Published on 24/06/2015 by admin

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Last modified 24/06/2015

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Case vignette

A 44-year-old female presents with severe depression. She was diagnosed with rheumatoid arthritis 3 years ago. She has experienced painful upper- and lower-extremity small joint arthritis despite therapy with multiple agents. The disease has progressed despite therapy, leading to deformed fingers, and she has had to give up her job as a designer. Lately she has experienced extreme fatigue and progressive dyspnoea. In the wake of these symptoms she has gone through the break-up of her 10-year marriage.
On examination the patient appears cushingoid and has a flat facial affect. Upper limb examination shows mild ulnar deviation of her fingers bilaterally. Proximal interphalangeal joints and metacarpophalangeal joints are tender, warm and boggy to palpation. On auscultation of her lung fields there are fine crepitations distributed widely. Her JVP is elevated and she has peripheral oedema.

Approach to the patient


The examination needs to be detailed and meticulous. Look for wasting or cushingoid body habitus. Note any skin bruises, oral ulcers, oral candidiasis or surgical scars. Look for features that are characteristic of rheumatoid arthritis, such as symmetrical distribution of deforming arthropathy, involvement of the proximal interphalangeal joint, metacarpophalangeal joint and the wrist (Fig 13.1, overleaf), Baker’s cyst of the popliteal fossa, and involvement of the upper cervical spine and the joints of the feet. Warm, tender and stiff joints may suggest active arthritis.
Assess the JVP and feel the precordium for a right ventricular heave. Auscultate the lung fields for fine crepitations of fibrosis. Listen to the heart for muffling of heart sounds due to pericardial effusion and loud P2 due to pulmonary hypertension. Palpate the abdomen, looking for splenomegaly. Perform a detailed eye examination and a neurological examination.
Assess the manual functional ability by asking the patient to pick up a pen and write their name, hold a cup, button and unbutton a shirt, and comb their hair.



Management of rheumatoid arthritis has three objectives: 1) control the symptoms, 2) optimise function and 3) retard progression.

Disease-modifying agents

These drugs prevent disease progression and joint damage. They should be commenced early in the disease for maximum benefit. However, their onset of action is usually delayed by about 2–4 months. Some commonly used agents are as follows:

Combination therapy
Methotrexate can be given in combination with infliximab, etanercept or rituximab. Other effective combinations include methotrexate and leflunomide or methotrexate and sulfasalazine together with hydroxychloroquine. The latter triple combination is becoming popular.


Case vignette

A 55-year-old woman with a background history of systemic sclerosis presents with progressive exertional dyspnoea of 1 month’s duration. She complains of significant debilitation recently—she can barely walk up a flight of stairs without experiencing significant dyspnoea. On examination there is evidence of sclerodactyly and pitting scars on her fingerpads. Tightness and cutaneous fibrosis is also evident in her face, with loss of skin creases and microstomia. There is a parasternal heave. On auscultation of the precordium there is a significant systolic murmur and a loud P2

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