Medicine — Rheumatology, NMC MBBS licence examination syllabus (Nepal Medical Council).
The painful joint: inflammatory or not?
Two questions from the history sort most of rheumatology before you touch the patient.
Joint disease looks like a memorisation problem — dozens of conditions, overlapping features, autoantibodies with unhelpful names. It is not. Almost all of it sorts on two questions asked in the history: is this inflammatory or mechanical? and how many joints, in what pattern?
Answer those and the differential narrows to a handful. Then one further question decides urgency: is there a single hot swollen joint? Because that is septic arthritis until proven otherwise, and it destroys a joint within days while the rest of rheumatology unfolds over months and years.
🩺 Where this lives: A patient with known gout presents with a hot, swollen, exquisitely painful first metatarsophalangeal joint. It is tempting — and usually correct — to call it a gout flare and treat it. But septic arthritis and crystal arthritis can occur in the same joint at the same time, and finding crystals in the aspirate does not exclude infection. If the joint looks septic, or the patient is systemically unwell, it is treated as septic while cultures are awaited. A joint destroyed by a missed infection does not recover.
The first question
The discriminating question is "is it better or worse after you have been moving about?" Inflammatory disease loosens with use and stiffens with rest — which is why these patients are worst on waking and better by mid-morning. Mechanical disease does the opposite. One question, asked properly, sorts most of the clinic.
The second question
💡 Exam angle: the distribution is asked constantly because it is genuinely discriminating. Rheumatoid arthritis affects the MCP and PIP joints and spares the DIP joints; osteoarthritis does the opposite, giving Heberden's nodes at the DIPs. Psoriatic arthritis is the exception that can involve DIP joints, often with nail changes. A question describing which rows of finger joints are involved is testing this and nothing else.
The hot joint
SEPTIC ARTHRITIS — why the urgency
Bacterial enzymes and the inflammatory response degrade
cartilage within DAYS. Delay causes permanent damage even
if the organism is eventually cleared.
RISK FACTORS
Pre-existing joint disease (especially RA)
Prosthetic joint · recent joint injection or surgery
Diabetes · immunosuppression · intravenous drug use
Skin breach anywhere
KEY POINTS
ASPIRATE BEFORE ANTIBIOTICS where possible — but do
not delay treatment in a septic patient.
A NORMAL temperature does not exclude it, particularly
in the elderly and immunosuppressed.
Staph aureus is the commonest organism. In young
sexually active adults consider gonococcal infection,
which may present with migratory arthritis, tenosynovitis
and a rash.
Treatment is antibiotics AND joint drainage — this is
the same source-control principle as the sepsis
chapter, applied to a closed space.
Rheumatoid arthritis
🔍 What it is and how it presents
MechanismA chronic autoimmune synovitis. The inflamed synovium proliferates into a pannus that invades and erodes cartilage and bone. It is a systemic disease that happens to present in joints.
PatternSymmetrical polyarthritis of the small joints — MCPs, PIPs, wrists, MTPs — with prolonged early morning stiffness. Spares the DIP joints and the lumbar spine.
Later deformitiesUlnar deviation, swan-neck and boutonnière deformities, subluxation. These represent damage that has already occurred — they are a treatment failure, not a diagnostic goal.
Extra-articularRheumatoid nodules, anaemia of chronic disease, dry eyes and mouth, pulmonary fibrosis and nodules, pericarditis, vasculitis, amyloidosis. Cardiovascular risk is raised — chronic inflammation is atherogenic, which is why these patients need vascular risk managed too.
SerologyRheumatoid factor is neither sensitive nor specific — it occurs in other diseases and in healthy people. Anti-CCP is more specific and carries prognostic weight. Seronegative RA exists; a negative test does not exclude the diagnosis.
💡 Exam angle: the cervical spine point matters practically. RA can cause atlantoaxial subluxation, so neck manipulation and — critically — intubation carry a risk of cord compression. A question about pre-operative assessment in a rheumatoid patient is usually testing whether you think of the neck before the anaesthetic.
TREATMENT PRINCIPLES
DMARDs — disease-modifying antirheumatic drugs
Methotrexate is the usual anchor drug. Others include
sulfasalazine, hydroxychloroquine and leflunomide.
They act over WEEKS, so treatment is started early and
reviewed rather than judged in days.
METHOTREXATE — the practical points
WEEKLY dosing, never daily. Daily administration is a
recognised and lethal prescribing error.
FOLIC ACID is co-prescribed to reduce toxicity.
Monitor FBC, LFTs and renal function — myelosuppression
and hepatotoxicity.
Pneumonitis is uncommon but serious.
CONTRAINDICATED IN PREGNANCY — teratogenic, and this
requires an explicit conversation with anyone who
might conceive.
BIOLOGICS
Anti-TNF and other targeted agents for inadequate
response. Screen for LATENT TUBERCULOSIS and hepatitis
B before starting — the tuberculosis chapter explains
why: these drugs dismantle the granuloma holding a
dormant infection in check.
GLUCOCORTICOIDS
Rapid control while DMARDs take effect — a bridge.
Long-term use brings its own disease.
NSAIDs
Symptom relief only. They do not alter the disease.
Gout
MECHANISM AND TRIGGERS
Monosodium urate crystals deposit in joints when urate
is persistently high — from UNDER-EXCRETION (most
patients) or over-production.
CONTRIBUTORS
Renal impairment · DIURETICS (thiazides and loop) ·
alcohol · purine-rich diet · obesity · metabolic
syndrome · cell turnover (tumour lysis)
ACUTE ATTACK
Sudden, severe, exquisitely tender monoarthritis —
classically the first MTP joint (podagra). Skin may be
red and peeling.
A NORMAL SERUM URATE DURING AN ACUTE ATTACK IS COMMON
Urate often falls during a flare, so a normal level
does not exclude gout — and a raised level in an
asymptomatic person is not gout either. The diagnosis
is clinical, supported by crystals in the aspirate.
MANAGEMENT
ACUTE: anti-inflammatory treatment. Do NOT start or
stop urate-lowering therapy during an attack — it
can precipitate or prolong a flare.
LONG TERM: urate-lowering therapy (allopurinol is
usual) for recurrent attacks, tophi or renal
involvement, started once the flare has settled and
introduced with cover.
Address the contributors — review the diuretic,
the alcohol, the weight.
The two commonest gout errors both involve timing. A normal urate during an attack does not exclude gout, because urate frequently falls when the flare begins. And urate-lowering therapy is neither started nor stopped mid-attack — a sudden change in urate concentration destabilises crystal deposits and can worsen the flare you are trying to treat.
The seronegative spondyloarthritides
🔍 A family united by what they share
Shared featuresAxial involvement (sacroiliitis, spinal inflammation), enthesitis — inflammation where tendon meets bone, such as Achilles or plantar fascia — dactylitis ("sausage digit"), asymmetric large-joint oligoarthritis, and an association with HLA-B27. Rheumatoid factor is negative, hence "seronegative".
Ankylosing spondylitisYoung adult, usually male, with inflammatory back pain — insidious onset, morning stiffness, better with exercise and worse with rest, waking in the second half of the night. Reduced spinal movement and chest expansion. Extra-articular: anterior uveitis, aortic regurgitation, apical lung fibrosis.
Psoriatic arthritisMay precede the skin disease. Can involve DIP joints with nail pitting and onycholysis — the exception to the "RA spares the DIPs" rule.
Reactive arthritisFollows gastrointestinal or genitourinary infection by days to weeks. Classically with conjunctivitis and urethritis. The joint itself is sterile — this is a reaction, not an infection.
EnteropathicAssociated with inflammatory bowel disease.
💡 Exam angle: inflammatory back pain in a young adult is a high-yield presentation, because mechanical back pain is so common that the inflammatory version gets missed for years. The discriminators are: onset before about 40, insidious, morning stiffness over 30 minutes, improvement with exercise, no improvement with rest, and night pain in the second half of the night. That combination in a young person warrants investigation rather than analgesia and reassurance.
Clinical reasoning: four presentations
🔍 Case 1 — the joint that cannot wait
PresentationA 68-year-old with rheumatoid arthritis on methotrexate has a hot, swollen, very painful right knee for one day. Temperature 37.2°C. She attributes it to a flare.
Key cluesA single hot joint, in a patient with damaged joints and on immunosuppression — two major risk factors for infection.
ReasoningRA flares are typically polyarticular and symmetrical. A single acutely hot joint in this patient is septic arthritis until proven otherwise, and the near-normal temperature is not reassurance — immunosuppressed patients frequently do not mount a fever.
AnswerUrgent joint aspiration for Gram stain, culture and crystals, then antibiotics and drainage. Do not treat as a flare on the basis of the underlying diagnosis.
🔍 Case 2 — the normal urate
PresentationA 52-year-old man on a thiazide has a sudden exquisitely painful, red first MTP joint overnight. Serum urate is 340 µmol/L — within the reference range. Gout is dismissed.
TrapUsing a mid-attack urate to exclude gout.
ReasoningUrate frequently falls during an acute flare, so a normal level is common and does not exclude the diagnosis. The presentation — sudden, nocturnal, first MTP, on a thiazide — is characteristic.
AnswerTreat the acute attack, confirm with aspiration where doubt exists, and recheck urate once settled. Review the thiazide, since it contributes to urate retention.
🔍 Case 3 — the young back
PresentationA 24-year-old man has had lower back pain for eight months. It is worst on waking with an hour of stiffness, eases as he moves, and wakes him at 4 a.m. He has had one episode of a painful red eye.
Key cluesYoung, insidious, morning stiffness, better with movement, night pain in the second half — inflammatory. The red eye suggests anterior uveitis.
ReasoningThis is inflammatory back pain, not mechanical. Axial spondyloarthritis with an extra-articular manifestation.
AnswerInvestigate for axial spondyloarthritis — imaging of the sacroiliac joints, inflammatory markers, HLA-B27 — and refer to rheumatology. Exercise and physiotherapy are central to management, not an afterthought.
🔍 Case 4 — the prescription that kills
PresentationA patient with RA is admitted for an unrelated problem. The admitting doctor transcribes her methotrexate onto the drug chart as a daily dose. Three days later she is neutropenic with severe mucositis.
Key clueMethotrexate is a weekly drug.
ReasoningDaily methotrexate at rheumatological doses causes severe myelosuppression and mucositis. This is a recognised, repeatedly fatal prescribing error, and it usually happens at transitions of care.
AnswerStop the drug, seek urgent specialist advice, and treat the toxicity with supportive care and folinic acid rescue as advised. The prevention is checking the frequency of every methotrexate prescription — always weekly, with folic acid on a different day.
Commonly confused
Confusion
The distinction
Why it matters
Inflammatory vs mechanical
Inflammatory improves with movement; mechanical worsens
Sorts most of rheumatology from the history alone.
Flare vs septic joint
A single acutely hot joint is septic until excluded
Cartilage is destroyed in days.
Crystals vs no infection
Gout and sepsis can coexist
Finding crystals does not permit stopping there.
RA vs osteoarthritis distribution
RA spares DIPs; OA affects them (Heberden)
The row of joints involved names the disease.
Normal urate vs not gout
Urate often falls during an acute attack
A normal level mid-flare excludes nothing.
NSAIDs vs DMARDs
NSAIDs relieve symptoms; only DMARDs alter the disease
Comfort while joints are destroyed is not treatment.
Weekly vs daily methotrexate
It is always weekly
Daily dosing is a recognised fatal error.
Rapid revision
MUST-KNOW FACTS
1. Two questions sort most joint disease: inflammatory or mechanical, and
how many joints in what pattern.
2. Inflammatory: morning stiffness > 30–60 min, BETTER with movement.
3. Mechanical: brief stiffness, WORSE with use, better with rest.
4. A single hot swollen joint is SEPTIC ARTHRITIS until proven otherwise.
5. Aspirate before antibiotics where possible — but never delay treatment.
6. A normal temperature does not exclude septic arthritis.
7. Septic arthritis needs antibiotics AND drainage.
8. Staph aureus is commonest; consider gonococcus in young adults.
9. Crystals in the fluid do NOT exclude coexisting infection.
10. Gout: needle-shaped, NEGATIVELY birefringent urate crystals.
11. Pseudogout: rhomboid, POSITIVELY birefringent CPPD crystals.
12. RA: symmetrical small-joint polyarthritis, SPARES the DIPs.
13. Osteoarthritis affects the DIPs — Heberden's nodes.
14. Psoriatic arthritis may involve DIPs, with nail changes.
15. Anti-CCP is more specific than rheumatoid factor; seronegative RA exists.
16. RA is systemic — raised cardiovascular risk, lung, eye and nodule disease.
17. RA can cause atlantoaxial subluxation — think of the neck before intubation.
18. Start DMARDs EARLY; erosions are irreversible.
19. NSAIDs relieve symptoms and change nothing about the disease.
20. METHOTREXATE IS WEEKLY. With folic acid. Never in pregnancy.
21. Screen for latent TB and hepatitis B before biologics.
22. A normal urate during an acute gout attack is common.
23. Do not start or stop urate-lowering therapy during a flare.
24. Thiazide and loop diuretics raise urate and precipitate gout.
25. Spondyloarthritis: axial disease, enthesitis, dactylitis, HLA-B27.
26. Inflammatory back pain in a young adult deserves investigation.
💡 Exam angle: the reliable threads are (a) inflammatory versus mechanical from the history, (b) the single hot joint, (c) crystals not excluding sepsis, (d) a normal urate mid-attack, and (e) weekly methotrexate. The last of these is the one most likely to matter on your first ward job — transcription errors at admission are where it happens.
Syllabus points
Inflammatory versus mechanical pain
Number and distribution of joints
Septic arthritis and why it is urgent
Synovial fluid analysis and crystal identification
Rheumatoid arthritis: mechanism and presentation
Extra-articular disease and cardiovascular risk
Serology: rheumatoid factor and anti-CCP
Why DMARDs are started early
Methotrexate: weekly dosing and monitoring
Biologics and pre-treatment screening
Gout: mechanism, triggers and management timing
The seronegative spondyloarthritides
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