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 Pagets 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 Crohns 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-
Schlatters disease, patellar tendinitis; hip avascular necrosis)
Adhesive capsulitis
Transient synovitis
Bursitis
Reiters 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, Reiters
disease, Behcets syndrome, juvenile chronic arthritis
Rheumatic fever

2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision