By: Dr. Sunir Kumar
Rheumatology is a subject that comes up daily in clinical practice, and is a favorite on the
ABIM Internal Medicine board exam. According to the ABIM Internal Medicine exam blue print,
Rheumatology / Orthopedics represents 8% of the exam. Here we cover five evidence-based
high-yield pearls that will help you be better prepared for the Internal Medicine ABIM
certification exam!
Pearl # 1: Rheumatoid Arthritis is a systemic, inflammatory and symmetrical condition
Systemic means that it not only involves joints but also will affect different parts of the
body like the lungs, heart, blood vessels, skin, kidneys, and the hematological system.
Inflammatory means that the joints that are affected will be erythematous, warm,
swollen, and tender to touch. Since it is an inflammatory condition, ESR and CRP
(inflammatory markers) will also be elevated.
Symmetrical condition means that both sides of the body will be affected. The main
joints that are affected are the wrist, MCP, and PIP joints.
DIP joint and lower back are usually not affected.
Most specific antibody for RA is anti-CCP.
The most common extra-articular manifestation of RA is subcutaneous nodules.
Poor prognostic factors for RA include:
o Progressive synovitis
o Vasculitis (ulcers of fingers and toes)
o Subcutaneous nodules
o HLA-DR4 marker
o Elevated ESR
o Elevated Rheumatoid Factor
o Erosive lesions on X-ray
Patients with syncope or numbness/tingling in the upper extremities or weakness may
have atlanto-odontoid subluxation. MRI of the cervical spine is the diagnostic test of
choice. Surgical compression is warranted if patient has symptoms or the size is greater
than 8 mm in diameter
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Certain medications used in the management of RA are: NSAIDs, Hydroxychloroquine,
Sulfasalazine, Methotrexate with Folic Acid, Leflunomide, Steroids, and anti-TNF alpha
inhibitors
o Hydroxychloroquine → frequent eye exams required
o Methotrexate → Check CBC and Liver function tests every 6-8 weeks
o Leflunomide → Contraindicated in pregnancy. Reverse with cholestyramine X
11 days
o Anti-TNF alpha inhibitors → PPD testing needs to be checked before starting
medication. NEVER give two anti-TNF alpha inhibitors concurrently as this
increases the risk of infections. Usually if one is not working, another anti-TNF
alpha inhibitor will work.
Pearl # 2: Osteoarthritis is a chronic, progressively debilitating disease that is non-
inflammatory and non-systemic
Non-inflammatory means that this condition does not present with erythema or warmth
to a joint but can have swelling. Since it is a non-inflammatory condition, the
inflammatory markers (ESR and CRP) are also normal usually.
Non-systemic means that only joints get affected without compromising the integrity of
the entire body.
Pathophysiology is based on progressive destruction of cartilage that surrounds bone
that leads to “bone on bone” phenomenon.
Some of the major risk factors for Osteoarthritis include obesity, repetitive use, older
age, and trauma to a joint.
Joint involvement can be mono-articular or asymmetrical, chronic poly-articular.
Major joints that are involved are the hip joint, knee joint, lower back, PIP (Bouchard’s
nodes), and DIP joints (Heberden nodes). Usually MCP joint is spared.
Mainstay of treatment is non-pharmacological, pharmacological, or surgical.
o Non-pharmacological intervention includes weight reduction and weight
resistance training.
o Pharmacological intervention includes NSAIDs and narcotics.
o Surgical intervention includes steroid injections or knee replacement therapy.
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Pearl # 3: Knowing antibodies and their associated conditions are very high yield for