This guide is designed to help you take a safe, structured, and clinically relevant history when assessing a patient with acute joint pain or swelling. It focusses on gathering the key information needed to identify red flags (such as septic arthritis), build a differential diagnosis, and guide appropriate investigations.
- Introduce yourself:
“Hello, my name is [Name]. I am a medical student working with the team today.” - Confirm patient details:
Ask for full name and date of birth. - Gain consent & set agenda:
- Ask how they would like to be addressed.
- Explain:
“I’d like to ask you a few questions about why you’ve come into hospital today and then examine your joint if that’s okay with you.”
- Check if anyone else is present and whether the patient is happy for them to stay.
Contents
Presenting complaint: acute joint pain/swelling
Start with open questions before narrowing down:
- “What has brought you into hospital today?”
- “Can you tell me a little more about that?”
Key elements to explore in history of presenting complaint
- Onset: When did the pain/swelling start? Sudden or gradual?
- Course: Constant or intermittent? Getting better, worse, or unchanged?
- Site: Which joint(s) are affected? One or multiple?
- Character: Pain description (sharp, throbbing, dull).
- Radiation: Does pain spread elsewhere?
- Associated symptoms:
- Fever, rigors (think infection)
- Morning stiffness (>30 min → inflammatory)
- Rash, eye symptoms, urethral discharge (think reactive arthritis)
- Precipitating/relieving factors: Any triggers? Anything that helps?
- Functional impact: Ability to weight-bear or use the joint.
- Sexual history: Particularly if suspecting gonococcal arthritis.
- Prosthetic joints or recent surgery: Risk factor for infection.
Red Flags (Septic Arthritis)
Always rule out septic arthritis first – this is a surgical emergency.
Typical presentation:
- Sudden painful, hot, swollen joint (often knee)
- Fever/rigors
- Unable to weight-bear
- Markedly reduced active and passive range of motion
Once this is ruled out, further differentials including crystal arthropathies, rheumatological conditions, and trauma are to be considered and appropriate treatment commenced.
Differential diagnoses
| Differentials | Symptoms |
| Septic arthritis | Acute onset Erythematous painful swollen joint Often single joint Reduced range of movement; ± infective symptoms (fever, rigors) Inability to weight bear |
| Crystal arthropathies: | |
| Gout | Often starts in 1st metatarsophalangeal joint (podagra) History of bouts of swollen red painful joint(s) which resolve Other joints often affected include wrists, knees, elbows, finger joints |
| Pseudogout | Similar presentation and risk factors to gout Differentiated through joint aspirate microscopy Driven by calcium crystals |
| Rheumatological conditions: | |
| Rheumatoid arthritis | Often affects small joints of hands and feet sparing DIPJs, but can be any joint Often symmetrical distribution Painful red swollen joints that are stiff particularly in the mornings May also have rheumatoid nodules and in older patients deformities of the digits including swan neck and Boutonniere’s with ulnar deviation of the fingers, however these are seen less frequently with DMARDs |
| Spondyloarthropathies: | |
| Reactive arthritis | Follows infection however the synovial fluid is sterile (the joint itself is not infected) Asymmetrical distribution with multiple joints affected Associated with HLA-B27 serotypeCan remain for 6 months |
| Psoriatic arthritis | Different joint distributions seen including multiple joints in a single finger (sausage finger/dactylitis) or DIPJs Skin often affected with psoriatic plaques seen on extensor surfaces and scalp |
| Osteoarthritis | Chronic condition caused by wear and tear of joints over lifetime Pain and stiffness of joint increase throughout the day (i.e. not an inflammatory condition) May see osteophytes (bony nodules) |
| Trauma | History of trauma to the affected joint causing haemarthrosis |
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history about the acute painful/swollen joint you can show how much you know about the various causes by explicitly asking about the following things…
Past Medical History/Risk Factors
- Septic arthritis risk factors: skin infection/ulceration (contiguous spread); intra-articular injection, prosthetic joint, recent joint surgery (direct inoculation); diabetes, HIV, immunosuppression, IVDU, osteoarthritis, sepsis, sexual activity for gonococcal arthritis (haematogenous spread)
- Reactive arthritis risk factors: recent gastroenteritis or dysentry (Shigella, Salmonella, Yersinia, Campylobacter); STI (Chlamydia); anterior uveitis; circinate balanitis; keratoderma blenorrhagica; urethritis (non-gonococcal)
- Psoriatic arthritis risk factors: psoriatic plaques on skin, nail changes (pitting, onycholysis, subungual hyperkeratosis, loss of nail); enthesitis
- Osteoarthritis risk factors: obesity, increased age, past trauma, female sex, hypermobility of joint, developmental dysplasia of hip, excessive use of the joint
- Gout risk factors: older age, high BMI, excess alcohol and meat consumption, male sex
- Haemarthrosis risk factors: anticoagulation use, haematological disorders that increase the risk of bleeding
Drug History
- Immunosuppressants / Biologics (e.g. anti-TNF, rituximab) – ↑ risk of septic arthritis, including atypical organisms
- Diuretics (thiazides, loop diuretics) – ↑ uric acid levels, can precipitate gout
- Anticoagulants (warfarin, DOACs, heparin) – ↑ risk of haemarthrosis, especially after minor trauma
- Quinolone antibiotics (e.g. ciprofloxacin) – associated with tendinopathy/tendon rupture → joint pain/swelling may be periarticular
- Colchicine / Allopurinol / Febuxostat – ask if patient is on treatment for gout or recently started urate-lowering therapy (may trigger flare)
Social History
- Smoking (RA risk)
- Alcohol (increases risk of gout)
- Recreational drug use (IVDU risk)
- Living environment and social support
Family History
- Family history of the condition is a risk factor for: rheumatoid arthritis, osteoarthritis, gout, psoriatic arthritis, spondylarthropathies.
References
1. British Society for Rheumatology (BSR): Guideline for management of hot swollen joints in adults. https://www.rheumatology.org.uk/guidelines
2. BMJ Best Practice: Evaluation of inflamed joint – Differential diagnosis of symptoms.
3. TeachMeSurgery. Acutely Swollen Joint. https://teachmesurgery.com/orthopaedic/principles/acutely-swollen-joint/
4. TeachMeSurgery. Septic Arthritis – Clinical Features – Management. https://teachmesurgery.com/orthopaedic/principles/septic-arthritis/
- Author: Dr Charlotte Smith
- Editor: Dr Wei Jia Liu
