Rheumatoid Arthritis

In station 5 you may be asked to assess a patient with joint pains.

HISTORY (3 minutes)

  • Timing questions (sudden/gradual, since when, intermittent/constant, progression, previous episodes)
  • Pattern of joint involvement (which joints, uni/bilateral, order they became affected in, large/small joints)
  • Joint pain/swelling/stiffness in the morning (how long for)/redness/deformity/nodules
  • Function
  • Extraarticular features
    • Systemic upset: fever, night sweats, weight loss, fatigue, lymph nodes
    • Raynauds
    • Skin, nails, hair: rashes, photosensitivity, hair loss, ulcers
    • Eyes: dry/red/painful/change in vision
    • CVS/Resp/GI/Neuro systems review
  • PMH joint disease/IBD/psoriasis/autoimmune conditions
  • Fx as above
  • Dx treatments tried including NSAIDs
  • Sx including impact, pregnancy problems/plans

EXAMINE (3 minutes)

  • Hand dorsum
    • Swellings of MCP, PIP, wrist, redness, guttering of interossei, deformities (subluxation and ulnar deviation at MCPJs, subluxation of wrist, swan neck, Boutonnieres, z thumb), nails (psoriasis, infarcts, vasculitis), thin and bruised skin (steroids), scars (carpal tunnel release, wrist arthrodesis, tendon transfer etc), rashes (psoriasis), dactylitis (psoriatic arthritis)
  • Hand palm
    • Palmer erythema, muscle wasting, scars
  • Elbow
    • Nodules, psoriatic plaques, gouty tophi, scars, bursitis
  • Feel
    • Palpate MCPJs, PIPJs, wrist for tenderness, swelling, temperature
    • Feel the pulse
    • Carpal tunnel tests if indicated (sensation, power, Tinel’s and Phalen’s tests)
    • Feel over the elbows
  • Move
    • Ask to straighten fingers fully
    • Ask to do prayer sign
    • Ask to make a fist and hide your nails
    • Grip my fingers and squeeze
    • Pincer grip (make an O and don’t let me open it)
    • Assess function eg. do a button, write, pick up a coin/glass.
    • Put both hands behind your head
    • Assess elbow and shoulder function if time allows as well as lower limb joints
  • Look behind the ears and in the hair line and scalp for psoriasis
  • Look at the eyes for redness and conjunctival pallor, listen to the breath sounds (creps) and heart sounds, palpate the abdomen (splenomegaly), look at the legs for rashes/ulcers (pyoderma gangrenosum, vasculitis), quick neuro assessment
  • If see psoriasis proceed as per Ankylosing spondylitis examination (see Station 5 Ankylosing spondylitis)

ICE and Explanation (2 minutes)



Present to the examiner:

“This lady has a peripheral symmetrical deforming polyarthropathy with palmar erythema, small muscle wasting and DIPJ sparing.  There was (no) active synovitis. The presence of nodules suggests seropositive RA. Hand function was preserved/restricted by deformity and weakness. With regards to treatment there was evidence of surgical scars, steroid usage.  With regards to complications and extraarticular manifestations- there was no evidence of carpal tunnel, ocular, cardiovascular, pulmonary, gastrointestinal or neurological involvement. “


RA is a chronic systemic inflammatory disorder

The synovium is the target of the autoimmune process

Suspect if 3 joint areas involved, MCPJs/MTPJs, early morning stiffness > 30 minutes and symmetrical joint involvement

Joints commonly involved: MCPJs, PIPJs, wrists, knees, shoulders, MTPJs, ankle, C spine, elbow. Not DIPJs.


ACR/EULAR 2010 criteria (need 6/10 score)

  1. Joints (swollen/tender/USS/MRI evidence of synovitis, small joints)
  2. Serology (RF or anti-CCP positive)
  3. Acute phase reactants (CRP/ESR raised)
  4. Duration ≥ 6 weeks



Differential Diagnoses: Exclude HLA-B27 spondyloarthritis (eg. ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBD associated arthritis), crystal arthritides (gout and pseudogout), connective tissue disease such as lupus with Jaccoud’s arthropathy, OA, viral, fibromyalgia.


Extraarticular features:

  1. Systemic: fever, lymph nodes, weight loss, fatigue (exclude infection, cancer and drug reaction)
  2. Skin: palmar erythema, nodules, vasculitis (purpura, infarcts), raynauds, pyoderma gangrenosum
  3. Ocular: (epi)scleritis, keratoconjunctivitis sicca, scleromalacia perforans
  4. MSK: osteoporosis
  5. Cardiac: pericarditis and pericardial effusion, myocarditis, endocarditis, valve defects, accelerated ischaemic heart disease, conduction problems, heart failure
  6. Resp: pleuritis, nodules, fibrosis, bronchiolitis obliterans, effusions, caplans syndrome, methotrexate pneumonitis, cryptogenic organising pneumonia, non-specific interstitial pneumonia
  7. GI: splenomegaly
  8. Neuro: peripheral neuropathy, mononeuritis multiplex, entrapment neuropathy eg. carpal tunnel, spinal cord compression, atlanto-axial subluxation
  9. Haem: Felty’s syndrome (splenomegaly and neutropenia +- thrombocytopenia, lymphoma, anaemia, thrombocytosis
  10. Renal: Glomerulonephritis
  11. Other: amyloid


Rheumatoid nodules are present in 20-35%.  They are associated with RF positive severe disease.  They can be seen on the extensor surfaces of the forearms and over joints.  Differential diagnosis: xanthoma, gout, granuloma annulare



FBC (reduced Hb, increased platelets), U+E (NSAID use, renal involvement), LFT (low albumin), clotting

ESR/CRP (raised)

RF (positive in 70-80%, indicates severe disease, associated with extraarticular features and nodules, not specific, can be positive in 5% of normal population)

Anti-CCP (positive in 60%, indicates severe erosive disease, more specific than RF)

ANA (positive in 30%), ANCA (usually negative)

Complement (normal or increased), immunoglobulins

X-Ray: periarticular osteopenia, symmetrical joint space loss, deformities, erosions, soft tissue swelling, nodules.

USS/MRI joints

Synovial fluid: inflammatory wcc 5000-50000, raised protein, low glucose, culture negative, no crystals

Renal: Urine dipstick, urine PCR, BP check, renal USS if indicated

CVS: ECG, echo

Resp: sats, ABG, CXR, lung function tests, HRCT etc if indicated

GI: USS, OGD, colonoscopy, barium swallow if indicated




Multidisciplinary (pharmacy, orthotics, nurse, medical, psych, dietician, OT, physio, podiatry etc)

Educate and support (support groups such as NRAS)

Treat early (within 3 months of symptom onset).  Methotrexate and another DMARD (eg. sulphasalasine/hydroxychloroquine) and short term prednisolone (or im/intraarticular steroid) and NSAIDs. Treat to target (target = low disease activity/remission). Gastro and bone protection.

Analgesia (paracetamol, codeine, COX2 inhibitors)

Measure disease activity (DAS-28 score) and function (HAQ)

Biologics- TNFalpha inhibitors, abatacept, tocilizumab, rituximab. Give biologic agent if severe disease (DAS-28 score high) and no response to 2 DMARDS including methotrexate.  Rituximab if fail 1 anti-TNF agent.

Manage CVS risk. Vaccines. Monitor for osteoporosis (give bone protection) and other steroid/treatment side effects such as infection and malignancy.

Surgical: joint replacement/fusion, tendon transfer


Written by Dr Sarah Kennedy


Resources used to write this document include those listed in the references section of this webpage and also:


Rheumatology Secrets by Sterling West