Rheumatoid arthritis

Vignette: A 25-year-old woman attends SDEC with a 12-week history of swollen, tender knuckles and some shoulder stiffness.

Past medical history: Irritable bowel syndrome

Medications: Paracetamol PRN, Mebeverine

Observations: HR 65 bpm, BP 120/82, Sats 95% on air, RR 20, Temp 37.1

Please discuss your approach in this patient.

Model answer:

Candidate should focus on history taking as this patient is haemodynamically stable.

History taking should cover any trauma, rashes/skin lesions, pattern of stiffness, exacerbating/relieving factors, sweating, may explore extra-articular features – eyes/lung disease. Should also explore family history.

Examine patient clinically – full joints examination reveals swelling, tenderness, warmth, and decreased range of motion (ROM) in bilateral DIPs. Other examination – normal.

Investigations: FBC, U&Es, CRP, LFTs, autoimmune profile, rheumatoid factors + anti-CCP.

X-ray the hands and feet (to establish whether erosions are present.)

Differential Diagnosis: CTD (SLE), fibromyalgia, Infectious arthritis, PMR, Psoriatic arthritis, Reactive arthritis, Seronegative spondyloarthritis

Further History: Early morning stiffness lasts for more than 1 hour, present in both hands in the same joints, Mother has rheumatoid arthritis.

How would you manage this patient further?

Patient will need referral to a rheumatologist for specialist assessment. May offer NSAID whilst awaiting rheumatology appointment, should not prescribe steroids.

Candidate should acknowledge that rheumatologist may choose to prescribe a DMARD such as methotrexate (patient will need pregnancy counselling) + folic acid, leflunomide and sulfasalazine. DMARDs require frequent blood tests monitoring (FBCs/U&Es/LFTs.)

High scoring candidates will mention physiotherapy as needed, need for yearly pneumococcal and influenza vaccines, signpost to support groups.