1. HPI A 35yo receptionist presents to your office complaining of intermittent episodes of pain, stiffness, and swelling in both hands and wrists for approximately 1 year. These episodes last for a few weeks and then resolve. Recently, though, she noticed similar symptoms in her knees and ankles. She is finding it harder to get of bed in the morning and harder to complete her work duties due to joint pain and stiffness. The stiffness lasts several hours before improving. She also reports malaise and easy fatigability for the past few months, but she denies any fever, chills, skin rashes, or weight loss.

2. Physical Exam Vitals: 120/70, 82 bpm, 14 br/min HEENT/Cardio/Pulm/Abd exams normal Skin: No rashes MSKL: blt swelling, redness, and tenderness of PIP and MCP joints, wrists, and knees

3. Differential Diagnosis Rheumatoid Arthritis Osteoarthritis SLE Hypothyroidism Viral Polyarthritis Reactive Arthritis

4. Labs CMP Na140 K4 Cl100 CO222 BUN20 Cr1 Glu95 Ca9.5 Total Protein7.6 Albumin4 Total Bilirubin0.7 Alkaline Phosphatase71 AST25 ALT40 UA No microalbuminuria or RBC TSH 2.2 ESR 75

5. Radiology Note: You can see synovial inflammation and ulnar deviation. The thumb exhibits Boutonniere’s deformity with PIP flexion and DIP hyperextension.

6. Pathology Chronic lymphocytic and plasma cell infiltration (blue areas) beneath articular nodular proliferation creating a pannus that will eventually erode the remaining articular cartilage

7. Gross Picture Swan neck deformity showing PIP hyperextension with DIP hyperflexion