Question of the week # 313

313) A 54 year old man is evaluated in your office for swelling of bilateral wrists and ankles. He also describes pain in his wrists and ankles as well as in the lower legs. Symptoms started 2  months ago and have been progressively worse. He reports limitation in walking because of extreme pain. He denies any stiffness. His past medical history is significant for chronic obstructive pulmonary disease for which he uses Tiotropium inhaler. He recently quit smoking but reports having smoked about 2 packs per day for 35 years. On physical examination, his vitals are within normal limits. Musculoskeletal exam reveals swelling and tenderness in bilateral wrists and ankles. There is an associated grade 3 clubbing in the fingers. There also tenderness all over the tibiae.  Overlying skin is thickened and erythematous. An erythrocyte sedimentation rate is elevated at 30 mm/hr. An x-ray of his upper extremity is shown below:

Which of the following investigations should be ordered next?

A) Arterial Doppler

B) Rheumatoid Factor

C) Hepatitis C serology

D) CT Scan of the Chest

E) Anti-Citrullin Peptide

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