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ESTER Reumatologia study materials
ESTER Reumatologia study resources

ESTER Reumatologia: General Rheumatology: Approach, Investigations and Red Flags

ESTER Reumatologia · Work through your exam, one topic at a time.

All guide sections

General Rheumatology: Approach, Investigations and Red Flags

The core framework

Rheumatology questions reward a disciplined approach: is the problem inflammatory or non-inflammatory, articular or extra-articular, monoarticular or polyarticular, and acute or chronic? Establish these four axes before reaching for a diagnosis. Inflammatory disease typically produces morning stiffness lasting more than 30–60 minutes, improvement with activity, night pain, and systemic features (fatigue, weight loss, low-grade fever); mechanical pain worsens with use and eases with rest.

Investigations

Know what each test can and cannot do. ESR and CRP are sensitive but non-specific; ESR is raised by anaemia, pregnancy and age, and is paradoxically low in polycythaemia and very high paraprotein states. Uric acid may be normal during an acute gout flare. Antinuclear antibody (ANA) is a screening test with poor specificity: it is positive in a substantial minority of healthy people, so a positive ANA in the absence of clinical features does not diagnose lupus. Rheumatoid factor is also non-specific (infections, malignancy, healthy elderly); anti-CCP is more specific. HLA-B27 is a susceptibility marker, not a diagnostic test.

Traps in questions

  • A single normal inflammatory marker does not exclude serious disease.
  • Septic arthritis is the classic "cannot-miss": a hot swollen joint with fever needs aspiration before any diagnosis of crystal disease is accepted - crystals and infection can coexist.
  • Drug monitoring questions: methotrexate needs folic acid supplementation and baseline plus periodic liver, renal and blood-count checks; it is teratogenic.
  • Always ask whether the patient has constitutional symptoms or a history of cancer, which reframes the differential toward malignancy or paraneoplastic disease.

Worked rule of thumb

For any monoarthritis: aspirate first, then think. Send fluid for cell count, Gram stain and culture, and polarised microscopy. Septic arthritis is a rheumatological emergency; delay risks permanent joint destruction.