Question 1#

A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the meta-carpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?

A) The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) should be obtained
B) The prodrome of lethargy suggests chronic fatigue syndrome
C) Lack of systemic symptoms suggests osteoarthritis
D) X-rays of the hand are likely to show joint space narrowing and erosion
E) An aggressive search for occult malignancy is indicated

Correct Answer is A


The clinical picture of symmetrical swelling and tenderness of the metacarpophalangeal (MCP) and wrist joints lasting longer than 6 weeks strongly suggests rheumatoid arthritis (RA). Rheumatoid factor, an immunoglobulin directed against the Fc portion of IgG, is positive in about two-thirds of cases and may be present early in the disease. The history of lethargy or fatigue is a common prodrome of RA. The inflammatory joint changes on examination are not consistent with chronic fatigue syndrome; furthermore, patients with CFS typically report fatigue existing for many years. The MCP-wrist distribution of joint symptoms makes osteoarthritis very unlikely. The x-ray changes described are characteristic of RA, but would occur later in the course of the disease. Although arthritis can occasionally be a manifestation of hematologic malignancies and, rarely, other malignancies, the only indicated screening would be a complete history and physical examination along with a CBC.