Rheumatoid Arthritis

History

Joint pain stiffness and swelling in a symmetrical distribution affecting the wrists, MCP and PIP joints of the hands and MTP joints of the feet. Large joints may also be affected.
Early morning stiffness (typically >30min)
Inactivity gelling (stiffness after a period of inactivity)

Examination

Soft tissue swelling and tenderness of affected joints
Pain on squeezing MCP and MTP joints (the squeeze test).

Investigations

FBC, ESR, LFT,
Anti-CCP antibodies
X-ray of the hands (periarticular osteoporosis, erosions)

JOINT DISTRIBUTION (0-5)
1 large joint	0
2-10 large joints	1
1-3 small joints (large joints not counted)	2
4-10 small joints (large joints not counted)	3
>10 joints (at least one small joint)	5

SEROLOGY (0-3)
Negative RF AND negative ACPA	0
Low positive RF OR low positive ACPA	2
High positive RF OR high positive ACPA	3

SYMPTOM DURATION (0-1)
<6 weeks	0
≥6 weeks	1

ACUTE PHASE REACTANTS (0-1)
Normal CRP AND normal ESR	0
Abnormal CRP OR abnormal ESR	1

M.A & S.R/H.B. 25-01-24

When to refer:

Patients with swollen joints, significant morning stiffness. Refer for urgent appointment if scoring( above) is high.

How to refer:

SCI Gateway > Rheumatology > WGH

Main differential diagnoses

Viral arthritis – Can present similarly but usually resolves within 4-6 weeks

Osteoarthritis – The distribution is different (affects DIP, PIP and 1^st CMC joints of the hands). There is bony joint swelling due to osteophytes. Levels of ESR and CRP are normal and CCP is negative.

Psoriatic arthritis – the distribution is different and CCP is negative.