Timing:
Since when, sudden/gradual (over days/weeks/months), all the time or coming and going? getting worse?, ever had this problem before? How many flares per year?
Pattern of joint involvement:
Which joints? Both sides? What order did they become affected? Large/small joints/both? Back/Neck pain?
Any trauma?
Pain:
When do you get the pain? Pain at night? At end of the day/after exercise?/after rest? Does anything help the pain? Does anything make the pain worse? Do you wake in the night?
Stiffness:
Stiff in the morning? For how long? Better or worse after exercise/using the joint? Which joints? Back?
Swelling:
Which joints?
Redness
Warmth
Deformity- nodules
Function: dressing, buttons, stairs, cooking, walking, shopping, sleeping, driving, work, getting out of bed etc
Extraarticular features:
Systemic: fever, night sweats, weight loss, fatigue, lymph nodes, sleep disturbance, appetite, malaise
Raynauds: do your fingers go cold and change colour in cold weather? (white-blue-red) how long before they return to normal? Which fingers? Thumbs too? Toes? Ears? nose? Does it ever happen in the warm? Any ulcers/infarcts?
Any nail problems?
Any rashes? In the sun? Hair loss? Scarring hair loss? Mouth ulcers? Genital ulcers? Swollen/tight skin of hands/arms?
Any dry eye/mouth? Sore/red eye? Any visual disturbance? Any swollen glands? Photophobia? Taste?
Dactylitis? Enthesitis? Tendonitis?
CVS/Resp: Chest pain, SOB (and on exertion), Orthopnoea, PND, Palps, Ankle swelling, Syncope, presyncope, Wheeze, Cough (and sputum colour, amount, consistency, blood, smell), Haemoptysis, Exercise tolerance. CVS risk factors.
GI/GU: Appetite/weight change, Dysphagia, Nausea, vomiting, haematemesis, Indigestion/heartburn, Jaundice, Abdominal pain, Bowels: change/constipation/diarrhoea/stool/blood/mucus/flatus/incontinence, Bloating, tenesmus, urgency, dysuria, urethral/vaginal discharge
Renal: high BP, blood/protein in urine
Neuro: Headaches, Vision- blurring/double/bits missing (jaw pain when chewing, scalp pain), Fits/faints/LOC, Dizziness, Hearing, Weakness, Numbness/tingling, Loss of memory/personality change/confusion/hallucinations, Anxiety/depression. PMH TIA/stroke.
Muscle: pain/weakness/stiffness, which muscles? (proximal/distal), swallow/voice/breathing
ENT: nasal discharge, crusting, sinusitis, nosebleeds
Pregnancy: miscarriages, baby have heart block/rash, any history of DVT/PE/MI, any premature births.
PMH:
Joint disease eg. Gout/RA/OA/SLE
Inflammatory bowel disease
Psoriasis
Autoimmune conditions eg. Thyroid, coeliac, diabetes
Other eg. Heart, lung, kidney problems, cancer, recent infections
FH: as per above
DH: Current medications. Are they helping? What medications have they had in the past?: how long for, what dose, why stopped? Any over-the-counter medications? Allergies. Enquire about NSAIDS, DMARDS, steroids and associated side effects.
SH:
Smoking
Alcohol
Illicit drugs
Occupation
Travel
Sexual history
Pregnant/ breastfeeding/pregnancy plans
Mood, sleep disturbance
Impact on life
ICE
Possible Investigations:
FBC, U+E, LFT, clotting
ESR, CRP, PV
ANA, RF, anti-CCP, ANCA (+PR3/MPO), Immunoglobulins, complement (+/- cryoglobulins)
Antiphospholipid Ab (anticardiolipin, antiB2GPI), lupus anticoagulant screen
(anti-dsDNA, antiscl70, anticentromere Ab, AntiRo, AntiRNP, antism, Antijo1, AntiLa, Antism/RNP, antichromatin, antihistone)
Serum electrophoresis+ bence jones proteins, LDH, blood film
HIV, Hep B+C screen, CMV, EBV
Muscle: CK, TFT
Vitamin D, Ca, P, PTH
Miscellaneous: ACE, HLA-B27, ferritin (stills), urate, anti-GBM, coeliac, ASOT
Nailfold capillaroscopy
Schirmers Test
Renal: BP, urine dip, urine PCR, renal USS, renal biopsy
Joints/Spine: xrays/USS, aspiration, MRI
CVS: ECG, troponin, ECHO, BNP, cMRI
Resp: Sats, ABG, CXR, pulmonary function tests, HRCT, Right heart catheterisation, BAL, broncoscopy
Muscle/Neuro: EMG/NCS, CT/MRI head
Bones: DEXA
GI: abdo USS,OGD, barium swallow, flexible sigmoidoscopy/colonoscopy, CT
Biopsy- skin, muscle, renal, nerve, salivary glands, temporal artery, lymph node