Rheumatology and musculoskeletal for AMC MCQ

A 45 year old woman has three months of pain and swelling in the small joints of both hands, symmetrically, with early morning stiffness lasting two hours that improves as the day goes on. The metacarpophalangeal and proximal interphalangeal joints are swollen and tender, sparing the distal joints. Her rheumatoid factor and anti-CCP are positive with raised inflammatory markers. What is the most likely diagnosis?

1. Systemic lupus erythematosus Joint pain that does not damage the bone, along with problems in other body systems. That does not match the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.
2. Viral arthritis Joint swelling that clears on its own after a virus. Here, the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests points elsewhere.
3. Psoriatic arthritis Joint inflammation with a skin condition called psoriasis and nail changes. It does not fit the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.
4. Rheumatoid arthritis correct Correct. Swelling in many small joints on both sides, with long morning stiffness and positive blood tests, is rheumatoid arthritis.
5. Osteoarthritis Joint pain that gets worse with use, in the end finger joints, without long stiffness. But the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests does not point to it.

The point: Rheumatoid arthritis is a long-term disease where the immune system attacks the joints, causing swelling and pain. It is more common in women. It causes swelling and pain in many small joints of the hands and feet, on both sides of the body at once. Morning stiffness lasts more than an hour and gets better with movement. The joints at the base of the fingers and the middle finger joints are usually affected. The joints at the very end of the fingers are usually spared, and this is what tells it apart from osteoarthritis (wear-and-tear joint disease). Two blood tests help confirm it: rheumatoid factor and anti-CCP antibodies. Blood markers of inflammation are also raised, and early damage (erosions) to the bone may show up on scans. The modern rule is to treat early and aim for the disease to go quiet (remission). A drug that changes the course of the disease, such as methotrexate, is started quickly to stop the joints being destroyed. Steroids are used for short bursts during flare-ups, and stronger drugs called biologics are used if the first drug does not work well enough. Rheumatoid arthritis can also affect other parts of the body: lumps under the skin (rheumatoid nodules), scarring in the lungs, a low blood count (anaemia), and a higher risk of heart disease. The trap to avoid is treating the pain for months while the joints quietly get damaged underneath. Getting the patient to a specialist early, and starting disease-changing treatment early, changes how things turn out.

Source: Therapeutic Guidelines (Australia) — Rheumatology: rheumatoid arthritis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 45 year old woman has three months of pain and swelling in the small joints of both hands, symmetrically, with early morning stiffness lasting two hours that improves as the day goes on. The metacarpophalangeal and proximal interphalangeal joints are swollen and tender, sparing the distal joints. Her rheumatoid factor and anti-CCP are positive with raised inflammatory markers. What is the most appropriate initial investigation?

1. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies correct Correct. Both tests being positive, with raised inflammation markers, supports the diagnosis and hints the disease may damage bone faster.
2. Assessment of the joint pattern and morning stiffness Checks which joints are affected and how long the morning stiffness lasts. It does not fit the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.
3. Inflammatory markers A raised ESR and CRP (two blood tests) show how active the disease is. That does not match the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.
4. Full blood count Checks for the low blood count that long-term inflammation can cause. Here, the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests points elsewhere.
5. Early rheumatology referral Gets the patient to a specialist quickly for disease-changing treatment. But the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests does not point to it.

The point: Rheumatoid arthritis is a long-term disease where the immune system attacks the joints, causing swelling and pain. It is more common in women. It causes swelling and pain in many small joints of the hands and feet, on both sides of the body at once. Morning stiffness lasts more than an hour and gets better with movement. The joints at the base of the fingers and the middle finger joints are usually affected. The joints at the very end of the fingers are usually spared, and this is what tells it apart from osteoarthritis (wear-and-tear joint disease). Two blood tests help confirm it: rheumatoid factor and anti-CCP antibodies. Blood markers of inflammation are also raised, and early damage (erosions) to the bone may show up on scans. The modern rule is to treat early and aim for the disease to go quiet (remission). A drug that changes the course of the disease, such as methotrexate, is started quickly to stop the joints being destroyed. Steroids are used for short bursts during flare-ups, and stronger drugs called biologics are used if the first drug does not work well enough. Rheumatoid arthritis can also affect other parts of the body: lumps under the skin (rheumatoid nodules), scarring in the lungs, a low blood count (anaemia), and a higher risk of heart disease. The trap to avoid is treating the pain for months while the joints quietly get damaged underneath. Getting the patient to a specialist early, and starting disease-changing treatment early, changes how things turn out.

Source: Therapeutic Guidelines (Australia) — Rheumatology: rheumatoid arthritis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 45 year old woman has three months of pain and swelling in the small joints of both hands, symmetrically, with early morning stiffness lasting two hours that improves as the day goes on. The metacarpophalangeal and proximal interphalangeal joints are swollen and tender, sparing the distal joints. Her rheumatoid factor and anti-CCP are positive with raised inflammatory markers. What is the most appropriate next step in management?

1. Biologic agents for inadequate response Stronger drugs used when the usual treatment does not work well enough. Here, the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests points elsewhere.
2. Early disease-modifying antirheumatic drug such as methotrexate correct Correct. Starting a disease-changing drug early stops the joints being destroyed.
3. Early rheumatology referral Instead of months of just treating the pain. It does not fit the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.
4. Manage cardiovascular risk Checks and treats the higher heart disease risk that comes with rheumatoid arthritis. But the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests does not point to it.
5. Short-term corticosteroids for flares Steroids used for a short time while the main drug starts working. That does not match the combination of swelling in many small joints on both sides, long morning stiffness, and positive blood tests.

The point: Rheumatoid arthritis is a long-term disease where the immune system attacks the joints, causing swelling and pain. It is more common in women. It causes swelling and pain in many small joints of the hands and feet, on both sides of the body at once. Morning stiffness lasts more than an hour and gets better with movement. The joints at the base of the fingers and the middle finger joints are usually affected. The joints at the very end of the fingers are usually spared, and this is what tells it apart from osteoarthritis (wear-and-tear joint disease). Two blood tests help confirm it: rheumatoid factor and anti-CCP antibodies. Blood markers of inflammation are also raised, and early damage (erosions) to the bone may show up on scans. The modern rule is to treat early and aim for the disease to go quiet (remission). A drug that changes the course of the disease, such as methotrexate, is started quickly to stop the joints being destroyed. Steroids are used for short bursts during flare-ups, and stronger drugs called biologics are used if the first drug does not work well enough. Rheumatoid arthritis can also affect other parts of the body: lumps under the skin (rheumatoid nodules), scarring in the lungs, a low blood count (anaemia), and a higher risk of heart disease. The trap to avoid is treating the pain for months while the joints quietly get damaged underneath. Getting the patient to a specialist early, and starting disease-changing treatment early, changes how things turn out.

Source: Therapeutic Guidelines (Australia) — Rheumatology: rheumatoid arthritis Therapeutic Guidelines (Australia) · tier 3, national formulary