Mrs. Dora Gray is a 47-year-old patient who presents to the clinic for evaluation of hand and wrist pain. She first noticed her pain located in the wrist that began about 2 months ago that is worse at work or during texting. She is an administrative assistant and responsible for the office typing. As a result of her responsibilities, she thought she had carpal tunnel syndrome. About 3 weeks ago, she purchased a wrist brace from the local pharmacy store wearing it all day. She relates no relief in her pain while wearing the wrist brace. She is concerned now that the pain has been radiating to her fingers. An associated symptom with her presentation is stiffness in the wrists predominantly in the morning lasting for about 2 hours. In an attempt to improve the pain, she started taking naproxen with mild pain improvement but no change in the morning stiffness. She has missed the last 3 days of work due to worsening stiffness and pain. Denies any trauma to the affected area. Denies loss of sensation in her fingers.
Mrs. Gray remembers that her grandfather has a history of rheumatoid arthritis. She does report smoking one pack of cigarettes per day for the past 28 years. She denies any hospitalizations, blood transfusions, trauma, or travel outside the United States.
Physical Exam Heart: Regular rate and rhythm, 2+ pulses in upper and lower extremities
Lungs: Clear throughout bilaterally with equal rise and fall of the chest
Extremities: first, third, and fifth metacarpophalangeal (MCP) joints are warm with decreased range of motion due to pain. Right and left wrist with generalized swelling, warm to touch with associated pain with passive flexion at ~50°.
Skin: No rash
Remainder of Physical Exam is unremarkable.
What is your differential diagnosis for this patient?
What diagnostic studies are warranted for this patient?
What is the patient’s calculated American College of Rheumatology/European League Against Rheumatism (ACR/EULA) score?
What is the treatment for this patient?