Rheumatoid Arthritis

A patient with bilateral swollen hands that are worst at 6 AM and improve by noon — that morning stiffness pattern is the signature that separates RA from every other joint disease.

Rheumatoid arthritis is a chronic systemic autoimmune disorder in which the immune system attacks the synovial membrane, causing inflammation, pannus formation, and progressive joint destruction. It targets small joints symmetrically — typically the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of both hands simultaneously. Morning stiffness lasting longer than 60 minutes is a hallmark; it improves with activity, not rest. Key labs include rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP), which is more specific. Elevated ESR and CRP confirm systemic inflammation. Over time, untreated RA produces characteristic deformities: swan-neck, boutonnière, and ulnar deviation. Because RA is systemic, extra-articular manifestations matter — subcutaneous rheumatoid nodules, pericarditis, interstitial lung disease, and scleritis can all appear. Disease-modifying antirheumatic drugs (DMARDs) like methotrexate are the treatment backbone, started early to prevent irreversible joint damage. Methotrexate requires concurrent folic acid supplementation and regular monitoring of hepatic and hematologic function. Nursing priorities include monitoring for immunosuppression, assessing functional status, promoting joint protection techniques, and teaching that heat relieves stiffness while cold reduces acute swelling.

Key Distinctions

Don't confuse RA (symmetric, small joints, morning stiffness >60 min, improves with movement) with osteoarthritis (asymmetric, weight-bearing joints, stiffness <30 min, worsens with activity). Students mix up swan-neck deformity (hyperextended PIP) with boutonnière deformity (flexed PIP) — opposite PIP positions. RF can be positive in other autoimmune conditions; anti-CCP is the more specific confirmatory marker for RA.

Clinical Pearl

Symmetric and small, stiff in the morning — if both hands mirror each other and loosen up with use, think RA, not OA.