She has noted swelling in the wrists, MCP'S, PIP'S and knees. There is also pain across the metatarsal region and she has had difficulty finding comfortable shoes. She has no prior joint complaints.
Past Hx: Unremarkable
ROS: Marked fatigue
PE: Synovitis of both wrists, 2 nd , 3 rd & 5 th MCP bilaterally
MTP are very tender
General exam is unremarkable