Rheumatoid arthritis is a chronic autoimmune disease in which inflamed joint lining damages cartilage and bone, mostly in the small joints of the hands and feet. Starting disease-modifying drugs early prevents joint destruction and disability.
Key symptoms
- Pain and swelling in several small joints of the hands and feet on both sides
- Morning stiffness lasting over an hour
- Fatigue, low fever and weight loss
- Trouble with grip, buttons or jars
What you find on exam
- Warm, boggy swelling of the wrists, knuckles (MCP) and middle finger joints (PIP)
- Painful squeeze test across the knuckles
- Late signs: ulnar deviation, swan neck and boutonniere deformities
- Rheumatoid nodules, dry eyes, lung crackles
Tests
- Rheumatoid factor and anti-CCP antibodies
- ESR and CRP raised
- Hand and foot X-rays: erosions and joint space narrowing
- Blood count, liver and kidney function and hepatitis screening before drugs
Treatment basics
- Methotrexate as first-line DMARD, with folic acid
- Short course of low-dose prednisone as a bridge
- Add hydroxychloroquine, sulfasalazine or a biologic such as a TNF inhibitor if needed
- Hand therapy, exercise and vaccines before immune suppression
Red flags
- Neck pain with hand tingling or weakness from cervical spine instability
- Fever on a biologic or methotrexate, suggesting serious infection
- One joint far more hot and swollen than the rest, which can be septic
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.