Rheumatoid Arthritis

History Taking

• Chief Complaint

  • Persistent joint pain

  • Swelling in multiple joints

  • Morning stiffness lasting more than 1 hour

• History of Presenting Complaint

  • Symmetrical joint involvement

  • Progressive worsening of symptoms over weeks to months

  • Exacerbation of symptoms with rest and improvement with activity

  • Fatigue and generalized weakness

• System Review

  • Musculoskeletal: Joint deformities, limited joint range of motion

  • Constitutional: Unexplained weight loss, fever

  • Respiratory: Shortness of breath, dry cough (indicating possible interstitial lung disease)

  • Cardiovascular: Chest pain, palpitations (suggesting pericarditis, endocarditis)

  • Ocular: Dry eyes, pain, redness (indicating Sjögren's syndrome or episcleritis)

  • Skin: Rheumatoid nodules, vasculitic rash

  • Neurological: Numbness or tingling in extremities (indicating possible peripheral neuropathy)

• Past Medical History

  • History of autoimmune disorders

  • Chronic infections, such as periodontitis

  • Non-specific symptoms which can indicate prodromal RA: fatigue, generalized weakness, anorexia, and weight loss

• Past Surgical History

  • Previous orthopedic surgery related to joint damage or deformity

• Drug History

  • Previous or current use of disease-modifying anti-rheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids

  • Response or lack of response to these treatments

• Family History

  • Relatives with rheumatoid arthritis or other autoimmune disorders

• Personal History

  • Smoking: A significant risk factor for RA

  • High body mass index: Obesity is a risk factor

• Social History

  • Occupational history: Jobs involving repetitive joint use

  • Alcohol consumption: Some studies suggest moderate alcohol consumption may have a protective effect against RA

Physical Examination

• General Examination

  • Pallor (due to chronic disease anemia)

  • Low-grade fever (reflecting systemic inflammation)

  • Rheumatoid nodules: Subcutaneous nodules often found on extensor surfaces such as the elbows

• Hands and Arms Examination

  • Swollen joints with symmetrical involvement

  • Tenderness on palpation of the metacarpophalangeal and proximal interphalangeal joints

  • Ulnar deviation of the fingers

  • Z deformity in the thumb

  • Boutonnière deformity (flexion of proximal interphalangeal joint and hyperextension of distal interphalangeal joint)

  • Swan neck deformity (hyperextension of proximal interphalangeal joint and flexion of distal interphalangeal joint)

  • Rheumatoid nodules may be present on the extensor surfaces of the forearm

• Mouth Examination

  • Dry mouth could be indicative of secondary Sjögren's syndrome

• Neck Examination

  • Limited range of motion of the cervical spine due to atlanto-axial subluxation (though this is a late feature)

• Cardiovascular Examination

  • Signs of pericarditis or endocarditis if relevant: muffled heart sounds, pericardial rub, new murmur

• Respiratory Examination

  • Signs of pleural effusion or interstitial lung disease if relevant: reduced chest expansion, dullness to percussion, decreased breath sounds

• Abdominal Examination

• Splenomegaly for Felty’s syndrome

Investigations

• Laboratory Investigations

  • Full Blood Count: To identify anemia of chronic disease, thrombocytosis

  • ESR and CRP: To assess level of inflammation, these markers are usually elevated in active disease

  • Rheumatoid Factor (RF): Positive in about 70-80% of patients with RA, though not specific

  • Anti-Cyclic Citrullinated Peptide (anti-CCP) Antibodies: High specificity for RA, may predict severe disease

  • Uric acid: To rule out gout

  • Liver Function Tests and Kidney Function Tests: Baseline before starting DMARDs; some of these medications can affect liver and kidney function

  • Antinuclear Antibodies (ANA): To rule out other autoimmune diseases like SLE

• Imaging

  • X-rays of affected joints: To assess for joint erosions, joint space narrowing, periarticular osteopenia

  • Ultrasound of joints: To visualize synovitis, joint effusions, bony erosions

  • MRI: Can detect early erosive changes and synovitis before visible on x-ray

• Invasive Investigations

  • Synovial fluid analysis: If joint effusion present, to rule out infection or crystal arthropathy

• Other Investigations

  • Pulmonary function tests: If there is suspicion of interstitial lung disease

  • Echocardiogram: If cardiac involvement such as pericarditis or endocarditis is suspected.

Management

• General Management

  • Patient education: Understanding the chronic nature of disease, importance of adherence to therapy

  • Physiotherapy: To maintain joint mobility and muscle strength

  • Occupational therapy: To provide assistive devices and strategies to minimize joint stress during daily activities

  • Regular exercise: To improve strength and flexibility, reduce pain

  • Smoking cessation: To reduce disease progression and comorbidity risk

• Medical Management

  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): For relief of acute symptoms

  • Glucocorticoids: Short-term use for acute flare-ups or as a bridge until DMARDs take effect

  • Disease-Modifying Antirheumatic Drugs (DMARDs): Methotrexate is first-line, others include hydroxychloroquine, sulfasalazine, leflunomide

  • Biological DMARDs: If poor response to traditional DMARDs, options include TNF inhibitors (e.g., etanercept, adalimumab), IL-6 inhibitors (e.g., tocilizumab), B-cell depleting agents (rituximab), T-cell costimulation blocker (abatacept)

  • JAK inhibitors: Such as tofacitinib, baricitinib, used when other therapies are ineffective or not tolerated

• Surgical Management

  • Joint replacement surgery (arthroplasty): For severe joint damage, particularly in the hips and knees

  • Synovectomy: To reduce pain and slow disease progression in a single joint

  • Tenosynovectomy: To prevent tendon rupture when the tendon sheath is inflamed or damaged

• Other Management

  • Regular follow-up: To monitor disease activity, side effects of medication, and comorbid conditions

  • Mental health support: To address psychological impact of living with a chronic disease

  • Multidisciplinary approach: Including rheumatologists, physiotherapists, occupational therapists, orthopedic surgeons, and primary care doctors

  • Vaccination: Against influenza and pneumococcus, given increased risk due to disease and therapy