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{{Rheumatoid arthritis}}
{{Rheumatoid arthritis}}
 
{{CMG}}; {{AE}}{{MKK}}
{{CMG}}; {{AE}}{{AN}}


==Overview==
==Overview==
Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disorder affecting the joints and sometimes other organs as well. It is by definition polyarticular; that is, it affects many joints. Most commonly, the small joints in the hands and feet are affected, but larger joints (shoulders, knees etc) can also be affected; the pattern of joint involvement can differ from patient to patient.<ref name="pmid17976416">{{cite journal |author=Majithia V, Geraci SA |title=Rheumatoid arthritis: diagnosis and management |journal=Am. J. Med. |volume=120 |issue=11 |pages=936–9 |year=2007 |pmid=17976416 |doi=10.1016/j.amjmed.2007.04.005}}</ref>
Patients with rheumatoid arthritis usually appear fatigued. On skin examination, [[Rheumatoid nodule|rheumatoid nodules]], [[erythema nodosum]], [[atrophy]] of the digital skin, [[palmar erythema]], and diffuse thinning of the skin may be found. If there is involvement of the eyes, [[scleritis]] and [[scleromalacia]] may be seen. On auscultation of lungs, decreased breath sounds on both sides and [[crackles]] may be observed. On palpation of the abdomen, [[hepatomegaly]] and [[splenomegaly]] is usually found when it is associated with [[Felty's syndrome]]. On examination of extremities, [[redness]], and swelling of the affected joints, [[tenderness]], pain on movement and decreased the range of movement is usually found.


==Physical examination==
==Physical examination==
The small joints of the cervical spine can also be involved.
===Appearance of the Patient===
*Patients with rheumatoid arthritis usually appear fatigued.  


Inflammation in the joints manifests itself as a soft, "doughy" swelling, pain, tenderness to palpation and movement, local warmth, and functional impairment. Morning stiffness is often a prominent feature and may last for more than an hour. These signs help distinguish rheumatoid and other inflammatory arthritides from non-inflammatory diseases of the joints such as [[osteoarthritis]] (sometimes referred to as the "wear-and-tear" of the joints).
===Vital Signs===
In RA, the joints are usually affected in a fairly symmetrical fashion although the initial presentation may be asymmetrical.
*[[Low-grade fever]]
====Skin====
*Rheumatoid nodule found over bony prominences, such as the [[olecranon]], the [[Calcaneus#Calcaneal_tuberosity|calcaneal tuberosity]], the [[metacarpophalangeal joint]]s, or other areas that sustain repeated mechanical stress <ref name="pmid15850993">{{cite journal |vauthors=Pham T, Gossec L, Fautrel B, Combe B, Flipo RM, Goupille P, Le Loët X, Mariette X, Puéchal X, Wendling D, Schaeverbeke T, Sibilia J, Sany J, Dougados M |title=Physical examination and laboratory tests in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion |journal=Joint Bone Spine |volume=72 |issue=3 |pages=222–8 |date=May 2005 |pmid=15850993 |doi=10.1016/j.jbspin.2004.10.010 |url=}}</ref> <ref name="pmid29464524">{{cite journal |vauthors=Medina YF, Ruíz-Gaviria RE, Buitrago-Lopez A, Villota C |title=Physical articular examination in the activity of rheumatoid arthritis: a systematic review of the literature : Systematic review of the literature regarding physical examination in rheumatoid arthritis |journal=Clin. Rheumatol. |volume= |issue= |pages= |date=February 2018 |pmid=29464524 |doi=10.1007/s10067-018-4015-4 |url=}}</ref>
*[[Erythema nodosum]]
*[[Atrophy]] of digital skin
*[[Palmar erythema]]
*Diffuse thinning (rice paper skin), and of  
*Beading on the nails


===Deformity===
==== Eyes ====
As the pathology progresses the inflammatory activity leads to erosion and destruction of the joint surface, which impairs their range of movement and leads to deformity. The fingers are typically deviated towards the little finger (''[[ulnar deviation]]'') and can assume unnatural shapes.  Classical deformities in rheumatoid arthritis are the [[Boutonniere deformity]] (Hyperflexion at the [[proximal interphalangeal joint]] with hyperextension at the [[distal interphalangeal joint]]), [[swan neck deformity]] (Hyperextension at the [[proximal interphalangeal joint]], hyperflexion at the [[distal interphalangeal joint]]).  The thumb may develop a "Z-Thumb" deformity with fixed flexion and [[subluxation]] at the [[metacarpophalangeal joint]], and hyperextension at the IP joint.
*Dry eyes
*[[Scleritis]]
*[[Scleromalacia]]


[http://www.radswiki.net Images courtesy of RadsWiki]
==== Lungs ====
On Auscultation of lungs:
*Decreased breath sounds on both sides.
*Crackles may be present.


<gallery>
==== Abdomen ====
Image:Rheumatoid-arthritis-001.jpg
*On palpation:
Image:Rheumatoid-arthritis-002.jpg
**[[Hepatomegaly]]
Image:Rheumatoid-arthritis-003.jpg
**[[Splenomegaly]]
Image:Rheumatoid-arthritis-004.jpg
Image:RA-distal-clavicle-erosion-001.jpg|Distal clavicle erosion
</gallery>


===Extra-articular (elsewhere)===
==== Extremities ====
Patients with RA usually exhibit signs of systemic inflammation, that is, the inflammatory process in the joint leaves its marks on other organs as well (and this may also help distinguish it from osteoarthritis). Examples are a general tiredness and lassitude, sometimes low-grade fever, and some abnormalities on blood tests such as an elevated erythrocyte sedimentation rate (ESR), and [[anemia]], which is often seen as a consequence of the disease itself ([[anaemia of chronic disease]]) although it may also be caused by [[gastrointestinal bleeding]] as a side effect of drugs used in treatment, especially [[NSAID]]s used for [[analgesia]]. Extra-articular manifestations (manifestations outside the musculoskeletal system) occur in about 15% of patients with rheumatoid arthritis.<ref name="pmid12860726">{{cite journal |author=Turesson C, O'Fallon WM, Crowson CS, Gabriel SE, Matteson EL |title=Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years |journal=Ann. Rheum. Dis. |volume=62 |issue=8 |pages=722–7 |year=2003 |pmid=12860726 |doi=}}</ref> Examples are [[Hepatosplenomegaly]] which may occur with concurrent [[leukopenia]] and is then referred to as [[Felty's syndrome]]), lymphocytic infiltration affecting the salivary and lacrimal glands ([[Sjögren's syndrome]]), [[Pericarditis]], [[pleurisy]], [[alveolitis]], [[scleritis]], and [[subcutaneous tissue|subcutaneous]] [[nodule (medicine)|nodule]]s.
*On inspection redness and swelling of the affected joints.
*On palpation:
**Tenderness
**Pain on movement
**Decreased range of movement


====Cutaneous manifestations====
==References==
# The '''rheumatoid nodule''' is the cutaneous (strictly speaking subcutaneous) feature most characteristic of rheumatoid arthritis. The initial pathologic process in nodule formation is unknown but is thought to be related to small-vessel inflammation. The mature lesion is defined by an area of central [[necrosis]] surrounded by palisading [[macrophages]] and [[fibroblasts]] and a cuff of cellular [[connective tissue]] and chronic inflammatory cells. The typical rheumatoid nodule may be a few millimetres to a few centimetres in diameter and is usually found over bony prominences, such as the [[olecranon]], the [[Calcaneus#Calcaneal_tuberosity|calcaneal tuberosity]], the [[metacarpophalangeal joint]]s, or other areas that sustain repeated mechanical stress. Nodules are associated with a positive RF titer and severe erosive arthritis. They can rarely occur throughout the body in internal organs.
{{Reflist|2}}
# A variety of forms of '''[[vasculitis]]''' is also a cutaneous manifestation associated with rheumatoid arthritis. A benign form occurs as microinfarcts around the nailfolds. More severe forms include [[livedo reticularis]], which is a network (reticulum) of erythematous to purplish discoloration of the skin due to the presence of an obliterative cutaneous capillaropathy. (This rash is also otherwise associated with the antiphospholipid-antibody syndrome, a hypercoagulable state linked to antiphospholipid antibodies and characterized by recurrent vascular thrombosis and second trimester miscarriages.
 
Other, rather rare, cutaneous features include:
*[[pyoderma gangrenosum]], a necrotizing, ulcerative, noninfectious neutrophilic dermatosis.
*[[Sweet's syndrome]], a neutrophilic dermatosis usually associated with myeloproliferative disorders
*viral infections
*drug reactions (6)
*[[erythema nodosum]]
*lobular [[panniculitis]]
*[[atrophy]] of digital skin
*[[palmar erythema]]
*diffuse thinning (rice paper skin), and skin fragility.
*beading of the nails
 
====Other====
In addition to articular and cutaneous features, rheumatoid arthritis has a multitude of other, rare, features:
 
;Pulmonary: The [[lungs]] may become involved as a part of the primary disease process or as a consequence of therapy.  [[Fibrosis]] may occur spontaneously or as a consequence of therapy (for example [[methotrexate]]). Caplan's nodules are found as are pulmonary effusions.
 
;Renal: [[Amyloidosis]] can occur.
 
;[[The Heart in Rheumatoid Arthritis|Cardiovascular]]: Possible complications that may arise include: [[pericarditis]], [[endocarditis]], left ventricular failure, valvulitis and [[fibrosis]]. The risk of cardiovascular, specifically [[myocardial infarction]] (heart attack) or [[congestive heart failure]] are greater in individuals with RA. Over 1/3 of deaths of people with RA are directly attributable to cardiovascular death.


;Ocular: Keratoconjunctivitis sicca (dry eyes), [[scleritis]], episcleritis and scleromalacia.
[[Category:Aging-associated diseases]]
 
[[Category:Arthritis]]
;Gastrointestinal: Felty syndrome, [[anemia]]
[[Category:Autoimmune diseases]]
 
[[Category:Diseases involving the fasciae]]
;Neurological: Peripheral neuropathy and [[mononeuritis multiplex]] may occur. The most common  problem is carpal tunnel syndrome due to compression of the median nerve by swelling around the wrist. Atlanto-axial subluxation can occur, owing to erosion of the odontoid process and or/transverse ligaments in the cervical spine's connection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. At first the patient experiences clumsiness but without due care this can progress to [[quadriplegia]].
[[Category:Rheumatology]]
 
;Vasculitis: [[Vasculitis]] in rheumatoid arthritis is common. It is typically presents as vasculitic nailfold infarcts.
 
;Osteoporosis: [[Osteoporosis]] classically occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatory cytokines.
 
;Lymphoma: The incidence of [[lymphoma]] is increased in RA as it is in most autoimmune conditions.
 
==References==
{{reflist|2}}


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Latest revision as of 20:57, 20 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

Patients with rheumatoid arthritis usually appear fatigued. On skin examination, rheumatoid nodules, erythema nodosum, atrophy of the digital skin, palmar erythema, and diffuse thinning of the skin may be found. If there is involvement of the eyes, scleritis and scleromalacia may be seen. On auscultation of lungs, decreased breath sounds on both sides and crackles may be observed. On palpation of the abdomen, hepatomegaly and splenomegaly is usually found when it is associated with Felty's syndrome. On examination of extremities, redness, and swelling of the affected joints, tenderness, pain on movement and decreased the range of movement is usually found.

Physical examination

Appearance of the Patient

  • Patients with rheumatoid arthritis usually appear fatigued.

Vital Signs

Skin

Eyes

Lungs

On Auscultation of lungs:

  • Decreased breath sounds on both sides.
  • Crackles may be present.

Abdomen

Extremities

  • On inspection redness and swelling of the affected joints.
  • On palpation:
    • Tenderness
    • Pain on movement
    • Decreased range of movement

References

  1. ↑ Pham T, Gossec L, Fautrel B, Combe B, Flipo RM, Goupille P, Le Loët X, Mariette X, Puéchal X, Wendling D, Schaeverbeke T, Sibilia J, Sany J, Dougados M (May 2005). "Physical examination and laboratory tests in the management of patients with rheumatoid arthritis: development of recommendations for clinical practice based on published evidence and expert opinion". Joint Bone Spine. 72 (3): 222–8. doi:10.1016/j.jbspin.2004.10.010. PMID 15850993.
  2. ↑ Medina YF, Ruíz-Gaviria RE, Buitrago-Lopez A, Villota C (February 2018). "Physical articular examination in the activity of rheumatoid arthritis: a systematic review of the literature : Systematic review of the literature regarding physical examination in rheumatoid arthritis". Clin. Rheumatol. doi:10.1007/s10067-018-4015-4. PMID 29464524.

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