History: A man in his early 40’s presents with 1 month of bilateral hand, wrist, elbow, shoulder, knee and ankle pain.  He denies injury, fever or other symptoms.  He denies recreational drugs but does smoke a little and drinks socially.

Exam: Vital signs are normal.  Exam is normal except for swollen hands and knees, especially the left knee, which has an effusion.  No other joints have appreciable effusions.  His hands are pictured below and do seem quite swollen.

Relevant Test Results:

  • Labs: CBC and BPM normal.  ESR 30 (nl <20), CRP 3.1 (nl <1.0)
  • Imaging: hands and L knee x-rays were negative

What is the most likely diagnosis?

  • A) CHF
  • B) RA
  • C) GC
  • D) SBE
  • E) Allergy

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QUIZ ANSWER:

  • A) CHF
  • B) RA – CORRECT – see tap results below. Outpatient follow-up confirmed rheumatoid arthritis
  • C) GC
  • D) SBE
  • E) Allergy

Outcome: knee tap showed 18,000 WBC with 85% Segs and no crystals or bacteria.  Culture was negative.  Started on prednisone 20mg QD and was better enough to return to work w/in 48h

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