Joint Pain

Joint pain is one of the most common presentations you will see. Again we are interested in the onset, timing etc. A key aspect for joint pain is working out whether this is an inflammatory or non-inflammatory problem. The difference in prognosis, treatment of osteoarthritis vs rheumatoid is substantial. So an important symptom to explore is STIFFNESS. Is it worse in the morning? How long does it last?

So what are the differentials for joint pain?

Inflammatory

• Rheumatoid arthritis
• Rheumatoid variants
• Gout
• Pseud-gout
• Bursitis
• Septic arthritis

Therefore, in the specific systems review, we need to check the MSK system for other joint involvement. Also check the local neuro-vascular structure of the joint, and finally an autoimmune screen for more sinister conditions. ‌

N.B. If experiencing back pain, a medical emergency is CAUDA EQUINA syndrome. This is pressure on the nerves which emerge from the lumbar-sacral plexus and can lead to permanent incontinence, disability. Leads to back pain + saddle anaesthesia + urinary incontinence and loss of anal sphincter tone!!! 

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
• So, what has brought you in to see the doctor today?

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?
• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain

• Joint pain – Ok, so you mentioned that you have experienced some joint pain, can you tell me a little bit more?

• Stiffness – Can you tell me a little bit more about this?

(I) Ideas, Concerns, Expectations

• Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
• Are you particularly concerned about anything?
• What were you hoping to get out of the visit today?

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

Specific Systems Review

• MSK:
  Are there any other joints affected?

• Neurovascular:
  Have you got any weakness in the muscles?
  Have you noticed any changes in sensation around the joint?

• Autoimmune:
  Have you noticed any rashes or changes in your nails? (Psoriasis)
  Have you noticed any changes in your vision?
  Have you got any breathing difficulties?

• Back pain (cauda equina screen): 
  Have you lost any sensation around your buttocks?
  Have you experienced any problems with urination?
  Have you experienced any problems passing stool?

General Systems Review: (Ask general questions to rule out red flags):

(Fever) Have you got a fever?

(Glands) Have you got any swollen glands?

(Weight) Have you noticed any weight loss?

(Appetite) Have you noticed any changes in your appetite?

(Bowels) Have you experienced any changes in your bowel movements?

(Waterworks) Are your waterworks all fine?

(Tired) Have you been feeling more tired than usual?

(Travel) Have you travelled anywhere recently?

(Night sweats) Do you wake up in the night drenched in sweat?

(Rash) Have you got any rashes?

(If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?

(P) Past Medical History

• And now, about your health in general, have you ever seen your doctor about something like this before?
• Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
• Have you ever had any surgeries?
• Have you ever been admitted into hospital before?

(F) Family History

• Is there any incidence of joint conditions in your family?
• Are there any other conditions which run in your family?

(D) Drug History

• Are you currently taking any prescribed medication?
• Do you take anything else, over the counter?
• Do you have any allergies?

(S) Social History

• (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
• (Home) Do you live with any family or friends? Are you married? Do you have any children?
• (Independence) Would you say that you are fairly independent?

And now these are some questions that we ask everyone:

• Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
• Do you drink? (How much a week? And for how long?)​
• Is there any recreational drug use?

Conclusion

• Ok, just to recap to make sure I haven’t missed anything (quick summary.)
• Thank you very much, I’ll relay this information to the consultant and then we can go from there. Do you have any questions?