History Taking · Foundation · Rheumatology

Joint Pain and Swelling in a 32-Year-Old Man

Practise this PLAB 2 history taking station on Reactive Arthritis. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a walk-in clinic. Mr Zain Malhotra, a 32-year-old man, has come to see you with joint pain and swelling that started two weeks ago. He reports recent gastrointestinal symptoms that have since resolved. Please take a focused history and discuss your initial assessment of his presentation.

Background notes: PMH: Nil significant

What this station tests

  • Connecting the temporal relationship: joint symptoms 1 to 3 weeks after a gastrointestinal infection
  • Asymmetric lower limb oligoarthritis as the characteristic pattern of reactive arthritis
  • Screening for the classic triad: arthritis, conjunctivitis, urethritis, plus skin and mucosal features
  • Taking a sexual history to consider chlamydial trigger alongside gastrointestinal causes
  • RF and anti-CCP negative: distinguishing reactive arthritis (seronegative spondyloarthropathy) from RA

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Post-infectious arthritis requires the candidate to connect the joint symptoms to the preceding infection. The classic triad (arthritis, urethritis, conjunctivitis) may not be complete. Mr Malhotra is 32, presenting with 2 weeks of joint pain and swelling in knees, ankles, and feet, starting about a week after a gastrointestinal illness. Open with: 'Tell me about the joint pain and when it started in relation to your stomach upset.'

Core approach

Establish the temporal relationship. GI illness (diarrhoea, abdominal cramps, fever) 3 weeks ago, resolved after 2 to 3 days. One week later, right knee became swollen and painful, followed by ankles and feet. This 1 to 3-week gap between infection and arthritis is the diagnostic clue for reactive arthritis.

Characterise the arthritis. Asymmetrical oligoarthritis predominantly affecting lower limbs (knees, ankles, feet). Large joint involvement. This pattern, asymmetric, lower limb, oligoarticular, post-infectious, distinguishes reactive arthritis from RA (symmetrical, small joints) and gout (monoarticular, acute onset).

Screen for the classic triad. Conjunctivitis: any eye redness, irritation, discharge? Urethritis: any dysuria, urethral discharge? (Ask sensitively.) Skin: keratoderma blennorrhagicum (soles), circinate balanitis? Oral ulcers? Nail changes? The full triad is present in only about 30% of cases, but screening for extra-articular features supports the diagnosis.

Identify the triggering organism. The GI illness suggests Campylobacter, Salmonella, Shigella, or Yersinia. Also consider Chlamydia (genitourinary trigger): take a sexual history sensitively.

Closing and safety netting

Explain the diagnosis: 'The joint swelling that developed after your stomach infection is a condition called reactive arthritis. Your immune system reacted to the infection and started attacking your joints. The infection itself has cleared, but the immune reaction is still causing inflammation.'

Investigations: ESR/CRP (elevated), RF and anti-CCP (negative, distinguishing from RA), stool culture (may identify organism), chlamydia testing if urethritis present, HLA-B27 (positive in 60 to 80% but not diagnostic). Joint aspiration if large effusion (exclude septic arthritis). Treatment: NSAIDs first-line for symptom relief. If severe or persistent: short course prednisolone or intra-articular steroid injection. If not responding: rheumatology referral for consideration of DMARDs.

Prognosis: most cases resolve within 3 to 6 months. Some become chronic (10 to 20%). Safety net: 'If you develop eye redness or pain, difficulty urinating, or your joints get significantly worse, come back.' Reassure about football: he should be able to return once the inflammation settles.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for reactive arthritis. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Temporal relationship established. Asymmetric oligoarthritis pattern documented. Triad screening (eyes, urethra, skin). GI infection characterised. Sexual history taken. Differentials considered (RA, gout, septic arthritis).

Costs marks: Not connecting to infection. Not screening triad. Not considering chlamydia. Missing the asymmetric pattern.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: NSAIDs first-line. Investigations: ESR/CRP, RF, stool culture, chlamydia. Joint aspiration if effusion. Steroid options for severe cases. Rheumatology referral if persistent. Prognosis discussed (3-6 months, most resolve).

Costs marks: No investigations. Not considering joint aspiration. No prognosis discussion.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining the autoimmune mechanism simply. Addressing football concern. Sensitive sexual history. Providing realistic recovery timeline.

Costs marks: Not explaining the mechanism. Being insensitive about sexual history. Not addressing functional impact.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not connecting the joint symptoms to the preceding GI illness. The 1 to 3-week gap is the diagnostic clue. Candidates who investigate the joints without asking about recent infections miss the aetiology.
  2. Not screening for conjunctivitis and urethritis. The classic triad is only present in 30% of cases, but asking about eye and urinary symptoms supports the diagnosis and identifies complications.
  3. Not considering chlamydia. Reactive arthritis can be triggered by genitourinary as well as gastrointestinal infections. Candidates who do not take a sexual history may miss a treatable cause.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the reactive arthritis history in this PLAB 2 station?

Post-infectious arthritis requires the candidate to connect the joint symptoms to the preceding infection. The classic triad (arthritis, urethritis, conjunctivitis) may not be complete. Mr Malhotra is 32, presenting with 2 weeks of joint pain and swelling in knees, ankles, and feet, starting about a week after a gastrointestinal illness.

What are examiners marking in this reactive arthritis station?

Marks are won for: Temporal relationship established. Asymmetric oligoarthritis pattern documented. Triad screening (eyes, urethra, skin). GI infection characterised. Sexual history taken. Marks are lost for: Not connecting to infection. Not screening triad. Not considering chlamydia. Missing the asymmetric pattern.

What is the most common mistake candidates make in this reactive arthritis station?

Not connecting the joint symptoms to the preceding GI illness. The 1 to 3-week gap is the diagnostic clue. Candidates who investigate the joints without asking about recent infections miss the aetiology.

How do I prepare for this station if I have not managed reactive arthritis in clinical practice?

This station rewards process over personal experience. The skill being assessed: Asymmetric lower limb oligoarthritis as the characteristic pattern of reactive arthritis. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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