Case #4 Answers:
Joint distribution, presence and degree of joint swelling, and presence of morning stiffness (>1 hour) are all helpful. Osteoarthritis typically causes pain with use, relieved with rest, at least until very late joint destruction occurs.
This patient has a chronic polyarthritis. The major considerations are RA and psoriatic arthritis. Other collagen vascular diseases (SLE, poly/dermatomyositis, Sjogren’s syndrome) are still possible. Gout is not likely given the absence of prior acute monoarthritis. Pseudogout occasionally presents like this. History should be directed to the skin, eyes, presence of low back pain or other organ system involvement.
With a 3 month hx of a symmetrical polyarthritis, involving the hands, RA is very likely present. RF should be ordered. While 20% of what we call RA is sero θ, a positive test also adds prognostic information. CBC, renal and liver function should be ordered, in large part as a baseline for needed drug therapy. ESR and CRP are optional. The presence of inflammation is not in question here given the PE, so the added value is questionable.
Rheumatoid arthritis is a chronic symmetrical polyarthritis that involves the hands. Positive RF, nodules or typical erosive radiographic changes are frequently also present.