A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months. The symptoms are worse when she wakes up and gradually improve after several hours. The patient also feels fatigued but has had no skin rashes, oral lesions, or fever. She recently began taking chlorthalidone for hypertension and takes no other medications. She works in a daycare center. The patient drinks alcohol occasionally and does not use tobacco or illicit drugs. Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus. Temperature and other vital signs are within normal limits. Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands. The remainder of the examination shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

Question

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0bf_fab9_8f63_4b31d3ef19ac_MD0005_00 This patient has chronic, symmetric polyarthritis and prolonged morning stiffness in the hands and wrists, consistent with rheumatoid arthritis (RA). RA is diagnosed primarily based on clinical findings, but serologic studies, such as rheumatoid factor (limited predictive value in the overall population) and cyclic citrullinated peptide antibodies (specificity >90%), may help clarify the diagnosis. Results are positive in most patients at some point in the disease course but may be negative in 50% of patients at the time of initial presentation. Acute-phase inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein) are nonspecific but should also be ordered, as they are usually elevated in active disease and can be used to follow the disease course. This patient should also be started on a nonsteroidal anti-inflammatory drug (eg, ibuprofen, naproxen), which can acutely relieve symptoms while the diagnostic evaluation is being completed. (Choice A) Lyme disease can occasionally present with small joint arthritis. However, symptoms are typically intermittent, asymmetric, and migratory, rather than chronic, progressive, and symmetric, as in this patient. In addition, most patients experience the characteristic rash before the onset of musculoskeletal symptoms. characteristic rash (Choice B) Parvovirus B19 can cause symmetric polyarticular arthritis of the hands, wrists, and feet that resembles RA. However, palpable synovitis is less prominent in parvovirus arthritis, and most patients have at least partial improvement within 3-6 weeks. (Choice C) Gout typically presents as acute monoarticular arthritis in the first metatarsophalangeal joint or knee. Chronic polyarticular symptoms are more consistent with RA. (Choice D) Evaluation of systemic lupus erythematosus starts with an antinuclear antibody assay (high sensitivity), which, if positive, is followed by a double-stranded DNA antibody assay (high specificity). However, the arthritis in systemic lupus erythematosus is typically transient, migratory, and associated with only brief morning stiffness. Educational objective: Rheumatoid arthritis is characterized by chronic, symmetric synovitis, most commonly in the small joints of the hands and wrists. Serologic markers (eg, rheumatoid factor, cyclic citrullinated peptide antibodies) are helpful for confirmation. Nonsteroidal anti-inflammatory drugs can relieve symptoms while the evaluation is in progress. References: Diagnosis and classification of rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/24568777)

A 45-Year-Old Woman Comes to the Office Due to Progressive