Health History and Physical Exam

Reviewed by: HU Medical Review Board | Last reviewed: December 2022

A health history and physical exam are important for diagnosing and managing axial spondyloarthritis (axSpA). The exam can help to identify any areas of concern and guide your doctor in further testing.1,2

During your visit, your doctor will ask about your symptoms, medical history, family history, and lifestyle. They will look, feel, and listen to different parts of your body. They may then order tests to look more deeply into your health.1,2

Medical and family history

Your doctor will start by asking for a detailed history of your health and your family's health. This will include questions about:1,2

  • Your symptoms, including when they started and how long you have been experiencing them
  • Any family history of axSpA or other inflammatory or autoimmune conditions
  • Any previous injuries or surgeries
  • Your overall health, including any other medical conditions or allergies you have
  • Your lifestyle habits, including whether you smoke or use drugs and how much alcohol you drink

Specific questions your doctor might ask include:1,2

  • Do you have any pain or stiffness in your joints?
  • When does the joint pain or stiffness happen? Is it worse or better with exercise?
  • Do you have any fatigue?
  • Do you have difficulty doing everyday activities, such as walking or dressing yourself?
  • Have you ever been treated for a back or neck problem?
  • Do you have other medical conditions, such as diabetes or high blood pressure?
  • Do you take any medication, including over-the-counter drugs or supplements?
  • Do you smoke cigarettes or use tobacco products?
  • How much alcohol do you drink weekly?

Be sure to answer these questions as fully and honestly as possible. The more your doctor knows about your condition, the better treatment suggestions they can give you.2

Physical exam

During the physical exam, your doctor will do a head-to-toe assessment. This will involve checking things like your blood pressure, heart rate, and breathing.2

After the general physical exam, your doctor will perform a focused exam. This will look at a specific area of concern. With axSpA, a focused exam of your spine, hips, and other joints may be needed to look for signs of inflammation. This exam might assess your:1

  • Flexibility
  • Mobility
  • Pain, including when it happens and its severity
  • Swelling and tenderness

Your doctor will use the information from your medical and family history and the results of your physical exam to make a diagnosis. If they suspect that you have axSpA, they may order additional tests to confirm the diagnosis.1

Additional tests

Your doctor may decide to order other tests to get more information about your condition. The types of tests will depend on your symptoms and history. They could include:1,3,4

  • Blood tests – These tests can help to look for signs of inflammation, such as an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level. Some tests look for biomarkers that are more common in some people with axSpA. One example of a biomarker is the HLA-B27 genetic marker.
  • X-ray – This imaging test can show if there is any damage to the bones in your spine or other joints.
  • Magnetic resonance imaging (MRI) – This scan can provide a more detailed look at the structures in your body, including your spine, hips, and other joints. It can also show if there is any inflammation or damage.
  • Schober test – This test is used to assess the flexibility of your spine. To do this, your doctor will measure how far you can bend forward from a standing position.
  • FABER test – This test assesses the range of motion in your hips. To do this, the doctor will have you lie on your back and move your legs in different directions.

AxSpA outcomes are better when the condition is diagnosed and treated early. A detailed physical exam and health history are the first steps to getting a timely diagnosis and the treatment you need to manage your condition. But other tests may be needed. Talk to your doctor about the best way to get an accurate diagnosis.1

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