History Taking · Foundation · Rheumatology

Symmetrical Joint Pain and Swelling in a 52-Year-Old Woman

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

Clinical scenario

You are an FY2 doctor in a general practice clinic. Mrs Cathy Hughes, a 52-year-old woman, has come to see you with symmetrical pain and swelling in her hands and feet over the past three months. She reports morning stiffness lasting more than an hour. She is having difficulty managing her work and household tasks. Please take a focused history and discuss your assessment and management plan.

Background notes: PMH: Mild hypothyroidism (age 35, on levothyroxine 75mcg OD), Appendectomy (age 22)

What this station tests

  • Distinguishing RA from OA through joint distribution: proximal small joints (MCPs, PIPs, wrists) versus distal (DIPs), and stiffness duration (>1 hour versus <30 minutes)
  • Anti-CCP antibodies as the most specific serological test for RA, alongside RF
  • Urgent rheumatology referral: NICE recommends within 3 working days of suspected RA to prevent joint damage
  • Screening for extra-articular features: dry eyes (Sjogren's), nodules, respiratory symptoms, carpal tunnel
  • Emphasising that early treatment prevents irreversible joint damage: the treatment window is the key message

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

Symmetrical inflammatory polyarthritis in a middle-aged woman is RA until proven otherwise. The candidate must identify the inflammatory pattern (morning stiffness >1 hour, symmetrical small joint involvement, swelling) and distinguish from osteoarthritis. Mrs Hughes is 52, presenting with 3 months of symmetrical hand and foot pain with morning stiffness lasting over an hour. Open with: 'Mrs Hughes, tell me about the pain in your hands and feet and how it is affecting your daily life.'

Core approach

Establish the inflammatory pattern. Symmetrical involvement of small joints: MCPs, PIPs, wrists, and MTPs. Morning stiffness lasting more than an hour (OA stiffness is typically 15 to 30 minutes). Swelling is soft tissue, not bony (unlike OA Heberden's/Bouchard's nodes). Pain improves with use during the day (inflammatory pattern, opposite of OA which worsens with use). Grip strength reduced.

Distinguish from OA through the pattern. RA: proximal joints (MCPs, PIPs, wrists), symmetrical, morning stiffness >1 hour, soft tissue swelling. OA: distal joints (DIPs), less symmetrical, brief stiffness, bony swelling. The joint distribution is the key differentiator.

Screen for extra-articular features. Fatigue (common in RA). Dry eyes or mouth (Sjogren's). Subcutaneous nodules. Respiratory symptoms (pleural effusion, pulmonary fibrosis). Carpal tunnel (median nerve compression). Screen for associated conditions: she has hypothyroidism (autoimmune association).

Functional impact: she is a hospital administrator and cannot type. Cannot grip properly. Struggling with buttons, cooking, driving. Lives alone since divorce. Independence is threatened.

Closing and safety netting

Explain the likely diagnosis: 'Mrs Hughes, the pattern of joint pain, the prolonged morning stiffness, the symmetrical swelling in your hands and feet, all suggest rheumatoid arthritis. This is an autoimmune condition where the immune system attacks the joint lining.' Emphasise that early treatment prevents joint damage: 'The good news is that treatments available now are very effective, especially when started early.'

Investigations: RF (rheumatoid factor), anti-CCP antibodies (more specific), ESR and CRP, FBC, U&E, LFTs (baseline before DMARDs), X-rays of hands and feet. Urgent rheumatology referral (NICE recommends within 3 working days of suspected RA). Do not start steroids or DMARDs in primary care: specialist initiation. Offer interim analgesia (NSAIDs with gastroprotection).

Safety net: 'If the pain becomes significantly worse, you develop a high fever, or you notice any new symptoms like breathlessness or eye problems, come back.' Follow-up after rheumatology review.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for rheumatoid 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: Inflammatory pattern established (symmetry, stiffness >1 hour, soft tissue swelling). Joint distribution documented (MCPs, PIPs, wrists, MTPs). OA actively distinguished. Extra-articular screening. Functional impact assessed.

Costs marks: Not establishing inflammatory pattern. Confusing with OA. Not screening extra-articular features. Not assessing function.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct investigations (RF, anti-CCP, ESR/CRP, baseline bloods, X-rays). Urgent rheumatology referral within 3 working days. Interim analgesia (NSAID with gastroprotection). Not starting DMARDs. Early treatment message emphasised.

Costs marks: Not requesting anti-CCP. Routine referral. Starting DMARDs in primary care. No interim pain management.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining RA in accessible terms. Emphasising treatment effectiveness and hope. Addressing functional impact (work, independence). Acknowledging the difficulty of living alone with reduced hand function.

Costs marks: Using jargon. Being pessimistic about prognosis. Not addressing functional concerns.

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. Confusing RA with OA based on age alone. A 52-year-old woman can have either, but the joint pattern (proximal, symmetrical, soft tissue swelling, prolonged morning stiffness) is inflammatory, not degenerative. Candidates who diagnose OA miss RA.
  2. Not arranging urgent rheumatology referral. NICE recommends referral within 3 working days for suspected RA. Delay in DMARD initiation leads to irreversible joint damage. Candidates who arrange routine referral demonstrate inadequate urgency.
  3. Starting DMARDs in primary care. Methotrexate, sulfasalazine, and hydroxychloroquine should be initiated by rheumatology. Candidates who prescribe these in a GP station demonstrate scope confusion.

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 rheumatoid arthritis history in this PLAB 2 station?

Symmetrical inflammatory polyarthritis in a middle-aged woman is RA until proven otherwise. The candidate must identify the inflammatory pattern (morning stiffness >1 hour, symmetrical small joint involvement, swelling) and distinguish from osteoarthritis. Mrs Hughes is 52, presenting with 3 months of symmetrical hand and foot pain with morning stiffness lasting over an hour.

What are examiners marking in this rheumatoid arthritis station?

Marks are won for: Inflammatory pattern established (symmetry, stiffness >1 hour, soft tissue swelling). Joint distribution documented (MCPs, PIPs, wrists, MTPs). OA actively distinguished. Marks are lost for: Not establishing inflammatory pattern. Confusing with OA. Not screening extra-articular features. Not assessing function.

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

Confusing RA with OA based on age alone. A 52-year-old woman can have either, but the joint pattern (proximal, symmetrical, soft tissue swelling, prolonged morning stiffness) is inflammatory, not degenerative. Candidates who diagnose OA miss RA.

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

This station rewards process over personal experience. The skill being assessed: Anti-CCP antibodies as the most specific serological test for RA, alongside RF. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

Related cases