Aligned with the National Board of Medical Examiners format. Authored & peer-reviewed by faculty, clinicians, and clerkship directors.
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A 58-year-old man presents to the clinic with bilateral hand and wrist pain that has been progressively worsening for 6 months. He says the pain is accompanied by morning stiffness that now lasts up to 45 minutes, which slows him down when getting up for work. On physical exam, you note the proximal joints of both hands are swollen and tender. Which of the following is the most likely diagnosis?
Rheumatoid arthritis is considered an autoimmune disease that presents with symmetrical, inflammatory polyarthritis, often associated with morning stiffness lasting over 30 minutes. Rheumatoid arthritis commonly affects the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. The joints are described as swollen and boggy, secondary to synovial hypertrophy or effusion. X-rays consistent with rheumatoid arthritis show bony erosions or subchondral cysts or both. The diagnosis can be confirmed with anti-cyclic citrullinated protein antibodies, with or without a positive rheumatoid factor. ESR and CRP are both nonspecific to rheumatoid arthritis but are likely to be elevated secondary to inflammation. Arthritis presenting for less than a few weeks should prompt further workup for alternate causes, as rheumatoid arthritis is a chronic condition and considered appropriate when symptoms have been present for 6 weeks or more.
Fibromyalgia (A) is a diagnosis of exclusion in a patient who presents with widespread pain as well as somatic or psychiatric symptoms. Although tenderness on exam is common in fibromyalgia, the presence of swelling, warmth, and decreased joint range of motion points more toward rheumatoid arthritis as the likely diagnosis. It is possible for fibromyalgia to develop concurrently with other conditions such as arthritis. Osteoarthritis (B) in the hands usually affects the distal interphalangeal (DIP) joints and reveals narrowed joint spacing on imaging. It may present with morning pain or stiffness, but it is transient, not lasting more than 30 minutes. Osteoarthritis is also classically associated with Heberden and Bouchard nodes, which are hard, bony swellings on the DIP and PIP joints, respectively, unlike the soft, boggy, swelling seen in the joints of rheumatoid arthritis. Reactive arthritis (C) is an inflammatory and asymmetric arthritis associated with infections. It affects the larger joints, as opposed to the smaller peripheral joints. The classic triad of reactive arthritis includes joint pain, conjunctivitis or uveitis, and urethritis or cervicitis. A patient who presents with recent urethritis or enteric infection along with monoarticular joint pain should lead to concern for reactive arthritis.
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