Common Orthopaedic/Rheumatological Histories

Presenting Exploding symptom Relevant system reviews Differential diagnoses Clues to differential complaint Grouping Differentials Lower back Pain General Orthopaedic Muscular •Acute onset lower back pain pain Site Fever, night sweats, weight loss •In paraspinal muscles, not central Onset Lumbar spondylosis •Chronic episodic mechanical lower back pain Character Neuro and facet joint •Backache related to standing/walking a Radiation •Motor: weakness/wasting, syndrome lot/sitting in one place Associated symptoms incontinence (lumbar arthritis) •Progressive stiffening Timing •Sensory: pain, numbness, Lumbar disc •Acute onset while lifting/bending Exacerbating/relieving factors tingling prolapse •Severe pain Severity •True sciatica GI/urinary •Neurological symptoms e.g. weakness, Associations •Incontinence numbness (usually L5/S1 distribution) Sciatica, stiffness/deformity, Discitis •Fever and systemic upset sciatica, incontinence, •Risk factors e.g. injecting drug user neurological symptoms Spinal fracture •History of trauma Red flags •Sudden onset •Cauda equina: urinary Rheumatological Ankylosing •Morning stiffness retention/incontinence, faecal spondylitis •Pain worse on rest incontinence, bilateral leg Other Myeloma bone lesions pain, severe/progressive differentials Bony metastasis neurological deficit Paget’s disease •Infection or cancer: age <16 Spondylolithesis or >55 years at onset, cancer, Osteoportic vertebral collapse weight loss, fever, night Non-orthopaedic/rhematological sweats, injecting drugs, Pyelonephritis immunosuppression PID •Fracture: trauma Pancreatitis •Spondyloarthropathy: EMS, AAA night pain, worse with rest

Joint pain/ Pain General Rheumatological Rheumatoid •Slowly progressive symmetrical polyarthritis stiffness/ Site(s) Fever, rashes, weight loss arthritis •Small joints (commonly of hand) swelling Onset •Deforming Character Rheumatological •Early morning stiffness Radiation •Joints: pain, stiffness, swelling Gout •First MTP joint most commonly affected Associated symptoms •Work down body: skin (rashes, •Isolated swollen, hot, painful joint Timing ulcers, raynauds), hair loss, eyes •Hyperuricaemia risk factors e.g. diuretics, Exacerbating/relieving factors (redness, dryness), mouth alcohol excess (esp beer), renal disease Severity (dryness), chest (breathlessness, Psoriatic arthritis •Associated skin plaques and nail changes SOB), GI (IBD symptoms), GU •Early morning stiffness Stiffness/swelling (discharge) •Many patterns of joint involvement •Worse in morning?, how long SLE •Systemically illness with intermittent fevers for (30mins=inflammatory, •Photosensitive rash 5mins=osteoarthritis) •Generalised myalgia and arthralgia •Better or worse after exercise •Other systemic Sx (e.g. psych disturbance, •Sleep disturbance pleurisy, ulcers) •Loss of function Enteropathic •Symmetrical arthritis of lower limb joints arthritis and SI joints •Early morning stiffness •Symptoms/diagnosis of Crohn’s or UC Orthopaedic Osteoarthritis •Elderly •Worse on movement (rest helps) and at end of day Septic arthritis •Isolated hot, red, swollen joint •Agonizingly painful •Systemically unwell with fever Other Single joint differentials Traumatic (dislocation/fracture/ligament injury) Haemophilia haemarthrosis Pseudogout Joint specific problems (e.g. knee – chondromalacia patellae, Osgood- Schlatter’s disease, patellar tendinitis; hip – avascular necrosis) Adhesive capsulitis Transient synovitis Bursitis Reiter’s disease Multiple joints Viral polyarthritis (flu, HIV, hepatitis, rubella) Other connective tissue disorders e.g. systemic sclerosis, polymyositis, polyarteritis nodosa Other spondyloarthropathies e.g. ankylosing spondylitis, Reiter’s disease, Behcet’s syndrome, juvenile chronic arthritis Rheumatic fever