ACC 1

You are a GP at a metro practice. Your patient, Marble, age 82, has come to see you
regarding her knee pain and reduction in the range of movements.

Task
Take relevant histories and interpret her knee xray.
SP information
 Marble, age 82, female

Presenting complaint
 3-year history of progressively worsening pain in both knees
 Knees were stiff for about 20 minutes when she arose in the morning and for a
minutes after getting up from a chair during the day.
 Symptoms are exacerbated by kneeling, squatting, or descending stairs
 Sitting, resting and reclining relieve her pain
 Becomes stiff if she stays in one position for too long
 Symptoms are worse on humid or cold days and occasionally felt as if one of her
knees would give out.
 Hand stiffness – limited range of movements in hands

Past medical history

 Breast cancer diagnosed age 55 – undergone b/l mastectomy and chemo – currently
not on any regime
 Hypertension
 Hypercholesterolemia
 Was hospitalized for dehydration previously.

Social history
 Lives with husband who has dementia
 Receives help from Bluecare twice a week
 Independent with ADLs
Rheumatological history taking
History of presenting complaint
Key rheumatological complaints
PRISMS
 Pain
 Rashes and skin lesions
 Immune
 Stiffness
 Malignancy
 Swelling and Sweats

Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
 Site – where is the pain? (e.g. monoarthritis vs polyarthritis)
 Onset – when did it start? / sudden vs gradual? / associated with trauma?
 Character – how would you describe the pain? (e.g. sharp/dull ache/burning)
 Radiation – does the pain move anywhere else?
 Associations – other symptoms associated with the pain? (e.g. stiffness)
 Time course – worsening/improving/fluctuating/time of day dependent? (e.g.
rheumatoid arthritis worse in mornings vs osteoarthritis worst during/after activity)
 Exacerbating / Relieving factors – does anything make the pain worse or better?
 Severity – on a scale of 0-10, how severe is the pain?

Rashes and skin lesions

 See the dermatological history guide
 Also, ask about nail changes (psoriasis)

Immune
Systemic sclerosis: CREST
 Calcinosis – “Have you noticed any skin changes?”
 Raynaud’s – “Do you notice that your fingertips change colour, particularly in the
cold or during stress?”
 Esophageal dysmotility – “Do you ever find it difficult to swallow?”
 Sclerodactyly – “Have you noticed any thickening/tightening of the skin of your
fingers?”
 Telangiectasia – “Do you notice small spider-like red lines on your face or
elsewhere?”

Systemic Lupus Erythematosus (SLE)

 Constitutional symptoms (fatigue, fever, weight changes)
 Musculoskeletal symptoms (arthralgia, myalgia) – “Do you have any aching in any of
your joints or muscles currently?”
 Dermatological symptoms (malar rash/butterfly rash), photosensitivity, discoid
lupus) – “Have you noticed any rashes or skin changes recently?”
 Renal (acute nephritic disease) – “Have you noticed any blood or other changes in
your urine?”
  Neuropsychiatric (seizure, psychosis) – “Have you noticed any changes in your
thoughts or mood?”
 Pulmonary (pneumonitis, interstitial lung disease) – “Have you felt more short of
breath recently?”
 Gastrointestinal (nausea, dyspepsia, abdominal pain)
 Cardiac (pericarditis, myocarditis) – “Have you experienced any chest pain recently?”
 Haematological (leukopenia, anaemia, thrombocytopenia) – “Have you felt more
fatigued or found that you are bruising more easily recently?”

Sjogren’s syndrome
 Dry eyes
 Dry mouth
 Chronic cough
Stiffness
 Reduced range of movement
 Locking of the joint
 Functional difficulties (e.g. writing, buttoning up shirt, brushing hair)

Malignancy
Ask about B symptoms to rule out malignancy:
 Fever
 Night sweats
 Weight loss

Swelling and Sweats

 Joint swelling – confirm which joints are affected and timescale for onset
 If joint swelling is present, is there associated erythema? – gout/septic arthritis

Ask about extra-articular manifestations of rheumatological joint disease:

 Red/painful eyes – uveitis – ankylosing spondylitis
 Dry eyes – Sjogren’s syndrome
 Breathing difficulties – interstitial lung disease – RA/SLE
 Urethritis – reactive arthritis
 Fever – inflammatory arthropathies/septic arthritis

Ask about history of recent infections

 Septic arthritis (often the causative organism is from another source e.g. urine)
 Reiter’s syndrome (STIs)

Ideas, Concerns and Expectations

Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the
consultation

Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on
certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.

Signposting
Signposting involves explaining to the patient:
 What you have covered – “Ok, so we’ve talked about your symptoms and your
concerns regarding them”
 What you plan to cover next – “Now I’d like to discuss your past medical history and
your medications”

Past medical history

Rheumatological disease
Autoimmune conditions
Peptic ulcers/duodenal ulcers/ischaemic heart disease/ischaemic stroke (NSAIDS would be
contraindicated)
ALLERGIES

Past surgical history

Joint surgery/replacements

Drug history
Analgesics
Immunosuppressants:
 Corticosteroids – e.g. prednisolone
 anti-TNF – e.g. infliximab
 Biologics – e.g. rituximab

Family history
Ask about any history of rheumatological disease in first-degree relatives.

Social history
Occupation:
 Are they currently working?
 Are their joint problems impacting their ability to work?
Mobility – How does the patient mobilise? – e.g.
wheelchair/stick/zimmer frame/independent
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type/volume/strength of alcohol
Recreational drug use – IV drug use is a potential source of joint sepsis

Living situation:
 Own home/care home – adaptations/stairs?
 Who lives with the patient? – is the patient supported at home?
 Any children?
  Any carer input? –what level of care do they receive?

Activities of daily living:

 Is the patient independent and able to fully care for themselves?
 Can they manage self-hygiene/housework/food shopping?

Systemic enquiry
Involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. arthralgia in
psoriatic arthritis).
Choosing which symptoms to ask about depends on the presenting complaint and your level
of experience.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral
oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain /
Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain

Closing the consultation

Thank the patient
Summarise the history
Radiographic features

The hallmarks of DJD are joint space narrowing, sclerosis, and osteophytosis. If all three of
these findings are not present, another diagnosis should be considered.

Joint space narrowing

 characteristically asymmetric in DJD

 least specific findings for DJD, though present in most cases

 joint space narrowing in other arthritides is usually symmetric

Sclerosis

 sclerotic changes occur at joint margins

 frequently seen unless severe osteoporosis is present

Osteophytosis

 are a common DJD finding

 will also be diminished in the setting of osteoporosis

 some osteophytes carry eponymous names, as discussed below

It affects the distal interphalangeal joints (Heberden nodes), the proximal interphalangeal
joints (Bouchard nodes), (mnemonic H-D, B-P) and the base of the thumb in a bilaterally
symmetric fashion. If it is not bilaterally symmetric, the diagnosis of primary osteoarthritis
should be questioned.

Joint erosions

 several joints exhibit erosions as a manifestation of DJD

o temporomandibular joint

o acromioclavicular joint

o sacroiliac joints

o symphysis pubis

Subchondral cyst

 also known as a geode

 cystic formations that occur around joints in a variety of disorders, including

DJD, rheumatoid arthritis, calcium pyrophosphate dihydrate crystal deposition
disease (CPPD) and avascular necrosis.