Rheumatology

Question 1

Rheumatoid arthritis - general

1. Which cells target normal tissue
2. Higher risk if do what
3. Classic presentation
4. Symptom onset - time frame
5. X-ray findings (4)
6. Blood protein in 70%
7. Highly specific antibody
8. Other bloods

Answer 1

1. T cells
2. Smoke
3. Symmetrical swollen/painful/stiff small joints, worse in morning, long duration (>6 weeks)
4. Over weeks/months
5. Soft tissue swelling, loss of joint space, joint deformity, juxta-articular osteopaenia
6. Rheumatoid factor - associated with more severe
7. Anti-CCP
8. Normo/microcytic anaemia, high platelets/ESR/CRP

Question 2

Rheumatoid arthritis - management

1. Assess disease activity with
2. General management - 1st line (+ monitoring)
3. Others
4. Side effects
5. TNF-inhibitors if
6. Hydroxychloroquine - what must be checked regularly
7. Flare - 1st line
8. Analgesia - most useful

Answer 2

1. DAS28 + CRP monitoring
2. DMARD monotherapy - methotrexate* (LFT, FBC)
3. Sulfasalazine, hydroxychloroquine,
4. GI upset, raised liver enzymes, bone marrow suppression, oral ulcers, pneumonitis
5. 2 DMARDs didn’t work
6. Retinal damage
7. IM methylprednisolone
8. NSAIDs

Question 3

Rheumatoid arthritis - examination

1. Joints affected
2. Typical distribution
3. Joint - pathological processes (4)
4. Boutonniere deformity =
5. Swan neck deformity =
6. Other hand/wrist signs
7. Extra-articular manifestations - nodule location (6)
8. Lungs (4)
9. Cardiovascular
10. Other
11. Felty syndrome - 2 additional features

Answer 3

1. Small-medium (MCP, PIP, wrist, MTP)
2. Symmetrical
3. Tenosynovitis, bursitis, thickened capsule, bone erosion, cartilage destruction
4. PIP flexion, DIP hyperextension
5. MCP flexion, PIP hyperextension, DIP flexion
6. Ulnar deviation, wrist/finger subluxation (radiocarpal), ulnar claw (MCP extension, PIP flexion)
7. Elbows, lungs, cardiac, CNS, lymphadenopathy, vasculitis
8. Pleural disease, interstitial fibrosis, bronchiolitis obliterans, organising pneumonia
9. IHD, pericarditis, pericardial effusion
10. Anaemia, carpal tunnel, peripheral neuropathy, splenomegaly
11. RA with splenomegaly + leukopaenia

Question 4

Spondyloarthropathies - general

1. Types (4)
2. Common features
3. Enthesitis - definition, examples (3)
4. Pathology - step 1
5. Pathology - step 2
6. Enteric arthropathy - associations
7. Management
8. Psoriatic arthritis - joint patterns (5)
9. Examination
10. Radiology
11. Management
12. Other HLA-B27-associated disease

Answer 4

1. Ankylosing spondylitis, enteric arthropathy, psoriatic arthritis, reactive arthritis
2. Seronegative (RhF -), HLA B27 associated, ‘axial’, asymmetrical, large joint, mono/oligo pattern, dactylitis
3. Inflammation at insertion of a tendon, ligament or capsule in a bone (plantar fasciitis, achilles tendonitis, chostrochondritis)
4. Initial inflammation + erosions
5. Fibrosis + ossification
6. IBD, GI bypass, Whipple’s disease, coeliac disease
7. Arthropathy improves if treat bowel, DMARD if resistant
8. Symmetrical poly, DIP only, asymmetrical oligo, spinal, mutilans
9. Nail changes, dactylitis, aceneiform rash, palmo-plantar pustulosis
10. Erosive, ‘pencil in cup’ if severe,
11. NSAIDs, sulfasalazine, methotrexate
12. Acute anterior uveitis

Question 5

Ankylosing spondylitis

1. Classic patient
2. Main joints affected (2)
3. Extra-skeletal features
4. Associated diseases
5. Examination
6. Diagnosis
7. Imaging findings
8. Bloods
9. Management

Answer 5

1. Young male - back pain worse at night with early morning stiffness >30 minutes (relieved by exercise)
2. Spine, sacroiliac
3. Apical fibrosis, anterior uveitis, aortic regurgitation, AV node block achilles tendonitis, amyloidosis, cauda equina, peripheral arthritis (25%, commoner if female)
4. Crohn’s/UC
5. Progressive loss of spine ROM in all directions, reduced thoracic expansion, sometimes progress to kyphosis + neck hyperextension
6. MRI spine + sacroiliac joints
7. MRI - marrow oedema (active inflammation), destructive changes (sclerosis, erosions, anklyosis).
   CXR can also show sacroiliac joint space narrow/wider, T11-L1 syndesmophytes, causing fusion
8. Normocytic anaemia, high ESR/CRP
9. NSAIDs, TNF inhibitors, exercise (physio imput)

Question 6

Osteoarthritis

1. Risk factors
2. Secondary predisposing factors (3)
3. Classic joint presentation (4)
4. Classic history
5. Common joints (4)
6. Examination - general
7. Bouchards nodes - location
8. Herberdens nodes - location
9. X-ray changes (4)
10. Bone screen - 3 components
11. Management

Answer 6

1. Age, obesity, female, occupation, muscle weakness, gout
2. Trauma, congenital/developmental, metabolic disease
3. Pain/crepitus, stiffness, swelling, deformity
4. Pain/crepitus worse on moving, background ache at rest, stiffness post-rest, perceived power loss from pain
5. Knee, hip, DIP + thumb CMC
6. Joint tenderness, derangement, bony swelling, mild sinovitis, reduced ROM
7. PIPJs
8. DIPJs
9. Loss of joint space, osteophytes, subchondral sclerosis, subchondral cysts
10. ALP, Ca2+, phosphate
11. Exercise, weight loss, analgesia (regular paracetamol + topical NSAIDs, short course PO + codeine if not enough), hot/cold packs, physio, joint replacement

Question 7

Methotrexate - counselling

1. Action
2. Timeline
3. How to take
4. Length of treatment
5. Effects - time before
6. Tests (+ when)
7. Important side effects
8. Complications (+ symptoms)
9. Contraindications
10. Supplementary advice - when to get help
11. What else to do to avoid infection
12. Avoid/limit what
13. When not to take
14. IMPORTANT LIFESTYLE ADVICE

Answer 7

1. Disease modifier, reduced inflammation, improves symptoms
2. Once weekly with folic acid at another time
3. Tablet usually, sometimes injection
4. Long-term
5. 4-6 months
6. FBC, U+E, LFT (at start, then every 2 weeks until stable, then every 3 months)
7. Alopecia, headaches, GI upset (mucosal damage)
8. Myelosuppression (infection, anaemia, unexplained bleed/bruise), hypersensitive (hepatitis/pneumonitis/rash)
9. Trying for baby (M/F), pregnant, active infection, liver / renal failure, breastfeeding, immunodeficiency.
10. Go to ED if myelosuppression or respiratory signs
11. Get pneumococcal vaccine before + yearly flu jab
12. Limit careful alcohol, no NSAIDs / aspirin / penicillin
13. If have infection
14. Contraception (M+F) whilst using + 3 months after

Question 8

Vasculitis - general

1. Classified using what
2. Can be primary, or secondary to what (6)
3. General symptoms/test result
4. Large vessel - types (3)
5. Polymyalgia rheumatica -features
6. Investigations
7. Differentials (4)
8. Management
9. Takayasu arteritis - classic presentation
10. Other signs
11. Association
12. Management

Answer 8

1. Modified Chapel Hill Criteria
2. SLE, RA, Hep B/C, HIV, malignancy
3. Overwhelming fatigue, raised ESR/CRP, maybe ANCA
4. Giant cell, polymyalgia rheumatica, takayasu arteritis
5. > 50, F, subacute onset of fatigue, bilateral aching, tenderness, morning stiffness in shoulders, hips, proximal limbs, weight loss, anorexia, depression. Associated mild polyarthritis, tenosynovitis, carpal tunnel. NO weakness.
6. CRP up, ESR >40/normal, ALP up in 30%, CK normal
7. RA, polymyositis, hypothyroidism, cervical spondylosis
8. Prednisolone 15mg PO (much better within 7 days)
9. Female, asian, aorta occlusion, absent limb pulse
10. Intermittent claudication, malaise, headache, carotid bruit
11. Renal artery stenosis
12. High dose prednisolone

Question 9

Medium vessel vasculitis - general

1. Types (2)
2. PAN - what is it
3. Associated with what
4. Features
5. Commonest cause of death
6. Diagnostic
7. Management
8. Kawasaki disease - features (6)
9. Management
10. Complications

Answer 9

1. Polyarteritis nodosa (PAN), kawasaki disease
2. Necrotising vasculitis, thrombosis/aneurysms
3. Hep B, middle-aged men
4. Fever, malaise, arthralgia, haematuria, renal failure
5. Renal artery stenosis, glomerular ischaemia, HTN
6. Renal/mesenteric angiography, renal biopsy
7. Control BP, steroids if mild, steroid-sparing if severe
8. High fever >5 days, conjunctival injection, cracked lips, strawberry tongue, cervical lymphadenopathy, red palms/soles of feet (peel)
9. High dose aspirin, IVIG, echo
10. Coronary artery aneurysm

Question 10

Small vessel vasculitis - general

1. Types (3)
2. Which associated with c-ANCA (targets PR3)
3. Which associated with p-ANCA (targets MPO)
4. Microscopic - signs
5. eGPA (Churg-Strauss) - other features
6. GPA (Wegener’s) - other features
7. Management - to go into remission
8. What to add if vital organ/life-threatening
9. Maintenance therapy

Answer 10

1. Eosinophilic granulomatosis with polyangiitis, granulomatosis with polyangiitis, microscopic polyangitis
2. GPA, sometimes microscopic
3. EGPA, microscopic polyangitis
4. Rapidly progressing glomerulonephritis, pulmonary haemorrhage
5. Asthma, sinusitis, mononeuritis multiplex, p-ANCA
6. URT (epistaxis, sinusitis, nasal crusting), LRT (dyspnoea, haemoptysis), vasculitis rash, eyes involved, pauci-immune glomerulonephritis, c-ANCA
7. IV cyclophosphamide/ rituximab, glucocorticoid
8. Plasma exchange
9. Methotrexate / azathioprine / rituximab, + taper glucocorticoids

Question 11

High-dose steroids

1. Things to check before starting

Answer 11

1. GI protection, bone protection, screen for DM, monitor BP/weight

Question 12

Antiphospholipid syndrome

1. Associated with (20-30%)
2. Characteristics - ‘CLOTS’
3. Main antibodies (2)
4. Management

Answer 12

1. SLE
2. Coagulation defect (arterial/venous)
   Livedo reticularis
   Obstetric (recurrent miscarriage)
   Thrombocytopaenia (cerebral, renal)
3. Anti-phospholipid (lupus anticoagulant, cardiolipin)
4. Anticoagulation, pregnancy counselling

Question 13

Systemic lupus erythematosus (SLE)

1. Autoantibody production against
2. Drugs that induce (3)
3. Type of arthritis
4. Dermatological features (4)
5. Cardiovascular features (3)
6. Non-infective endocarditis - type, valve affected
7. Respiratory features (3)
8. Haematological features (4)
9. Commonest cause of lupus-related death
10. Main serological test
11. Antibodies present
12. Other bloods
13. Management - mild
14. Moderate
15. Severe

Answer 13

1. Nuclear material (ANA, homogenous)
2. Minocycline, oral contraceptive, hydralazine
3. Non-erosive
4. Photosensitivity, butterfly rash, hair loss, mucosal ulceration
5. Pericarditis, myocarditis, raynaud phenomenon
6. Libman-sacks endocarditis, mitral valve
7. Pleurisy, pleural effusions, pneumonitis
8. Lymphopaenia, neutropaenia, anaemia, antiphosphalipid syndrome
9. Glomerulonephritis
10. ANA (95%)
11. anti-dsDNA (60%), RF (40%), ENA in 20% (Ro, La, Sm, RNP), antiphospholipid (cardiolipin/Lupus anticoagulant)
12. Low complement (C3/4/50), positive direct coombs
13. NSAIDS / hydroxychloroquinine
14. Corticosteroids / azathiprine / methotrexate
15. Corticosteroids + cyclophosphamide / tacrolimus

Question 14

Sjogren’s syndrome

1. Which glands affected, consequence
2. Cause
3. Commoner in
4. Increased risk of
5. Features
6. Name for dry eyes
7. Associated renal disease
8. Type of neuropathy
9. Investigations - what present in nearly all patients
10. What positive in 70%
11. What positive in 30%
12. Test to measure tear formation
13. Histology
14. Other bloods - significant results (2)

Answer 14

1. Exocrine, so dry mucosal surfaces
2. Primary, or secondary to RA/other CTDs
3. Women
4. Lymphoid malignancy
5. Dryness (eyes, mouth, vagina), joints (arthralgia, raynaud’s, myalgia,
6. Keratoconjunctivitis sicca
7. Renal tubular acidosis
8. Sensory polyneuropathy
9. Rheumatoid factor
10. ANA, Anti-Ro (if primary)
11. Anti-La
12. Schirmer’s test: filter paper near conjunctival sac
13. Focal lymphocytic infiltration
14. Hypergammaglobulinaemia, low C4

Question 15

Raynaud’s syndrome

1. Management - 1st line

Answer 15

1. Nifedipine

Question 16

Fibromyalgia

1. Risk factors (3)
2. Associated symptoms (7)
3. Investigations to rule out other diseases
4. Diagnostic requirements
5. Main pharmalogical treatment
6. What not to use
7. Chronic fatigue syndrome (myalgic encephalomyelitis)
   - definition

Answer 16

1. Female, middle age, stress
2. Depression, fatigue, poor concentration, sleep disturbance, headache, paraesthesia, anxiety
3. TSH, vit D, B12, iron studies, magnesium, ESR/ CRP
4. Chronic (> 3 months), widespread (L/R, upper/lower)
5. Amitriptyline
6. NSAIDs
7. Persistent disabling fatigue >6 months, present >50% of the time + 4 of: myalgia, polyarthralgia, worse memory, unrefreshing sleep, exertional fatigue >24 hours, sore throat, tender lymph nodes

Question 17

Gout

1. Type of crystals
2. Deposited where (3)
3. Symptoms/signs - ‘G O U T’
4. Urate high - threshold
5. Primary - causes
   Secondary gout
6. Over-production of uric acid - causes (4)
7. Under-excretion of uric acid - causes (4)
8. Bloods (2)
9. Aspiration - findings
10. X-ray - early
11. Late

Answer 17

1. Urate
2. Joints, kidneys, soft tissues
3. Great toe (MTP), One joint, Uric acid raised, Tophi
4. > 0.4 mmol/L
5. Uricaemia inherited disorder, hypothyrodism
6. Psoriasis, polycythaemia rubra vera, leukaemia, primary hyperparathyroidis, diet (alcohol, red meat, sweeteners\0
7. HTN, renal disease, alcohol, elderly, diuretics
8. Urate, U+Es
9. Needle shaped crystals, negatively birefringent
10. Soft tissue swelling
11. Periarticular erosion + disruption, NORMAL joint space

Question 18

Pseudogout (CPPD)

1. Risk factors (4)
2. Joints affected
3. Acute - pattern
4. Chronic - pattern
5. Aspiration - findings
6. X-ray - finding
7. Management - acute
8. Prophylaxis
9. Complications

Answer 18

1. Arthritis, DM, hyperparathyroidism, haemochromatosis, low phosphate
2. Knees, wrists, hips
3. Large joint mononeuropathy post illness/surgery/trauma
4. Inflammatory, symmetrical, polyarthritis/sinovitis
5. Oval / rhomboid crystals, weakly positively birefringent
6. Chondrocalcinosis (soft tissue calcium deposits)
7. Usually self limiting, rest, NSAIDs, cool packs, intra-articular steroids
8. NSAIDs (+ PPI) + colchicine
9. Secondary osteoarthritis

Question 19

Gout - management

1. Conservative
2. Avoid what
3. Acute flare
4. Long-term prophylaxis - what
5. Indication
6. How long to wait before starting post-flare
7. Titration
8. Other indications (2)
9. Side effects
10. Give what alongside when starting
11. What happens in next flare
12. Alternative if contraindicated (+ side effect)

Answer 19

1. Weight loss
2. Purine rich food, alcohol excess, aspirin, diuretics
3. NSAIDs / Colchicine / Steroids (if renal impairment so can’t have other two), rest/elevate, ice packs
4. Allopurinol
5. > 1 flare in 12 months, but especially if >2 flares, renal disease, uric acid renal stones, tophi
6. Wait until inflammation reduced (3 weeks)
7. 100mg a day, increase every 4 weeks until plasma urate < 0.3.
8. Cytotoxics, diuretics
9. Rash, fever, low WCC, can preciptate flare
10. NSAID (6 weeks) / colchicine 0.5mg bd 6 months
11. Don’t stop allopurinol
12. Febuxostat (deranged LFTs)

Question 20

Antibodies/protein markers present

1. Rheumatoid arthritis (2)
2. SLE (5)
3. Drug-induced SLE
4. Sjogren’s (4)
5. Anti-phospholipid syndrome (2)
6. Polymyositis / dermatomyositis (2)
7. Limited cutaneous systemic sclerosis
8. Diffuse systemic sclerosis
9. Which can cross placenta in pregnancy

Answer 20

1. Rheumatoid factor, anti-CCP
2. ANA (95%) anti-dsDNA (60%), RF (40%), ENA in 20% (Ro, La, Sm, RNP), antiphospholipid (cardiolipin/Lupus anticoagulant)
3. Anti-histone
4. ENA (Ro, La), ANA, rheumatoid factor, anti-CCP
5. Anti-phospholipid (cardiolipin, lupus anticoagulant)
6. Anti-Jo, ANA
7. Anti-centromere, ANA
8. Anti-Scl70
9. Anti-Ro, anti-La

Question 21

Rheumatology history - general

1. Screening questions (3)
2. Presenting symptoms
3. Extra-articular features
4. Related diseases
5. Current/past drugs
6. Family history
7. Social history

Answer 21

1. Free from pain/stiffness in joints/muscle/back, dress self, walk up/down stairs
2. Pattern, symmetry, morning stiffness >30 minutes, pain, swelling, loss of function, erythema, warmth
3. Rash/photosensitivity, Raynaud’s, nodules/nodes, ulcers (mouth/genitals), dry eyes/mouth, anterior uveitis, diarrhoea/urethritis, weight loss
4. Crohn’s/UC, preceding infections, psoriasis
5. NSAIDs, DMARDs, biological agents
6. Arthritis, psoriasis, autoimmune disease
7. Age, occupation, sexual history, smoking (may worsen RA), home help

Question 22

Arthritides - differentials

1. Monoarthritis (4)
2. Oligoarthritis (5)
3. Symmetrical polyarthritis (4)
4. Asymmetrical polyarthritis (3)

Answer 22

1. Septic, crystal, osteorthritis, trauma (haemarthrosis)
2. Crystal, psoriatic, reactive, ankylosing spondylitis, osteoarthritis
3. Rheumatoid, osteoarthritis, viruses (Hep A/B/C, mumps), systemic conditions
4. Reactive, psoriatic, systemic

Question 23

Reactive arthritis

1. Joint pattern
2. Causative organisms (broad areas)
3. Other clinical features
4. Reiter’s syndrome - triad
5. Investigations - investigate reactive cause
6. Management

Answer 23

1. Oligoarthritis, asymmetrical
2. GI (salmonella, campylobacter, yersinia), GU (chlamydia)
3. Iritis, keratoderma blenorrhagia (raised brown plaques on soles/palms), circinate balanitis (painless penile ulceration from chlamydia), mouth ulcers, enthesitis
4. Arthritis, urethritis, conjunctivitis
5. ESR, CRP, stool culture if diarrhoea, sexual health review, viral serology
6. No specific cure; splint joints, NSAIDs, local steroid injections

Question 24

Synovial fluid (appearance, viscosity, WBC, neutrophils)

1. Normal
2. Osteoarthritis
3. Haemorrhagic
4. Rheumatoid arthritis
5. Crystal arthritis (gout/CPPD)
6. Septic arthritis
7. Bloods - general

Answer 24

1. Clear, normal V, WBC <200, neuts 0
2. Clear/straw, high V, WBC <1000, neuts <50%
3. Xanthochromic, varied V, WBC <10000, neuts <50%
4. Turbid/yellow, low V, WBC 1-50,000, neuts varied
5. Turbid/yellow, low V, WBC 5-50,000, neuts 80%
6. Turbid/yellow, low V, WBC 10-100,000, neuts >90%
7. FBC, ESR, urate, U+E, CRP, culture if ? septic

Question 25

NSAIDs - side effects and how to manage 1. GI Avoid concomitant prescription of 2. CV NSAID with lowest CV risk 3. Renal Higher risk if 4. Counselling - important points

Answer 25

1. Bleeding/ulcers/perforation; prescribe PPI if >45 or other bleeding risk Anticoagulants, antiplatelets, SSRI, spironolactone, steroids, bisphosphonates 2. MI/stroke Naproxen 3. Failure Diuretics, ACE-i, ARBs, elderly, HTN, T2DM 4. Only take when need, stop + get help immediately if new abdominal pain / any signs of GI bleeding (black stool, fainting), no mixing NSAID types, smoking/alcohol increase risk

Question 26

Systemic sclerosis 1. Features 2. Limited cutaneous (CREST) - location, association 3. Antibodies (2) 4. Diffuse - antibodies (2)

Answer 26

1. Scleroderma, internal organ fibrosis, microvascular abnormality 2. Face, hands, feet; subclinical pulmonary HTN (sildenafil) 3. ANA (anti-centromere) 4. Anti-SCL-70, anti-nucleolar, anti-CCP, anti-RNAP (20%)

Question 27

Myositis 1. Definition 2. Polymyositis - definition 3. Associated muscular symptoms 4. Extra-muscular signs 5. Dermatomyositis - skin signs 6. Associated malignancies 7. Bloods 8. Diagnostic test 9. Other tests + findings (2) 10. Antibodies 11. Management - general 12. Skin

Answer 27

1. Autoimmune striated muscle inflammation 2. Insidious progressive symmetrical proximal muscle weakness 3. Myalgia, dysphagia, dyphonia, respiratory weakness 4. Fever, arthralgia, Raynaud's, interstitial lung fibrosis, myocarditis, aryythmias 5. Gottron's papules (rough/red, knuckle/elbow/knee), macular rash ('shawl sign' if on shoulders), eyelid heliotrope + oedema, nailfold erythema 6. Lung, pancreas, ovary, bowel 7. Raised muscle enzymes (e.g. CK, ALT, AST, LDH) 8. Muscle biopsy 9. EMG (fibrillation potentials), MRI (muscle oedema 10. Anti-Mi2, anti-Jo1 11. Prednisolone, immunosuppressant/cytotoxic if resistant 12. Hydroxychloroquine / topical tacrolimus

Question 28

Vasculitis - variable vessel size 1. Behcet's syndrome - triad 2. Associated with which HLA 3. Classic patient 4. Other symptoms 5. Test suggestive of diagnosis 6. Cogan syndrome - inflamed where 7. Other features

Answer 28

1. Oral ulcers, genital ulcers, anterior uveitis 2. B51 3. Young middle eastern men, positive FH 4. Thrombophebitis, DVT, arthritis, aseptic meningitis, erythema nodosum, GI (abdominal pain, diarrhoea, colitis) 5. Positive pathergy test (puncture site following needle prick becomes inflamed with small pustule forming) 6. Cornea 7. Fever, fatigue, weight/hearing loss, vertigo, tinnitus

Question 29

Systemic disease + skin - description, causes 1. Erythema nodosum 2. Erythema multiforme 3. Erythema migrans 4. Erythema marginatum

Answer 29

1. Painful, blue-red, raised, on shins. Sarcoid, drugs (sulphonamides, OCP), streptococcal infection, Crohn's 2. 'Target' lesions (symmetrical/central blister, on limbs, palms/soles. Stevens-Johnson syndrome post-drugs, or collagen disorder 3. Small papule at site of tick bite, forming large erythematous ring with central fading ('bullseye'). Lyme 4. Transient trunk pink coalescent rings. Rheumatic fever

Question 30

Methotrexate - general (non-counselling) 1. Prevents which cellular function 2. Used in what (3) 3. Long-term use - complications (2)

Answer 30

1. Cellular replication 2. DMARD for RA, chemotherapy, severe psoriasis 3. Hepatic cirrhosis, pulmonary fibrosis

Question 31

Juvenile idiopathic arthritis 1. Definition 2. Stills disease - features 3. Polyarticular - specific features 4. Pauci-articular (oligo) - specific features

Answer 31

1. Arthritis without any other cause, lasting more than 6 weeks in patients under the age of 16 2. Salmon-pink rash, swinging fever, lymphadenopathy, splenomegaly, joint pain, ANA/RF negative 3. 4+ joints, symmetrical, RF negative 4. <4, larger joints (but not hips), uveitis, positive ANA