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Rheumatoid arthritis - Management
When should I suspect rheumatoid arthritis?

  • Suspect rheumatoid arthritis (RA) in anyone with persistent synovitis, where no other underlying cause is obvious (for example, psoriatic arthritis).
    • Clinical judgement should be used to decide if the synovitis is 'persistent' (lasting a few weeks rather than days).
  • RA typically causes symmetrical joint synovitis of the small joints of the hands and feet, although any synovial joint may be affected. Clinical features of synovitis include:
    • Pain — usually this is worse at rest or during periods of inactivity.
    • Swelling — around the joint (not bone swelling).
    • Stiffness and loss of function — stiffness is common in the morning and with inactivity, and usually lasts more than 30 minutes.
    • A tender and warm joint — giving a 'boggy' feel on palpation.
  • In addition to joint synovitis, RA may present with:
    • A family history of RA (although concordance rates in monozygotic twins are only 15%).
    • Rheumatoid nodules — hard, firm swellings over extensor surfaces occur in a third of people with RA.
    • Extra-articular features such as lymphadenopathy, or involvement of other body systems (for example, eye, lungs, and heart).
    • Systemic features of malaise, fatigue, fever, sweats, and weight loss.
  • The presentation of RA is variable.
    • Most people have an insidious onset, but others can have a rapid, or relapsing and remitting course (such as a palindromic presentation).

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