II. Pearls

  1. History and Examination are most important
    1. Symmetric involvement
    2. Morning stiffness and gelling
    3. Hand and wrist (esp. MCP joints) involvement
    4. Shaking hands is painful (withdraws hand on squeeze)
    5. Characteristics of onset
      1. Onset over weeks to months
      2. Prodromal symptoms of Anorexia, weakness, Fatigue
      3. Usually starts in one joint
  2. Lab and x-ray add little help in diagnosis
    1. Erythrocyte Sedimentation Rate (ESR) may be normal
    2. C-Reactive Protein may be normal
    3. Rheumatoid Factor may be normal
    4. X-Ray may be normal

III. Indications: Evaluation for Rheumatoid Arthritis

  1. At least one joint with definite clinical synovitis or swelling and
  2. Synovitis not better explained by another condition

IV. Criteria: ACR Rheumatoid Arthritis Diagnostic Criteria (2010)

  1. Joint Involvement
    1. Large joints: Shoulders, elbows, hips, knees and ankles
    2. Small joints: MTP, PIP, DIP and wrists
    3. Points 0: One large joint involved
    4. Points 1: Two to ten large joints involved
    5. Points 2: One to three small joints involved (with or without large joint involvement)
    6. Points 3: Four to ten small joints involved (with or without large joint involvement)
    7. Points 5: More than 10 joints involved (with at least one small joint involved)
  2. Serology (Rheumatoid Factor, Anti-Citrullinated Protein Antibody)
    1. Points 0: RF negative and ACPA negative
    2. Points 2: Low positive RF or ACPA
    3. Points 3: High positive RF or ACPA
  3. Acute Phase Reactants (C-Reactive Protein, Erythrocyte Sedimentation Rate)
    1. Points 0: Normal C-RP and ESR
    2. Points 1: Abnormal C-RP or ESR
  4. Duration of symptoms
    1. Points 0: Less than 6 weeks
    2. Points 1: Six weeks or more

V. Interpretation

  1. Total score (four components above are added)
    1. Score of 6 or greater is needed for definitive diagnosis of Rheumatoid Arthritis

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