Question of the week # 56, 57

Q56) A 42 year old presents with a  pain & swelling in the left knee. The symptoms started 3days ago and have been progressively worsening. Upon further questioning, the patient tells you that he has experienced intermittent pain and swelling in the toes, wrists and ankles for more than 10 years. On examination the left knee is swollen and warm to touch. There is also soft tissue swelling of the wrists, ankles and right foot.  He has  a 10  year history of intermittent  pain & swelling in the toes, wrists & ankles. On examination the right knee is warm to touch with an effusion, & there is soft tissue swelling of the wrists, right ankle & right foot. X-ray of the wrist is shown below. Laboratory studies reveal increased ESR at 90mm/hr WBC are elevated at 12k.
The most likely diagnosis :

A. Early erosive osteoarthritis

B. Reactive Arthritis

C. Psoriatic Arthritis

D. Pseudo-Gout

E. Rheumatoid Arthritis

Q57) The most important next step in management :

A) Obtain Rheumatoid Factor level

B) Obtain Anti citrullin peptide level

C) Start prednisone

D) Start ibuprofen and Methotrexate

E) Arthrocentesis of the Right knee

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