Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.
A 40-year-old female complains of 7 weeks of pain and swelling in both wrists and knees. The patient complained of fatigue and lethargy several weeks before noticing the joint pain. The patient notes that after a period of rest, resistance to movement is more striking. On exam, the metacarpophalangeal 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
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
The clinical picture of symmetrical swelling and tenderness of the metacarpophalangeal (MCP) and wrist joints lasting longer than 6 weeks strongly suggests rheumatoid arthritis. Rheumatoid factor, an immunoglobulin directed against the Fc portion of IgG, is positive in about two-thirds of cases and is present early in the disease. The history of lethargy or fatigue is a common prodrome of RA. The inflammatory joint changes are not consistent with chronic fatigue syndrome. 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.