptom of sero-negative inflammatory arthritis. In patients with arthritis, the history allows the doctor to answer the following questions and thus make a diagnosis. • Is it monoarthritis, oligoarthritis (affecting four joints or fewer) or polyarthritis (affecting more than four joints)? • Is the arthritis inflammatory or non-inflammatory? • Is the patient’s problem caused by symmetrical or asymmetrical arthritis? • Does it affect large joints or small joints? Rheumatoid arthritis (RA) is typically a symmetrical, inflammatory polyarthritis that principally affects small joints (Figure 1). Reactive arthritis is an inflammatory oligoarthritis that typically affects the large joints of the lower limb.
General principles Ensure that the patient is comfortable before you begin. This may require rearranging the seating to accommodate those who have difficulty getting in and out of ordinary chairs, or who are confined to a wheelchair. It is important to start with an ‘open’ question that encourages a descriptive answer; for example: ‘Tell me about your joint problems’. This allows the patient to give a broad overview of his or her story. Fill in the details with focused (closed) questions, such as: ‘Which joints are affected? Do they feel stiff? Do they swell?’ Rheumatological histories may be complicated and may span several years. To avoid confusion, take the history chronologically:
Pain is the most common presenting complaint but is often vague; specific questions are required. The severity of the pain does not necessarily reflect the severity of the underlying condition. It may be difficult for patients to describe the location of their pain; it is important to ask them to show you both the general area and the place at which the pain is at its maximum intensity. Some conditions cause nerve or nerve root pain distant from the lesion. Thus, a prolapsed inter-vertebral disc may present with pain over the lateral aspect of the foot, as a result of irritation of the L5 nerve root in the back. Carpal tunnel syndrome presents with pain in the radial half of the hand as a result of median nerve irritation at the wrist, but wrist symptoms are typically absent. In addition,
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London. Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
THE FOUNDATION YEARS 2:2
43
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Diurnal variation of pain severity in arthritis
Severity of pain
Degenerative arthritis
Inflammatory arthritis 1 The hands of a patient with severe inflammatory arthritis, showing symmetrical deformity. Getting up in the morning
pain may be referred. Pain from the shoulder causes an ache over the upper arm, hip pain is often attributed to the knee and sacroiliac pain radiates to the posterior thigh. The quality of the pain may give a clue to its cause. Joint pain is often described as an ache, root pain as tingling or burning, pain from a soft tissue lesion as sharp and specific in location, and bone pain as a deep, intense, aching pain. Pain may be related to movement, and it should be asked whether the patient’s pain gets better with rest or on exercise. Pain that gets better on activity or as the day progresses is likely to be caused by inflammation. Pain that gets worse during the day probably results from degenerative change (Figure 2). Most locomotor system pain is less intense at night; however, pain from severe arthritis or malignant disease keeps patients awake or may even wake them from sleep. This is a very important feature, and should be asked about in all cases of musculoskeletal pain. Some regional conditions cause pain that can be localized precisely; in tennis elbow, for example, the pain is localized to the lateral epicondyle of the elbow, and patients can often point to the exact place. Intermittent locking of the knee, which may be painful, suggests a loose body interfering with joint mechanics.
2
Fluctuant swelling is soft tissue swelling caused by fluid. It may cause concern because effusions may be large. Patients may feel that the joint is hot and may have noticed limitation in movement. Any large swelling that develops rapidly is most likely to be an effusion. Bony swelling is associated with degenerative conditions and causes joint deformity about which the patient may be worried. There is little associated heat and redness. Bony swelling tends to be of longer duration than soft tissue swelling. It is often painful as the deformity develops, but then settles (e.g. Heberden’s node in the distal interphalangeal joint). Deformity often results from an arthritic process. The most common form is flexion deformity; patients complain of inability to straighten the joint. Ask how long the deformity has been developing and whether it is associated with swelling and pain. The deformity may be associated with the primary condition or may result from secondary osteoarthritis.
Stiffness is an inability to get the joints moving after rest. In inflammatory conditions, it is generally worse in the morning and improves gradually over several hours. The duration relates to the activity of the disease, or to the severity of the inflammation. Patients with degenerative change (osteoarthritis) also suffer stiffness related to inactivity, but this is of much shorter duration (always < 30 minutes) (Figure 3).
Severity of stiffness
Stiffness in arthritis following a period of rest
Swelling: in patients with joint pain and stiffness, it is important to ask about local swelling. Patients may report that a painful joint is swollen when it is not, as a result of altered sensation in that joint. Any report of joint swelling should therefore be followed up by examination. Swelling may be symmetrical or asymmetrical, depending on the type of arthritis, and may occur in soft tissue or bony tissue (Figure 4). Synovial swelling – this soft tissue swelling is often symmetrical and is associated with inflammatory conditions. Patients may complain of associated pain, heat and stiffness, and several joints may be involved.
THE FOUNDATION YEARS 2:2
Going to bed in the evening
Getting up after rest
Active inflammatory arthritis
Osteoarthritis
30 minutes
60 minutes
120 minutes
3
44
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Previous and family history It is important to establish that patients with rheumatological problems are otherwise well. This can be achieved by a brief enquiry about general health, with a more formal, systems-based enquiry if appropriate. Ask about past illness affecting the locomotor system or elsewhere. Patients with generalized osteoarthritis may have a problem with one large joint now, but may not mention that they showed evidence of cervical spondylosis in the past because they have not related the two conditions. It must be established whether any affected joint has been inflamed or damaged in the past; for example, a shortened leg may give rise to osteoarthritis in the other knee (Figure 5). This is important in osteoarthritis, in which mechanical damage may be a pre-disposing factor (e.g. patients who have undergone menisectomy are likely to develop osteoarthritis of the knee). In the inflammatory arthritides, it is important to ask specifically about conditions that the patient may not realize are associated (e.g. iritis, psoriasis, sexually transmitted infections, inflammatory bowel disease). Inflammatory musculoskeletal diseases such as RA and ankylosing spondylitis have an inherited component, so ask about a family history of inflammatory arthritis and associated disorders such as inflammatory bowel disease and psoriasis. Research in twins suggests that osteoarthritis also has an inherited element. Many patients remember that their grandparents had ‘rheumatism’ but cannot recall the diagnosis. Ask them to describe the abnormalities they remember and to tell you what they think was wrong.
4 Acute, polyarticular tophaceous gout.
Systemic illness: connective tissue diseases are multisystem conditions that may present with locomotor system problems. It is important to ask about nonspecific symptoms of systemic disease (fever, weight loss, fatigue, breathlessness, lethargy). A comprehensive systems review should follow. The patient may have a rash (particularly the photosensitive rash of SLE). Disability: while taking a rheumatological history, the clinician should estimate how much the patient is able to do and how much the disease interferes with daily life. It is important to determine whether patients can perform simple, everyday tasks of self-care (e.g. washing, dressing) and daily living (e.g. laundry, cooking) and how much help they require. Ask about mobility – can they move easily around their home, are they able to leave the house and do they have a car that they can drive? Finally, ask about their occupation. Specific questions to ask depend on the patient’s level of normal daily activity. Medically minor locomotor complaints may have disastrous psychosocial consequences; for example, tennis elbow may be severely disabling in a manual worker, and a knee problem may render a scaffolder unemployable because of the risk of falling. Patients with disability that affects the activities of daily living may require aids and appliances (e.g. stair-lift, lever taps, raised toilet seat). It is also important to ascertain whether their accommodation is appropriate (e.g. a ground floor flat with wheelchair access). Ask how they manage their shopping and whether they can carry the bags. Finally, ask whether they live alone or have a partner or carer, and whether they have dependants such as young children. Patients with arthritis may suffer anxieties about their sexual relationships. This is a delicate subject but can be explored gently by questions such as: ‘Do you have any problems with the physical side of your relationship? Would you like to discuss it?’ It is important to maintain a sympathetic and non-judgemental attitude and to explore practical solutions, encouraging discussion between the patient and his or her partner and helping them to consider experimenting with different positions for intercourse. Depression is a common cause of disability in patients with musculoskeletal problems, particularly in those with chronic problems such as back pain or fibromyalgia. Depression maybe subclinical, so ask whether the patient feels depressed, tired or ‘weepy’. It is sometimes difficult to determine whether depression is a primary or secondary problem.
THE FOUNDATION YEARS 2:2
Occupational history and leisure activities The occupational history is particularly important because some occupations predispose individuals to specific problems (e.g.
5 Long-leg arthropathy.
45
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Rheumatological Examination
Important points in the history • Constant, unremitting pain suggests the possibility of malignant disease • Pain that keeps the patient awake suggests malignant disease or severe arthritis • Root pain is often burning or tingling in nature • Pain and stiffness that improve with activity suggest an inflammatory disorder • Musculoskeletal disease may be drug-induced
Jane E Dacre Jennifer G Worrall
The locomotor system can be difficult to examine because it involves many different anatomical structures. A full examination is time-consuming and seldom necessary. Most rheumatologists perform a short screening examination followed by a more detailed assessment of the affected structures, with additional examination of other systems if indicated. Variations in examination technique reflect individual practice. This contribution outlines the GALS (gait, arms, legs, spine) screen, which is a quick, reliable screen of the locomotor system, and describes more detailed examination of the lumbar spine, hip, knee, shoulder, elbow, hand and wrist, which are the most common sites for symptoms of locomotor disease.
osteoarthritis of the neck in dentists, osteoarthritis of the feet in dancers). Specific occupational rheumatic diseases such as housemaid’s knee (prepatella bursitis) and weaver’s bottom (ischial bursitis) should also be considered. Ask patients about their job, what they do exactly and how they do it, and how often they take a break. Excessive wrist action (e.g. in a painter and decorator) may cause tenosynovitis. Leisure activities can also predispose individuals to joint pain (e.g. tennis elbow). Ask about violent physical exercise (e.g. contact sports) and excessive joint movement (e.g. gymnastics, yoga); these may cause long-term damage to joints. It is useful to ask about general exercise and the patient’s level of fitness. Individuals who are unfit may develop nonspecific aches and pains in their joints and muscles.
Anatomy and physiology of the locomotor system The locomotor system comprises bones, joints and muscles with associated ligaments, tendons and bursae. The principal types of joint are fibrous and synovial. Synovial joints permit a wide range of movement. Fibrous joints have a simpler structure than synovial joints and are less susceptible to disease and injury; the bones are connected by dense fibrous tissue and only a small range of movement is permitted. In a synovial joint (Figure 1), the bone ends are covered by hyaline cartilage and the whole structure is enclosed in a capsule. The capsule is lined with synovium – a specialized tissue responsible for lubricating the joint and nourishing the articular cartilage, which has no blood supply of its own. Synovium produces synovial fluid by a combination of ultra-filtration of plasma and active secretion of large molecules (e.g. hyaluronan). Normal synovial fluid is highly viscous because of entanglement of these molecules, whereas inflammatory synovial fluid has a low viscosity because the enzymes and free radicals associated with inflammation break them down. The two main causes of arthritis are degeneration and inflammation. In degenerative disease (osteoarthritis), the articular cartilage becomes dehydrated, thin and fibrillated. Abnormal mechanical stress is transmitted to the underlying bone, which
Treatment history Ask the patient about treatment with aspirin and non-steroidal anti-inflammatory drugs, to assess efficacy and side effects (particularly gastric irritation and gastrointestinal bleeding). Establish whether those with RA have taken any second-line therapy (e.g. sulfasalazine, methotrexate, sodium aurothio-malate, D-penicillamine, azathioprine, hydroxy-chloroquine) and whether they developed any side effects (e.g. rashes) that led to stopping of the drug. Remember that patients with inflammatory arthritic conditions may also be taking long-term corticosteroid therapy and may have associated side effects (e.g. diabetes, osteoporosis). Some connective tissue diseases are drug-induced; for example, patients taking long-term phenothiazines for psychiatric conditions may develop a lupus-like syndrome.
FURTHER READING Dacre J E, Kopelman P. Handbook of Clinical Skills. London: Manson, 2002. Doherty M, Dacre J, Dieppe P, Snaith M. The (GALS) Locomotor Screen. Ann Rheumatol 1992; 51: 1165–9.
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London.
Acknowledgement The authors thank Manson Publishing and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
THE FOUNDATION YEARS 2:2
Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
46
© 2006 Elsevier Ltd
'When did this start? Did anything trigger it? What happened then?’ Work towards the present: ‘How is it affecting you now? Is it better, worse or the same?’ A useful technique is reiteration of the important points to check your understanding; for example: ‘So this episode of joint swelling has been present for 6 weeks now, is that correct?’ It is also helpful to give patients time to collect their thoughts – do not worry about long silences, and encourage them to take their time over the details that you consider important. Some areas require less detail, however, so do not be afraid to change the subject. The phrase ‘Can we move on to... now?’ may be useful. It is important to show empathy, using phrases such as: ‘I can see that it must be very difficult for you to manage on your own’. Rheumatology patients, particularly those with disabling inflammatory arthritis, often struggle to maintain their independence. The recording of a rheumatological history follows the same format as a general history. It is helpful to summarize the salient points and to record your impressions.
The rheumatological history Jane E Dacre Jennifer G Worrall
A wide range of diseases may affect the musculoskeletal system, from minor regional soft tissue conditions (e.g. tennis elbow), to life-threatening systemic connective tissue diseases (e.g. systemic lupus erythematosus, SLE). The taking of a rheumatological history must therefore be flexible. Appropriate information must be gathered to make a quick diagnostic hypothesis, and time and understanding must be given to patients with severe disability. History-taking is an essential part of any consultation. It is important to recognize that several processes are occurring while you talk – you are gathering sufficient information to make an appropriate diagnosis, in addition to putting the patient at ease and developing a good relationship with him or her. An effective consultation is one in which a rapport is established with the patient. Patients generally feel better after talking to a doctor who listens to their problems and appears to be taking them seriously, and are also more likely to comply with proposed treatments. This is particularly important in patients with inflammatory arthritides or connective tissue diseases. These are chronic diseases requiring long-term follow-up. Patients need education and support, and may need to take toxic drugs under the doctor’s supervision. Patients with degenerative and overuse syndromes also need education and advice on how they can manage their symptoms for themselves.
Presenting complaints The cardinal symptoms of joint disease are pain, stiffness, swelling and deformity. Systemic illness may be present. The degree of disability and handicap must also be assessed. The combination of these symptoms with the pattern of joint involvement often leads to diagnosis of the rheumatic condition. Questions should be asked about the frequency of the symptoms, whether they are constant or intermittent and their duration. Recurrent episodes of acute pain and swelling in a single joint (often the joint at the base of the big toe) suggests gout. Pain in the hip or knee worsening slowly over several years suggests osteoarthritis. The mode of onset may be important; for example, a minor injury may precipitate shoulder capsulitis, or an episode of diarrhoea or influenza may be the first symptom of sero-negative inflammatory arthritis. In patients with arthritis, the history allows the doctor to answer the following questions and thus make a diagnosis. • Is it monoarthritis, oligoarthritis (affecting four joints or fewer) or polyarthritis (affecting more than four joints)? • Is the arthritis inflammatory or non-inflammatory? • Is the patient’s problem caused by symmetrical or asymmetrical arthritis? • Does it affect large joints or small joints? Rheumatoid arthritis (RA) is typically a symmetrical, inflammatory polyarthritis that principally affects small joints (Figure 1). Reactive arthritis is an inflammatory oligoarthritis that typically affects the large joints of the lower limb.
General principles Ensure that the patient is comfortable before you begin. This may require rearranging the seating to accommodate those who have difficulty getting in and out of ordinary chairs, or who are confined to a wheelchair. It is important to start with an ‘open’ question that encourages a descriptive answer; for example: ‘Tell me about your joint problems’. This allows the patient to give a broad overview of his or her story. Fill in the details with focused (closed) questions, such as: ‘Which joints are affected? Do they feel stiff? Do they swell?’ Rheumatological histories may be complicated and may span several years. To avoid confusion, take the history chronologically:
Pain is the most common presenting complaint but is often vague; specific questions are required. The severity of the pain does not necessarily reflect the severity of the underlying condition. It may be difficult for patients to describe the location of their pain; it is important to ask them to show you both the general area and the place at which the pain is at its maximum intensity. Some conditions cause nerve or nerve root pain distant from the lesion. Thus, a prolapsed inter-vertebral disc may present with pain over the lateral aspect of the foot, as a result of irritation of the L5 nerve root in the back. Carpal tunnel syndrome presents with pain in the radial half of the hand as a result of median nerve irritation at the wrist, but wrist symptoms are typically absent. In addition,
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London. Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
THE FOUNDATION YEARS 2:2
43
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Diurnal variation of pain severity in arthritis
Severity of pain
Degenerative arthritis
Inflammatory arthritis 1 The hands of a patient with severe inflammatory arthritis, showing symmetrical deformity. Getting up in the morning
pain may be referred. Pain from the shoulder causes an ache over the upper arm, hip pain is often attributed to the knee and sacroiliac pain radiates to the posterior thigh. The quality of the pain may give a clue to its cause. Joint pain is often described as an ache, root pain as tingling or burning, pain from a soft tissue lesion as sharp and specific in location, and bone pain as a deep, intense, aching pain. Pain may be related to movement, and it should be asked whether the patient’s pain gets better with rest or on exercise. Pain that gets better on activity or as the day progresses is likely to be caused by inflammation. Pain that gets worse during the day probably results from degenerative change (Figure 2). Most locomotor system pain is less intense at night; however, pain from severe arthritis or malignant disease keeps patients awake or may even wake them from sleep. This is a very important feature, and should be asked about in all cases of musculoskeletal pain. Some regional conditions cause pain that can be localized precisely; in tennis elbow, for example, the pain is localized to the lateral epicondyle of the elbow, and patients can often point to the exact place. Intermittent locking of the knee, which may be painful, suggests a loose body interfering with joint mechanics.
2
Fluctuant swelling is soft tissue swelling caused by fluid. It may cause concern because effusions may be large. Patients may feel that the joint is hot and may have noticed limitation in movement. Any large swelling that develops rapidly is most likely to be an effusion. Bony swelling is associated with degenerative conditions and causes joint deformity about which the patient may be worried. There is little associated heat and redness. Bony swelling tends to be of longer duration than soft tissue swelling. It is often painful as the deformity develops, but then settles (e.g. Heberden’s node in the distal interphalangeal joint). Deformity often results from an arthritic process. The most common form is flexion deformity; patients complain of inability to straighten the joint. Ask how long the deformity has been developing and whether it is associated with swelling and pain. The deformity may be associated with the primary condition or may result from secondary osteoarthritis.
Stiffness is an inability to get the joints moving after rest. In inflammatory conditions, it is generally worse in the morning and improves gradually over several hours. The duration relates to the activity of the disease, or to the severity of the inflammation. Patients with degenerative change (osteoarthritis) also suffer stiffness related to inactivity, but this is of much shorter duration (always < 30 minutes) (Figure 3).
Severity of stiffness
Stiffness in arthritis following a period of rest
Swelling: in patients with joint pain and stiffness, it is important to ask about local swelling. Patients may report that a painful joint is swollen when it is not, as a result of altered sensation in that joint. Any report of joint swelling should therefore be followed up by examination. Swelling may be symmetrical or asymmetrical, depending on the type of arthritis, and may occur in soft tissue or bony tissue (Figure 4). Synovial swelling – this soft tissue swelling is often symmetrical and is associated with inflammatory conditions. Patients may complain of associated pain, heat and stiffness, and several joints may be involved.
THE FOUNDATION YEARS 2:2
Going to bed in the evening
Getting up after rest
Active inflammatory arthritis
Osteoarthritis
30 minutes
60 minutes
120 minutes
3
44
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Previous and family history It is important to establish that patients with rheumatological problems are otherwise well. This can be achieved by a brief enquiry about general health, with a more formal, systems-based enquiry if appropriate. Ask about past illness affecting the locomotor system or elsewhere. Patients with generalized osteoarthritis may have a problem with one large joint now, but may not mention that they showed evidence of cervical spondylosis in the past because they have not related the two conditions. It must be established whether any affected joint has been inflamed or damaged in the past; for example, a shortened leg may give rise to osteoarthritis in the other knee (Figure 5). This is important in osteoarthritis, in which mechanical damage may be a pre-disposing factor (e.g. patients who have undergone menisectomy are likely to develop osteoarthritis of the knee). In the inflammatory arthritides, it is important to ask specifically about conditions that the patient may not realize are associated (e.g. iritis, psoriasis, sexually transmitted infections, inflammatory bowel disease). Inflammatory musculoskeletal diseases such as RA and ankylosing spondylitis have an inherited component, so ask about a family history of inflammatory arthritis and associated disorders such as inflammatory bowel disease and psoriasis. Research in twins suggests that osteoarthritis also has an inherited element. Many patients remember that their grandparents had ‘rheumatism’ but cannot recall the diagnosis. Ask them to describe the abnormalities they remember and to tell you what they think was wrong.
4 Acute, polyarticular tophaceous gout.
Systemic illness: connective tissue diseases are multisystem conditions that may present with locomotor system problems. It is important to ask about nonspecific symptoms of systemic disease (fever, weight loss, fatigue, breathlessness, lethargy). A comprehensive systems review should follow. The patient may have a rash (particularly the photosensitive rash of SLE). Disability: while taking a rheumatological history, the clinician should estimate how much the patient is able to do and how much the disease interferes with daily life. It is important to determine whether patients can perform simple, everyday tasks of self-care (e.g. washing, dressing) and daily living (e.g. laundry, cooking) and how much help they require. Ask about mobility – can they move easily around their home, are they able to leave the house and do they have a car that they can drive? Finally, ask about their occupation. Specific questions to ask depend on the patient’s level of normal daily activity. Medically minor locomotor complaints may have disastrous psychosocial consequences; for example, tennis elbow may be severely disabling in a manual worker, and a knee problem may render a scaffolder unemployable because of the risk of falling. Patients with disability that affects the activities of daily living may require aids and appliances (e.g. stair-lift, lever taps, raised toilet seat). It is also important to ascertain whether their accommodation is appropriate (e.g. a ground floor flat with wheelchair access). Ask how they manage their shopping and whether they can carry the bags. Finally, ask whether they live alone or have a partner or carer, and whether they have dependants such as young children. Patients with arthritis may suffer anxieties about their sexual relationships. This is a delicate subject but can be explored gently by questions such as: ‘Do you have any problems with the physical side of your relationship? Would you like to discuss it?’ It is important to maintain a sympathetic and non-judgemental attitude and to explore practical solutions, encouraging discussion between the patient and his or her partner and helping them to consider experimenting with different positions for intercourse. Depression is a common cause of disability in patients with musculoskeletal problems, particularly in those with chronic problems such as back pain or fibromyalgia. Depression maybe subclinical, so ask whether the patient feels depressed, tired or ‘weepy’. It is sometimes difficult to determine whether depression is a primary or secondary problem.
THE FOUNDATION YEARS 2:2
Occupational history and leisure activities The occupational history is particularly important because some occupations predispose individuals to specific problems (e.g.
5 Long-leg arthropathy.
45
© 2006 Elsevier Ltd
HISTORY TAKING AND EXAMINATION
Rheumatological Examination
Important points in the history • Constant, unremitting pain suggests the possibility of malignant disease • Pain that keeps the patient awake suggests malignant disease or severe arthritis • Root pain is often burning or tingling in nature • Pain and stiffness that improve with activity suggest an inflammatory disorder • Musculoskeletal disease may be drug-induced
Jane E Dacre Jennifer G Worrall
The locomotor system can be difficult to examine because it involves many different anatomical structures. A full examination is time-consuming and seldom necessary. Most rheumatologists perform a short screening examination followed by a more detailed assessment of the affected structures, with additional examination of other systems if indicated. Variations in examination technique reflect individual practice. This contribution outlines the GALS (gait, arms, legs, spine) screen, which is a quick, reliable screen of the locomotor system, and describes more detailed examination of the lumbar spine, hip, knee, shoulder, elbow, hand and wrist, which are the most common sites for symptoms of locomotor disease.
osteoarthritis of the neck in dentists, osteoarthritis of the feet in dancers). Specific occupational rheumatic diseases such as housemaid’s knee (prepatella bursitis) and weaver’s bottom (ischial bursitis) should also be considered. Ask patients about their job, what they do exactly and how they do it, and how often they take a break. Excessive wrist action (e.g. in a painter and decorator) may cause tenosynovitis. Leisure activities can also predispose individuals to joint pain (e.g. tennis elbow). Ask about violent physical exercise (e.g. contact sports) and excessive joint movement (e.g. gymnastics, yoga); these may cause long-term damage to joints. It is useful to ask about general exercise and the patient’s level of fitness. Individuals who are unfit may develop nonspecific aches and pains in their joints and muscles.
Anatomy and physiology of the locomotor system The locomotor system comprises bones, joints and muscles with associated ligaments, tendons and bursae. The principal types of joint are fibrous and synovial. Synovial joints permit a wide range of movement. Fibrous joints have a simpler structure than synovial joints and are less susceptible to disease and injury; the bones are connected by dense fibrous tissue and only a small range of movement is permitted. In a synovial joint (Figure 1), the bone ends are covered by hyaline cartilage and the whole structure is enclosed in a capsule. The capsule is lined with synovium – a specialized tissue responsible for lubricating the joint and nourishing the articular cartilage, which has no blood supply of its own. Synovium produces synovial fluid by a combination of ultra-filtration of plasma and active secretion of large molecules (e.g. hyaluronan). Normal synovial fluid is highly viscous because of entanglement of these molecules, whereas inflammatory synovial fluid has a low viscosity because the enzymes and free radicals associated with inflammation break them down. The two main causes of arthritis are degeneration and inflammation. In degenerative disease (osteoarthritis), the articular cartilage becomes dehydrated, thin and fibrillated. Abnormal mechanical stress is transmitted to the underlying bone, which
Treatment history Ask the patient about treatment with aspirin and non-steroidal anti-inflammatory drugs, to assess efficacy and side effects (particularly gastric irritation and gastrointestinal bleeding). Establish whether those with RA have taken any second-line therapy (e.g. sulfasalazine, methotrexate, sodium aurothio-malate, D-penicillamine, azathioprine, hydroxy-chloroquine) and whether they developed any side effects (e.g. rashes) that led to stopping of the drug. Remember that patients with inflammatory arthritic conditions may also be taking long-term corticosteroid therapy and may have associated side effects (e.g. diabetes, osteoporosis). Some connective tissue diseases are drug-induced; for example, patients taking long-term phenothiazines for psychiatric conditions may develop a lupus-like syndrome.
FURTHER READING Dacre J E, Kopelman P. Handbook of Clinical Skills. London: Manson, 2002. Doherty M, Dacre J, Dieppe P, Snaith M. The (GALS) Locomotor Screen. Ann Rheumatol 1992; 51: 1165–9.
Jane E Dacre MBBS BSc MD FRCP ILTM is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London.
Acknowledgement The authors thank Manson Publishing and the Photography and Illustrations Centre at the Archway Campus, Royal Free and University College London, UK.
THE FOUNDATION YEARS 2:2
Jennifer G Worrall MD FRCP is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
46
© 2006 Elsevier Ltd