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 A non-erosive arthritis with multisystem features. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology suggests it.
2. Viral arthritis A self-limiting polyarthritis after a viral illness. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes the course matter.
3. Psoriatic arthritis An inflammatory arthritis with psoriasis and nail changes. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology points to it.
4. Rheumatoid arthritis correct Correct. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology is rheumatoid arthritis.
5. Osteoarthritis Joint pain worse with use, affecting the distal interphalangeal joints, without prolonged stiffness. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes the pattern matter.

The point: Rheumatoid arthritis is a chronic autoimmune inflammatory arthritis, commoner in women, presenting with a symmetrical polyarthritis of the small joints of the hands and feet, with pain, swelling and early morning stiffness lasting more than an hour that eases with use. The metacarpophalangeal and proximal interphalangeal joints are typically involved, sparing the distal interphalangeal joints, which distinguishes it from osteoarthritis. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies support the diagnosis, and inflammatory markers are raised; early erosions may be seen on imaging. The principle of modern management is to treat early and to target remission, starting a disease-modifying antirheumatic drug such as methotrexate promptly to prevent joint destruction, with short-term corticosteroids for flares and biologic agents where the response is inadequate. Extra-articular features include rheumatoid nodules, interstitial lung disease, anaemia and an increased cardiovascular risk. The trap is treating it symptomatically for months while erosions develop; early referral and early disease-modifying therapy change the outcome.

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. Their positivity with raised markers supports the diagnosis and predicts a more erosive course.
2. Assessment of the joint pattern and morning stiffness Symmetrical small joints with prolonged stiffness. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it discriminating.
3. Inflammatory markers Raised ESR and CRP reflect activity. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it supportive.
4. Full blood count For the anaemia of chronic disease. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it useful.
5. Early rheumatology referral For prompt disease-modifying therapy. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it key.

The point: Rheumatoid arthritis is a chronic autoimmune inflammatory arthritis, commoner in women, presenting with a symmetrical polyarthritis of the small joints of the hands and feet, with pain, swelling and early morning stiffness lasting more than an hour that eases with use. The metacarpophalangeal and proximal interphalangeal joints are typically involved, sparing the distal interphalangeal joints, which distinguishes it from osteoarthritis. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies support the diagnosis, and inflammatory markers are raised; early erosions may be seen on imaging. The principle of modern management is to treat early and to target remission, starting a disease-modifying antirheumatic drug such as methotrexate promptly to prevent joint destruction, with short-term corticosteroids for flares and biologic agents where the response is inadequate. Extra-articular features include rheumatoid nodules, interstitial lung disease, anaemia and an increased cardiovascular risk. The trap is treating it symptomatically for months while erosions develop; early referral and early disease-modifying therapy change the outcome.

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 Where conventional therapy fails. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it the escalation.
2. Early disease-modifying antirheumatic drug such as methotrexate correct Correct. Starting a disease-modifying drug early prevents joint destruction.
3. Manage cardiovascular risk Given the raised risk in rheumatoid arthritis. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it comprehensive.
4. Short-term corticosteroids for flares Bridging therapy while disease-modifying drugs take effect. A symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology makes it adjunctive.
5. Treat-to-target aiming for remission Therapy is adjusted to target remission, the principle of modern management, and a symmetrical small-joint polyarthritis with prolonged morning stiffness and positive serology here points elsewhere.

The point: Rheumatoid arthritis is a chronic autoimmune inflammatory arthritis, commoner in women, presenting with a symmetrical polyarthritis of the small joints of the hands and feet, with pain, swelling and early morning stiffness lasting more than an hour that eases with use. The metacarpophalangeal and proximal interphalangeal joints are typically involved, sparing the distal interphalangeal joints, which distinguishes it from osteoarthritis. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies support the diagnosis, and inflammatory markers are raised; early erosions may be seen on imaging. The principle of modern management is to treat early and to target remission, starting a disease-modifying antirheumatic drug such as methotrexate promptly to prevent joint destruction, with short-term corticosteroids for flares and biologic agents where the response is inadequate. Extra-articular features include rheumatoid nodules, interstitial lung disease, anaemia and an increased cardiovascular risk. The trap is treating it symptomatically for months while erosions develop; early referral and early disease-modifying therapy change the outcome.

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