History taking and examining the patient are essential to making an accurate diagnosis. A thorough medical history is key to the first step towards a diagnosis and will inform the examination and determine appropriate investigations. A clinical history taking can guide the practitioner to a diagnosis whereas examination and investigations merely confirm or refute that considered diagnosis.
The essentials of good consultation and history taking
• Put the patient at ease.
• Establish a rapport with the patient.
• Use open questions to allow the patient to tell their story. Explore the presenting problem, using open and closed questions to clarify and elicit a full history.
• Use your listening skills to be attentive to the patient and the information they provide.
• Remember non-verbal communication is as important as verbal, e.g. eye contact, facial expression, posture, and position.
• Clarify, reflect back, and summarize to verify your understanding of what the patient is saying.
• Explore the patient’s ideas and beliefs, concerns, and expectations.
• Establish a logical sequence of events.
• Show empathy and interest.
History taking consists of a series of topics, which move sequentially to explore the whole of the history (Box 8.1).
This is a short statement summarizing the patient’s presenting symptoms that have brought the patient to seek advice.
History of presenting complaint
An exploration of the symptoms to elicit the cause and effect and factors that precipitated the problem or specific factors that brought on the symptoms. If the patient is able to recount any specific event consider factors such as trauma, overuse, or infections. Infections prior to onset of symptoms are important in viral or reactive forms of arthritis. When the symptoms are insidious in nature, they are less likely to be able to pinpoint any specific event.
As pain is the most common presenting complaint in MSCs, it is important to explore the nature of the pain.
A structured approach to the consultation and examination should be undertaken and mnemonics such as ‘SOCRATES’ may be helpful (Table 8.1).
Table 8.1 An example of using SOCRATES for exploring pain
Where? Radiation? Numbness? Pattern
When and how it started? Changed factors?
E.g. type of pain—shooting, burning, tingling?
Does the pain go elsewhere?
Is it best or worse at different times of day?
Exacerbating or relieving factors
Rated on a scale of 1–10, e.g. effect on sleep
Previous medical history
Related to an existing diagnosis/long-standing disease? Relevance of past medical history, e.g. associated diagnostic criteria. Previous blood tests, investigations, or presenting features, e.g. an asthmatic using long-term steroids leading to osteoporosis.
There are three key screening questions to ask the patient:
• Do you have any pain or stiffness in your muscles, joints, or spine?
• Are you able to dress or undress yourself without any difficulty?
• Are you able to walk up and down stairs without any difficulty?
In addition to the routine clinical history taking and full examination some specific factors should be considered:
• Stiffness—present in both IJD and degenerative joint disease. Ask the patient if there is any particular time of day when symptoms are present or worse:
• The presence of EMS is a classic finding in IJD. Duration of stiffness is an indicator to the severity of the problem, e.g. in poorly controlled inflammatory arthritis (e.g. RA) stiffness can last all day.
• In contrast, mechanical or degenerative joint disease (e.g. OA) stiffness is usually associated with inactivity or at the end of the day.
• Swelling—in the absence of trauma may be indicative of an inflammatory process:
• Is the swelling localized or diffuse?
• Site of swelling, e.g. on the joint line or in the periarticular structures such as tendons (tenosynovitis) or bursae (bursitis)?
• Patterns of joint involvement aid diagnosis, e.g. distribution of joint involvement in seronegative spondyloarthropathies.
• Tingling, numbness, or paraesthesia—may indicate nerve entrapment, e.g.:
• Tingling in the thumb, index, middle finger, and half of the ring finger seen in CTS.
• Numbness and tingling down the leg below the knee—consider sciatica nerve entrapment.
• Muscle weakness—is this localized or generalized weakness?
• Localized weakness indicates a focal problem, e.g. peripheral nerve lesion.
• Generalized weaknesses—consider a systemic cause such as a myopathy.
• Deformity—may be associated with pain but can cause concern to the patient even if symptoms are absent, e.g. Heberden’s nodes, on the DIP joints caused by OA, can be quite disfiguring, but are not always painful.
• Systemic symptoms—may indicate a more serious inflammatory process or sinister pathology:
• Weight loss.
• Night sweats.
• Sleep disturbance—several factors may interfere with normal sleep patterns including anxiety and depression. Poor sleep pattern is also a feature of fibromyalgia.
Are symptoms related to an existing diagnosis/long-standing disease? Explore past medical history for causal factors that may put patient at risk, e.g. an asthmatic using long-term steroids without bone protection leading to osteoporosis.
Detailed drug history (past and present):
• Consider a drug side effect (e.g. statins causing myalgias) or precipitating problems (e.g. drug-induced lupus or diuretics precipitating an acute flare of gout).
• Review prescribed medications and if benefits of treatment were achieved. May also provide an indication of an existing diagnosis the patient has failed to mention.
Some rheumatic conditions have a familial predisposition (e.g. family history of psoriasis, uveitis, or inflammatory bowel disease may point to a diagnosis of a spondyloarthropathy).
Provides an insight into how the condition affects the patient’s life. Considerations should include:
• Marital status and dependants.
• Home environment (bathroom facilities, stairs, etc.).
• Occupation and ability to maintain work with current symptoms.
• Infrastructures that maintain independence, e.g. car owner or ability to access public transport.
• ADL restrictions or problems as a result of the current problem, including hobbies and participation in social interaction.
• Psychological status including perceptions related to the presenting complaint, expectations, needs, and health beliefs/behaviours will have an effect on the individual’s ability to cope with symptoms and possible treatment options. Managing expectations of the patient may need to be negotiated.
Review of systems
This is a methodical approach to examine all health systems to identify key indicators that may lead to or confirm a diagnosis.
The clinical examination is part of a comprehensive process necessary to identify clinical findings in relation to a patient’s presenting complaint. Combined with history taking, the clinical examination should enable the practitioner to define abnormalities or indicators that build a diagnostic picture ( see ‘Assessing the patient’, pp. [link]–[link]; ‘Primary care walk-in clinics’, Chapter 6, p. [link]).
A full clinical examination should always include a review of all body systems to ensure an accurate diagnostic picture. There are many common characteristics or links in MSCs, yet there are also areas where a differential diagnosis is sought between one MSC and another (e.g. scleroderma or SLE). Take note of:
• General: weight loss, anorexia, night sweats are all common systemic features of IJD.
• Cardiovascular or respiratory: episode of pleuritic or pericardial pain (SLE); breathlessness may be associated with anaemia of chronic disease (RA) or pulmonary fibrosis (seropositive arthritis); absence of peripheral pulses (vasculitis); haemoptysis (GPA).
• GI/abdominal GI symptoms such as diarrhoea (ReA or a seronegative arthritis associated with inflammatory bowel disease if chronic); oesophageal reflux and dysphagia (systemic sclerosis).
• Genitourinary/gynaecological symptoms: urethral discharge (ReA); genital ulceration (Behçet’s disease); dyspareunia due to vaginal dryness (SS); late miscarriages (APS).
• Skin and mucous membranes: psoriasis, photosensitive rash (SLE or another CTD); oral ulceration (SLE); xerostomia, i.e. dry mouth (SS); symptoms of Raynaud’s phenomenon worsening in later life or new-onset Raynaud’s is associated with CTDs or exacerbated by medications, e.g. beta blockers.
• Eye symptoms, particularly episodes of acute red eyes: conjunctivitis (ReA); uveitis (spondyloarthropathies); episcleritis (painless); scleritis (painful); keratoconjunctivitis (RA) or xerophthalmia, i.e. dry eyes (SS); visual disturbance and blindness (temporal arteritis).
General examination including joint examination
All patients with musculoskeletal disease, whether being admitted to a ward or being seen in clinic, should have regular assessments that include:
• Urinalysis checked for blood, protein, and glucose:
• Blood and protein are indicative of renal involvement; particularly important if the patient has a CTD.
• Blood and protein may indicate an infection in a patient on immunosuppressive therapy, indicating a need for further investigation (e.g. midstream specimen of urine).
• Glycosuria may be present and may indicate the development of diabetes (key in those treated with long-term corticosteroid therapy).
• Blood pressure:
• ↑ blood pressure may again indicate renal involvement in CTD or hypertension requiring further treatment.
• Regular monitoring is required for some medications of the blood pressure, e.g. ciclosporin and leflunomide.
• Weight and height should be recorded for baseline measurements:
• Weight may be required to calculate drug dosages.
• Height is also useful for assessing if there is a loss of height as a result of osteoporosis.
A good musculoskeletal examination relies on patient cooperation in order for them to relax their muscles so that important clinical signs are not missed:
• Always introduce yourself before undertaking any joint examination.
• Explain what you are going to do and gain the consent of the patient.
• Ask the patient to let you know if they experience any pain or discomfort at any time during the examination.
Gait, arms, legs, spine (GALS)
GALS is a brief and sensitive way of assessing the whole of the musculoskeletal system for any signs of early disease and to identify areas where there is a problem that needs to be examined in more details. It looks at the first movements affected in any musculoskeletal disease or pathology.
Table 8.2 shows the recording of a normal GALS screen where gait is normal, and appearance and movement of arms, legs, and spine are all normal. The findings of the GALS screen can be tabulated in a shorthand form.
Table 8.2 A normal GALS screen
If an inflammatory arthritis is suspected
If an inflammatory arthritis is suspected based upon the clinical assessment and presenting signs and symptoms, patients should be promptly managed so that a firm diagnosis is made, and, if appropriate, treatment can be instigated based upon a treat to target approach. For RA this approach would require a 28 joint-count disease assessment tool (DAS28). Tender and swollen joints commonly affected are examined and scored, together with bloods for ESR or CRP and a patient global assessment of their general well-being using a VAS. The DAS28 has been validated for use with either ESR or CRP. However, whichever blood test is used, the subsequent assessments should use the same blood test for calculating the DAS28 score. The calculation (using a DAS calculator) provides a composite score, e.g. 5.15, the DAS28 score. The DAS28 score for high disease activity is >5.15 with scores between 3.2 and 5.1 considered moderate disease activity. A score <3.2 is considered low disease activity and <2.6 remission.
Also see ‘Rheumatoid arthritis: assessing and managing the disease’, Chapter 4, pp. [link]–[link].
There are three key screening questions to ask the patient
• Do you have any pain or stiffness in your muscles, joints, or spine?
• Are you able to dress or undress yourself without any difficulty?
• Are you able to walk up and downstairs without any difficulty?
Observe the patient walking, turning, and walking back:
• Look for symmetry of movement in the arms, legs, and pelvic movements; normal stride length; and the ability to turn quickly.
• Observe for an asymmetric antalgic gait where pain or deformity causes the patient to hurry from one leg onto the other.
Inspection of the patient standing in the anatomical position
• Observe from posterior, anterior, and lateral views.
• Inspect for normal muscle bulk and symmetry of shoulder girdles, spine, arms, buttocks, thighs, and calves.
• Observe for any obvious signs of swollen or deformed joints, including knees and toes or signs of flexion deformity, e.g. at the elbows.
• Inspect for normal spinal curves—cervical lordosis, thoracic kyphosis, lumbar lordosis, or signs of scoliosis in the spine.
• Look at symmetry of level iliac crests and gluteal folds.
• Signs of valgus or varus deformities in the knees or ankles, hip or knee flexion deformities, or signs of hyperextension of the knee (known as genu recurvatum).
• Signs of rheumatoid nodules of extensors surfaces of elbows and Achilles tendons.
• Signs of olecranon bursitis (at the elbow) or Achilles bursitis.
• Normal alignment and thickness of the Achilles tendon.
• Popliteal swelling, indicating a Baker’s cyst.
• Loss of the medial arches of the foot.
• Ask the patient to open their jaw and move it from side to side (temporomandibular joint).
• Ask the patient to try and put their ear to their shoulder on each side (lateral flexion of cervical spine).
• Press over the midpoint of the supraspinatus muscle and roll the skin over the trapezius muscle. A wince and withdraw indicates the hyperalgesic response of fibromyalgia.
• Ask the patient to bend forward from the waist to touch the toes, place a couple of fingers over the spinous processes and see if they move together on standing upright (if they do not this may be a sign of inflammatory spine disease).
• Place the patient’s hands behind their head and push their elbows back (this tests abduction and external rotation of the shoulders as well as flexion at the elbows).
• Inspect the palms of the hands for swelling, wasting, or other deformity.
• Turn the hands over, keeping the elbows tucked in to the side (this tests pronation and supination of both elbows and wrist).
• Inspect the dorsum of the hands for muscle wasting, swelling, and deformity.
• Inspect the nails for any signs of pitting or onycholysis (seen in PsA), nailfold infarct, or splinter haemorrhages (possible vasculitis activity).
• Ask the patient to make a fist, test power grip.
• Touch the pulp of each of the fingers to the thumb (opposition).
• Squeeze across the MCP joints—pain indicates signs of inflammatory synovitis.
Examination of the patient lying on the couch
• Ask the patient to bend their knee and bring their heel as close in to their buttock as they can, one leg at a time.
• Place your hand over the knee to feel for any crepitus.
• While the knee is flexed, take the hip up to 90° and internally rotate the hip:
• Achieved by holding the lower part of the leg and pushing the foot outwards.
• Note how far the hip moves—in ♀ this ROM is > ♂.
• Early disease in the hip will elicit pain radiating into the groin.
• Return the leg to the neutral straight position and test for any signs of swelling using:
• A balloon and bulge sign.
• A patellar tap.
• Inspect the feet for any signs of deformity.
• Inspect the toe nails (as for the finger nails).
• Inspect the soles of the feet for any signs of callus formation due to subluxation of the metatarsal heads.
• Squeeze across the metatarsals—pain on doing this is indicative of signs of synovitis in the metatarsals.
Also see ‘Regional examination of the musculoskeletal system’, Chapter 8, pp. [link]–[link]; ‘Primary care walk-in clinics’, Chapter 6, p. [link]; ‘History taking and clinical examination’, pp. [link]–[link].
Regional examination of the musculoskeletal system is a system of examination developed to ensure that examinations are conducted in a standardized way.
The key steps in any musculoskeletal examination are:
• Always start with a visual inspection of the patient at rest.
• Compare both sides for symmetry.
• Skin changes, scars, muscle bulk, and swelling in and around the joint and the periarticular structures.
• Signs of deformity in alignment and posture of the joint.
• Feel the skin for temperature using the back of the hand, in particular across the joint line and at other relevant sites.
• Any swellings should be assessed for fluctuance and mobility.
• Hard, bony swellings of OA can be distinguished from the soft, boggy swelling of synovitis in IJD.
• Tenderness is an important clinical sign to elicit both in and around the joint.
• Synovitis is detected by the triad of warmth, swelling, and tenderness around the joint line.
• The full ROM of the joint should be assessed.
• Both sides need to be compared.
• As a general rule, both active and then passive movement should be assessed. (Active is where the patient moves, passive where the examiner moves the joint.)
• When examining the joint, loss of full flexion or extension should be detected, and that restriction recorded as mild, moderate, or severe restriction in ROM.
• The quality of the movement should also be noted with reference to abnormalities such as crepitus being recorded.
• In some instances the joint may move beyond the normal range—this is called hypermobility.
It is important as part of a musculoskeletal examination to relate findings to function, e.g. limited elbow flexion—can the patient still feed themselves?
Also see ‘Musculoskeletal physical examination’, pp. [link]–[link]; ‘Regional -examination of the musculoskeletal system’, pp. [link]–[link]; ‘Primary care walk-in clinics’, Chapter 6, p. [link]; ‘History taking and clinical examination’, Chapter 8, pp. [link]–[link].
Examination of the hand and wrist
• With hands palm down, look for obvious swelling, deformity, posture, muscle wasting, particularly of the interosseous muscles of the back of the hand, and scarring.
• Skin for thinning and bruising (steroid use) or rashes.
• Nail changes of psoriasis (pitting and onycholysis), splinter haemorrhages, and nailfold infarct (vasculitis).
• Which joints are affected, are the changes symmetrical or asymmetrical?
• Ask the patient to turn their hands over.
• Inspect the palmar aspect of the hands, look for the same things as palms down, in particular, wasting of the thenar and hypothenar eminences, and signs of palmar erythema.
• Assess for temperature over the joint lines of wrist and MCP, PIP, and DIP joints using the back of the hand.
• Feel for radial pulses.
• Gently squeeze across the MCP joints to assess for tenderness.
• Feel for swelling and tenderness over each of the joint lines and over the tendon sheaths.
• Test for median and ulnar nerve sensation by stroking over thenar and hypothenar eminences.
• Assess radial sensation over the web space of the thumb and index finger.
• Palpate the patient’s wrists.
• Feel up the arm to the elbow to look and feel for rheumatoid nodules or psoriatic plaques over the extensor surface.
• Ask the patient to straighten their fingers fully.
• Get the patient to make a fist (power grip).
• Assess wrist flexion and extension, with the patient actively doing, then passively.
• Touch finger pulp of each finger to thumb (pincer grip).
• Move each joint passively feeling for crepitus.
• Ask the patient to grip two of your fingers to assess power grip.
• Ask the patient to pinch your finger to assess pincer grip.
• Ask the patient to pick up a small object such as a coin or paper clip from your hand. This is to assess pincer grip and function.
• Skin changes (scars, psoriatic plaques).
• Swelling (synovitis, bursitis over the olecranon process, rheumatoid nodules).
• Deformity or muscle wasting.
• Joint line for:
• Crepitus on movement.
• Medial and lateral epicondyles for tenderness.
• Olecranon bursa for swelling and tenderness.
• Active and passive flexion and extension, pronation, and supination.
• Compare one side to the other.
• From the front (skin changes, scars, swelling, attitude).
• From behind (wasting, deformity).
• Compare both sides, are they symmetrical?
• Is posture normal?
• Palpate in turn the sternoclavicular joint, ACJ, and glenohumeral joint for:
• Joint line tenderness.
• Swelling or crepitus.
• Palpate the muscle bulk of supraspinatus, infraspinatus, and deltoid.
• Identify any muscle tenderness.
• Ask the patient to put their hands behind their head and then behind their back.
• Abduction (assessing for scapular movement and painful arc).
• Flexion and extension.
• Passive range of movement, if active movement is restricted.
• Includes getting the hands behind the head and behind the back as these movements are needed for washing and grooming.
See ‘The elbow’, p. [link].
Inspection of the patient when standing:
• From the front for a pelvic tilt or rotational deformity.
• From the side for flexion deformity or scars overlying the hip.
• From behind for muscle wasting (gluteal muscle bulk in particular).
• Is there any suggestion of leg length inequality?
• Measure real leg length with a tape measure.
• Assess full hip flexion with the knee flexed at 90o; observe the patient’s face for signs of pain.
• Assess for fixed flexion deformity of the hip by performing Thomas’ test. To do this, fully flex hip while the opposite hip is observed to see if it lifts off the couch if it does this confirms a fixed flexion deformity in that hip.
• Assess internal and external rotation with the knee in 90° flexion, passively—often limited particularly in internal rotation in hip disease.
• A Trendelenburg test involves the patient standing on one leg—if there is any hip disease the pelvis dips on the non-weight-bearing side when the patient stands on the affected hip.
• Inspection of the patient on the couch.
• Skin changes, scars, psoriasis.
• Valgus or varus deformity.
• Quadriceps wasting.
• For temperature ↑ using the back of the hand.
• Palpate the borders of the patella for tenderness.
• With the knee flexed, palpate for joint line tenderness.
• Feel in the popliteal fossa for swelling (Baker’s cyst).
• Insertion of the collateral ligaments.
• Effusion—include bulge sign, patellar tap, and balloon sign.
• Assess full flexion and extension actively and passively.
• Assess stability of the collateral ligaments of the knee by placing the leg in 15° of flexion and alternately stressing the joint line on each side, by placing one hand on the opposite side of the joint line to that which you are testing.
• Anterior drawer test for ACLs is performed by placing both hands around the upper tibia, with thumbs over the tibial tuberosity and index fingers tucked under the hamstrings to make sure they are relaxed. Stabilize the lower tibia with the upper forearm and gently pull the upper tibia forward. If there is any laxity of the ACLs, there will be a significant degree of movement.
Foot and ankle
With the patient sitting on the bed:
• Observe the feet, comparing both side for symmetry.
• Inspect the dorsal surface for skin changes, nail changes, and scars.
• Observe alignment of the toes and evidence of hallux valgus of the big toe.
• Look for joint clawing of the toes, swelling, and callus formation.
• Soles of the feet for callus formation and adventitious bursae.
• Inspect the patient’s footwear for any abnormal wearing or evidence of poor fit. Also look at any orthoses.
With the patient weight-bearing:
• Look at the forefoot for toe alignment and the midfoot for foot arch position.
• From behind, look at the Achilles tendon for thickening or swelling.
• Observe for normal alignment of the hindfoot; in disease of the ankle there may be varus or valgus deformity at the ankle.
• Temperature over the foot and ankle and check for peripheral pulses.
• Metatarsal squeeze for MTP joint tenderness.
• Palpate the midfoot, ankle, and sub-talar joint for tenderness.
• Move actively and passively assessing for pain, crepitus, and ↓ ROM.
• True ankle joint—dorsiflexion and plantar flexion.
• Subtalar joint—abduction and adduction.
• Mid-tarsal joints—inversion and eversion.
• First MTP joint—flexion and extension.
Look at the patient when standing:
• From the back for any signs of scoliosis, muscle spasm, pelvic tilt, and skin changes.
• From the side for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis (Fig. 8.3).
Palpate the spine starting at the occiput to the sacrum and sacroiliac joints feeling for:
• Paraspinal muscles for spasm or tenderness.
• Spinous processes for alignment or local tenderness.
With the patient standing:
• Lumbar spine flexion and extension (assess using fingers on a couple of spinous processes).
• Lateral flexion of lumbar spine, by asking the patient to run each hand in turn down the outside of the adjacent leg.
With the patient sitting:
• Thoracic spine rotation.
• Cervical spine movements of flexion, extension, lateral flexion, and rotation.
• With the patient lying as flat as possible, perform a SLR.
• Assess limb reflexes (upper and lower) and dorsiflexion of the big toe.