Complete Rheumatoid Arthritis Workup
A complete rheumatoid arthritis workup includes a comprehensive rheumatologic history and examination of all peripheral joints for tenderness, swelling, and range of motion, along with laboratory tests including autoimmune panels (ANA, RF, anti-CCP), inflammatory markers (ESR, CRP), and appropriate imaging studies to assess joint damage. 1
Clinical Assessment
History
- Duration and pattern of joint symptoms (morning stiffness lasting at least 1 hour is typical)
- Distribution of affected joints (symmetric involvement is characteristic)
- Presence of extra-articular manifestations
- Family history of autoimmune diseases
- Assessment of functional impairment and impact on daily activities
Physical Examination
- Detailed examination of all peripheral joints for:
- Swelling
- Tenderness
- Range of motion
- Warmth and erythema
- Special attention to metacarpophalangeal, proximal interphalangeal, wrists, and metatarsophalangeal joints
- Examination of the spine
- Assessment for extra-articular manifestations (rheumatoid nodules, vasculitis)
Laboratory Tests
Core Laboratory Tests
- Complete blood count (CBC) with differential
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Rheumatoid factor (RF)
- Anti-citrullinated protein antibody (ACPA/anti-CCP) - has high specificity (90%) for RA 1
- Antinuclear antibody (ANA)
Additional Tests Based on Clinical Presentation
- Liver and kidney function tests
- Urinalysis
- HLA-B27 testing (if symptoms suggest reactive arthritis or affect the spine) 1
- Synovial fluid analysis (if septic or crystal-induced arthritis is suspected)
Imaging Studies
Initial Imaging
- Plain radiographs of affected joints to:
- Exclude metastases
- Evaluate joint damage (erosions)
- Establish baseline for future comparison
Advanced Imaging (When Clinically Indicated)
- Ultrasound of affected joints to detect:
- Synovial thickening
- Early inflammatory changes not visible on radiographs
- Tenosynovitis
- MRI for:
- Early detection of bone edema and erosions
- Assessment of synovitis
- Evaluation of complex joint involvement
Disease Activity Assessment
Quantitative assessment of disease activity using validated composite measures:
- Disease Activity Score using 28 joint counts (DAS28)
- Simplified Disease Activity Index (SDAI)
- Clinical Disease Activity Index (CDAI)
- Health Assessment Questionnaire Disability Index (HAQ-DI)
Common Pitfalls to Avoid
Relying solely on clinical assessment: Studies show that rheumatologists relying only on clinical assessment without laboratory or imaging data have diagnostic accuracy of only 19% for RA 2
Overlooking seronegative RA: Not all RA patients are positive for RF or anti-CCP; seronegative RA requires careful clinical evaluation
Delayed referral: Early diagnosis is critical to prevent irreversible joint damage; patients with suspected early RA should be seen within 1-2 weeks of referral 1
Inadequate monitoring: Patients with inflammatory arthritis should be monitored with serial rheumatologic examinations and inflammatory markers every 4-6 weeks after treatment initiation 1
Missing extra-articular manifestations: RA can affect multiple organ systems beyond joints
Special Considerations
For patients on immunosuppressive therapy, screening for hepatitis B, C, and tuberculosis is essential before initiating disease-modifying antirheumatic drugs (DMARDs) 1
Patients with early morning stiffness, swollen joints, and positive ACPA for 6 weeks or more fulfill the criteria for RA according to the 2010 ACR/EULAR Classification Criteria, and disease-modifying therapy should be initiated 1
Consider early referral to a rheumatologist if there is joint swelling (synovitis) or if symptoms persist despite initial treatment 1