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. Q' B. I recognize your concern; we have very effective treatments availablethat may prevent progression of your disease and help you regainfunction. Q' C. I ll have you talk with our social worker about getting a home healthnurse to assist you at home. Q' D. We now have effective medications that can cure rheumatoid arthri-tis; don t worry. Key Concept/Objective: To recognize the importance of patient education regarding the effective-ness of treatment as a critical component in the care of the patient with a rheumatic diseasePatients who present with complaints of joint pain often express the opinion that nothingcan be done for their arthritis.One of the most important things the physician can do isto correct this misconception.It is important that the patient understands that treatmentgreatly improves the condition of most patients with arthritis.Educating the patient aboutthe effectiveness of treatment is the first step toward a successful outcome.It is importantto provide realistic goals regarding the effectiveness of treatment options.Very effectivetherapies for rheumatoid arthritis have been available for 20 years, such that long-termoutcome has distinctly improved.New treatments with biologic agents that block theinflammatory cytokines tumor necrosis factor and interleukin-1 are very effective, havea rapid onset of action, and prevent radiographic progression of disease.To date, there is 15 RHEUMATOLOGY 3no therapy available that is curative of rheumatoid arthritis.This case illustrates theimportance of obtaining a functional assessment as a part of the history.After pain, loss offunction is of the greatest concern to the patient.Patients with significant functionalimpairment should be asked more detailed questions about routine activities of daily liv-ing.(Answer: B I recognize your concern; we have very effective treatments available that may pre-vent progression of your disease and help you regain function. )4.A 48-year-old man with a history of rheumatoid arthritis presents to clinic complaining of left wrist painand swelling.He has been maintained on prednisone and methotrexate.The patient expresses frustra-tion with this flare, because he had been doing very well the past few months.Vital signs are significantfor a temperature of 100.6 F (38.1 C).Which of the following statements regarding the evaluation of this patient is most accurate?Q' A.The affected joint should be examined; the examination shouldinclude appropriate maneuvers in an attempt to reproduce the patientcomplaintQ' B.Frank redness of the skin overlying the left wrist is always present ifthe pain is secondary to inflammationQ' C.Increased temperature of the skin overlying the left wrist is common ininflammatory arthritis and is best detected by palpation with the palmsQ' D.Arthrocentesis of the left wrist is not indicated, because the patient isknown to have rheumatoid arthritisKey Concept/Objective: To understand the components and findings of the joint examination ina patient with inflammatory arthritisBy looking at and palpating the joints, the physician can identify the exact anatomicstructures that are the source of the patient s pain and decide whether the pain is causedby inflammation.A goal of the examination is to reproduce the patient s pain, either bymotion of the joint or by palpation.Frank redness of the skin overlying a joint is unusual;however, increased temperature, best detected by palpation with the backs of the fingers(not the palms), is common and, when present, indicates inflammation.Palpation for ten-derness may reveal whether the problem lies within the joint or is discretely localized toan overlying bursa or tendon sheath.Arthrocentesis of the left wrist should be performedas part of the evaluation of this patient.When patients with established rheumatoid arthri-tis have fever and an apparent flare, joint infection should be excluded by joint aspirationbecause septic arthritis occurs more frequently in such patients.(Answer: A The affected jointshould be examined; the examination should include appropriate maneuvers in an attempt to reproducethe patient complaint)For more information, see Ruddy S: 15 Rheumatology: I Introduction to the RheumaticDiseases.ACP Medicine Online (www.acpmedicine.com).Dale DC, Federman DD, Eds.WebMD Inc., New York, March 2005Rheumatoid Arthritis5.A 41-year-old woman comes in for a checkup.You diagnosed her with rheumatoid arthritis (RA) severalyears ago when she presented with bilateral metacarpophalangeal joint swelling with stiffness andfatigue.The course of this patient s disease has been mild, and the patient has been maintained on non-steroidal anti-inflammatory drugs (NSAIDs) and methotrexate therapy.Today she is doing well; she hasminimal pain and functional impairment.She asks you about the cause of RA.This stimulates you toread about current evidence regarding the pathogenesis of this illness.Which of the following statements regarding the pathogenesis of RA is false?Q' A.Damage to bone and cartilage by synovial tissue and pannus is mediat-ed by several families of enzymes, including serine proteases andcathepsins 4 BOARD REVIEWQ' B.IgG rheumatoid factor is most commonly detected in patients with RAQ' C.Interaction of rheumatoid factors with normal IgG activates comple-ment and thereby starts a chain of events that includes production ofanaphylatoxins and chemotactic factorsQ' D.Although many cytokines are involved in the pathogenesis of RA,tumor necrosis factor (TNF-) and interleukin-1 (IL-1) are majorpathogenic factorsKey Concept/Objective: To understand the pathogenesis of RADamage to bone and cartilage by synovial tissue and pannus is mediated by several fami-lies of enzymes, including serine proteases and cathepsins.The most damaging enzymesare the metalloproteinases (e.g., collagenase, stromelysin, and gelatinase) and cathepsins(especially cathepsin K), which can degrade the major structural proteins in the joint.IgMrheumatoid factor is most commonly detected; IgG and, less frequently, IgA rheumatoidfactors are also sometimes found.The presence of IgG rheumatoid factor is associated witha higher rate of systemic complications (e.g., necrotizing vasculitis).Interaction ofrheumatoid factors with normal IgG activates complement and thereby starts a chain ofevents that includes production of anaphylatoxins and chemotactic factors.Macrophage-and fibroblast-derived cytokines (e.g
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