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 »