Rheumatoid Arthritis

In Station 5 you may be asked to assess a patient presenting with joint pain and swelling.

1. Key History-Taking Points

Timing, Onset & Pattern of Joint Involvement

• Onset: sudden vs gradual, since when, intermittent vs constant, progression, previous episodes
• Active symptoms: stiffness (morning or night, duration — >30 min suggests inflammatory), pain (worse in morning or after exertion/evening), warmth, weakness
• Pattern: number of joints, bilateral vs unilateral, small vs large joints, legs and feet involvement; falls or difficulty walking on uneven surfaces
• Aggravating factors: cold weather, pain with colour change (Raynaud’s)
• Back or neck pain: any reduced range of movement, numbness or weakness in shoulders or arms (atlanto-axial subluxation, cervical myelopathy)

Functional Impact

• Shopping, dressing, cleaning, washing, cooking, cutlery use
• Dropping objects, fine motor difficulties (buttons, writing, mobile phone use)
• Occupational impact; past use of vibrating/drilling tools
• Adapted aids already in use: cutlery, key grips, walking aids
• Physiotherapy input received

Extra-Articular & Systemic Symptoms

• Constitutional: weight loss, fevers, night sweats (exclude infection, malignancy, drug reaction)
• Skin: rash (butterfly, psoriatic plaques, vasculitic rash), hair loss, skin ulcers
• Lumps: over elbows or ankles (rheumatoid nodules)
• Raynaud’s phenomenon: cold-induced colour change
• Eyes: dry eyes, redness, pain, change in vision (scleritis, keratoconjunctivitis sicca)
• Mouth: oral ulcers, dry mouth (Sjögren’s overlap); genital ulcers (reactive arthritis / Behçet’s)
• Chest: sharp chest pain, breathlessness, cough — consider pleuritis, fibrosis, methotrexate pneumonitis, bronchiolitis obliterans
• Neurological: numbness, burning pain, pins and needles in feet or fingers (peripheral neuropathy, carpal tunnel); neck pain with arm weakness (myelopathy)
• GI / swallowing: dysphagia (onset, food sticking, washing food down with fluids), heartburn, water brash, nausea, diarrhoea, bloating, perianal abscess, haematemesis, PR bleeding — screen for GI involvement and NSAID complications
• Renal: polyuria, increased thirst, haematuria, burning urine (amyloid, vasculitis, NSAID nephropathy)
• Infections: recent sore throat, fever, diarrhoea, unwell contacts (reactive arthritis trigger; immunosuppression risk)
• Travel: TB-endemic areas, country of origin, TB contacts (before starting biologics)

Past Medical, Drug & Family History

• PMH: previous joint surgery, IBD, psoriasis, other autoimmune conditions; pregnancy or breastfeeding (impacts DMARD choice)
• Drug history:
  • NSAIDs — PPI cover, indigestion, black stools, ankle swelling, blood pressure effects
  • DMARDs currently or previously — side effects experienced
  • Steroids (oral or injected), bone protection (calcium/vitamin D), biologics
• Family history: autoimmune conditions — HLA-DR4 (extra-articular RA, SLE, T1DM); HLA-B27 (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis)
• Social history: smoking, alcohol; occupation; hobbies; home adaptations

2. Key Examination Findings

Preliminary

• Temperature of hands (feel dorsum), radial pulse, capillary refill time

Hand Dorsum — Look (flat on pillow, then raised parallel to face)

• Deformities: Z-thumb, Boutonnière deformity, swan-neck deformity, ulnar deviation, MCP subluxation
• Swellings: MCP joints, PIP joints, wrist — boggy (synovitis) vs bony (OA); note DIPJ sparing in RA
• Guttering: dorsal interossei wasting
• Nails: nail-fold infarcts (vasculitis), psoriatic pitting, onycholysis, hyperkeratosis
• Skin: thin/bruised (steroid use), calcinosis, rashes
• Scars: carpal tunnel release, wrist arthrodesis, tendon transfer
• Other: dactylitis (psoriatic arthritis), psoriatic plaques

Hand Palm — Look

• Palmar erythema
• Thenar and hypothenar wasting
• Surgical scars

Elbows — Look & Feel

• Rheumatoid nodules (extensor surface), calcinosis
• Psoriatic plaques, gouty tophi, olecranon bursitis, scars
• Measure blood pressure both arms (asymmetry suggests cervical rib or subclavian involvement)

Feel

• Palpate MCPJs, PIPJs, wrist for tenderness, boggy swelling (synovitis), warmth
• Carpal tunnel assessment if indicated: sensation, power (APB), Tinel’s sign, Phalen’s test
• Palpate over elbows for nodules

Move & Function

• Pincer grip — make an O, don’t let me open it
• Power grip — grip my fingers and squeeze
• Spread fingers like a fan (intrinsic power)
• Make a fist — don’t let me bend your wrist
• Straighten fingers fully (extension)
• Prayer sign (wrist extension)
• Function: pick up a coin, hold cutlery or cup, undo buttons, write with a pen, brush hair, hands behind head/undo bra strap (shoulder abduction and external rotation)

Sensation

• Test radial, median and ulnar nerve distributions
• Phalen’s and Tinel’s tests for carpal tunnel

Neck

• Inspect for surgical scar (atlanto-axial stabilisation)
• Assess range of movement; screen for upper limb myelopathy (cervical spinal disease)

Feet & Lower Limbs

• Inspect feet: fibular deviation, deformities, rheumatoid nodules at Achilles tendon
• Knee and ankle examination if time allows
• Inspect legs for vasculitic ulceration, pyoderma gangrenosum

Targeted Systemic Examination

• Scalp and behind ears: psoriatic plaques
• Eyes: dry eyes, xerostomia, episcleritis, scleritis, conjunctival pallor (anaemia)
• Vasculitis: nail-fold infarcts, scleritis, leg ulceration
• Lungs: auscultate for crackles (ILD), pleural rub/effusion, bronchiolitis obliterans, Caplan’s; perform lung examination fully if indicated
• Cardiovascular: screen for pulmonary hypertension, ILD-related cor pulmonale
• Abdomen: palpate for splenomegaly (Felty’s syndrome)

3. Specific Investigations

Bloods

• FBC: anaemia (chronic disease, Felty’s, methotrexate myelosuppression, GI bleeding from NSAIDs), raised platelets
• U&E: NSAID nephropathy, renal vasculitis, amyloid; monitor DMARDs
• LFTs: low albumin (disease activity); methotrexate and leflunomide monitoring
• ESR / CRP: raised in active disease
• Clotting
• Rheumatology-specific:
  • RF — positive in 70–80%; severe disease, extra-articular features and nodules; not specific (positive in 5% of normal population)
  • Anti-CCP — positive in ~60%; more specific; indicates severe erosive disease
  • ANA — positive in ~30%; if positive consider scleroderma screen (anti-centromere, anti-Scl-70, anti-RNA polymerase, immunoglobulins)
  • SLE screen if suspected — C3/C4 complement (reduced), anti-dsDNA, ENA
  • ANCA — usually negative in RA
  • Complement — normal or raised in RA

Urinalysis

• Urine dipstick and PCR — proteinuria or haematuria: renal vasculitis, amyloidosis, urine infection (myelosuppression), interstitial nephritis (NSAIDs)

Imaging

• X-ray hands and feet: reduced joint space, periarticular osteopenia and erosions, deformities, soft tissue swelling
• USS / MRI joints: detect early synovitis and erosions not seen on X-ray
• CXR ± HRCT chest: ILD, pleural effusions, pulmonary nodules, bronchiolitis obliterans, Caplan’s syndrome; + pulmonary function tests
• MRI cervical spine: if signs of myelopathy (atlanto-axial subluxation)
• Renal USS: if renal involvement suspected

Other

• Nerve conduction studies: if carpal tunnel syndrome suspected
• Synovial fluid: inflammatory WCC 5,000–50,000; raised protein; low glucose; culture negative; no crystals
• ECG and echocardiogram: if cardiovascular involvement suspected (pericarditis, pulmonary hypertension)

4. Management

General Principles

• Multidisciplinary team: rheumatologist, specialist nurse, pharmacist, OT, physiotherapist, podiatrist, orthotist, dietician, psychologist, orthopaedic surgeon
• Education and support: NRAS (National Rheumatoid Arthritis Society), Arthritis Research Council leaflets, hospital patient information
• Treat early: within 3 months of symptom onset; treat to target (low disease activity / remission)
• Monitor disease activity: DAS-28 score; functional status: HAQ

Occupational Therapy & Physiotherapy

• Splints, resting and working
• Adapted cutlery (large handles), key grips, jar openers, long-handled aids for picking up objects
• Community OT: bath seats, shower rails, home modifications
• Physiotherapy: muscle strengthening, joint protection, preserving function

Pharmacological

• Analgesia: paracetamol, codeine, COX-2 inhibitors
• NSAIDs: with PPI gastroprotection
• Steroids: short-term oral prednisolone or IM/intra-articular; provide bone protection (bisphosphonate + calcium/vitamin D) if >3 months; DEXA scan if any previous fragility fractures
• First-line DMARDs: methotrexate + sulphasalazine ± hydroxychloroquine (triple therapy) or methotrexate + leflunomide
• Biologics (if persistent high disease activity after ≥2 DMARDs including methotrexate):
  • Anti-TNFα: infliximab, adalimumab, etanercept
  • Anti-CD20: rituximab (if ≥1 anti-TNF failure)
  • Anti-IL-6: tocilizumab
  • T-cell co-stimulation blockade: abatacept
  • JAK inhibitors: baricitinib, tofacitinib
• Cardiovascular risk management: statins, antihypertensives, smoking cessation
• Vaccines: influenza, pneumococcal, hepatitis B — especially before biologics
• Monitor for: osteoporosis, infection, lymphoma risk

Key DMARD Side Effects & Monitoring

• Methotrexate: hepatitis, cytopenia, pneumonitis/ILD — FBC + LFTs every 2 weeks then every 1–3 months; men: 3-month washout before conception; women: 6-month washout, avoid in pregnancy and breastfeeding
• Hydroxychloroquine: retinopathy, visual disturbance — baseline visual acuity and annual eye checks
• Sulphasalazine: hepatitis, rash, discolouration of sweat/urine — FBC + LFTs every 2 weeks for 3 months then every 3 months
• Leflunomide: hepatitis, myelosuppression, rash — FBC + LFTs every 2 weeks then every 2 months
• Azathioprine: cytopenia, oncogenicity — FBC + LFTs every 2 weeks then every 3 months
• Ciclosporin: renal impairment, hypertension — FBC, creatinine and BP weekly then monthly
• Cyclophosphamide: haemorrhagic cystitis, interstitial nephritis — FBC and urinalysis monthly
• Corticosteroids: weight gain, bruising, fluid retention, diabetes, osteoporosis, cataract, glaucoma — bone density measurement and bone protection for all patients on >3 months of steroids
• Gold: rash, eosinophilia, cytopenia — FBC and urinalysis before each injection

Surgical

• Joint replacement (arthroplasty) — hip, knee, MCP joints
• Joint fusion (arthrodesis)
• Synovectomy
• Tendon transfer; carpal tunnel decompression
• Atlanto-axial stabilisation if subluxation threatens the spinal cord

Rheumatoid Arthritis Cheat Sheet