GPSI Dr Louise Warburton’s tips on spotting patients early so they can be treated quickly
1. The diagnosis will often be made on the strength of the history.
It is useful to ask about ‘morning stiffness’ – how long does it take the patient to ‘get going’ in the mornings? Do they need to take a hot shower in order to limber up? Also ask if they stiffen up after resting during the day. Remember that patients with osteoarthritis stiffen up after exercise.
2. Fatigue is an important factor.
You should consider how the patient feels, and if they have had to make changes in their day-to-day life because of the way that they feel.
3. Inflammatory arthritis will cause pain and swelling in joints.
Ask the patient about pain and where the pain is felt. Also find out if they are sleeping well or if the pain is interfering with sleep. Discuss how far they can walk now and how far they could walk before.
4. The pattern of joint involvement is important.
In typical rheumatoid arthritis, the metacarpophalangeal joints tend to be involved. In seronegative arthritis, large joints such as knees, hips and ankles can also be involved. But don’t be put off by an atypical presentation of joint swelling and pain.
5. Refer the patient as early as possible.
There is a clear ‘window of opportunity’ during which starting therapy has a very good chance of preventing or even aborting the arthritis.1 You can refer patients to either a secondary care rheumatology service or intermediate care clinic.
6. If you suspect an inflammatory arthritis, check the patient’s FBC, ESR, C-reactive protein and rheumatoid latex.
There is no point taking X-rays because joint erosions don’t appear for 12 months.
7. Gout can mimic inflammatory arthritis.
If your patient is overweight, hypertensive and drinks alcohol or has metabolic syndrome, check their uric acid. Widespread gout can cause pain and inflammation in many joints, not just the big toe.
8. Raised inflammatory markers and normochromic, normocytic anaemia are suggestive of inflammatory arthritis.
Even if inflammatory markers are normal, the patient may still have arthritis, so refer if you suspect it is inflammatory arthritis.
9. Rheumatoid factor can be positive in many cases that are not inflammatory arthritis.
Several situations, such as the presence of some infections, can give false positive results. So diagnosis should not be made on the strength of a positive rheumatoid factor alone.
10. Be careful of a diagnosis of polymyalgia rheumatica.
Not all patients with a raised ESR and vague aches and pains who respond to oral steroids will have polymyalgia. Steroids often mask an inflammatory arthritis, or even an underlying malignancy.
Dr Louise Warburton is a GPSI in musculoskeletal medicine for NHS Telford and Wrekin and president of the Primary Care Rheumatology Society
Rheumatiod arthritis Rheumatiod arthritis