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A 32-year-old nurse presents to your office with a complaint of intermittent episodes of pain, stiffness, and swelling in both hands and wrists for approximately I year. The episodes last for several weeks and then resolve. More recently, she noticed similar symptoms in her knees and ankles. Joint pain and stiffness are making it harder for her to get out of bed in the morning and are interfering with her ability to perform her duties at work. The joint stiffness usually lasts for several hours before improving. She also reports malaise and easy fatigability for the past few months, but she denies having fever, chills, skin rashes, and weight loss. Physical examination reveals a well-developed woman, with blood pressure 120/70 mmHg. heart rate 82 bpm, and respiratory rate 14 breaths per minute. Her skin does not reveal any rashes. Head, neck, cardiovascular, chest, and abdominal examinations are normal. There is no hepatosplenomegaly. The joint examination reveals the presence of bilateral swelling, redness and tenderness of most proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, the wrists, and the knees. Laboratory studies show a mild anemia with hemoglobin 11.2 g/dL, hematocrit 32.5%, mean corpuscular volume (MCV) 85.7 fL, white blood cell (WBC) count 7.9/mm3 with a normal differential, and platelet count 300,000/mm3. The urinalysis is clear with no protein and no red blood cells (RBCs). The erythrocyte sedimentation rate (ESR) is 75 mm/h, and the kidney and liver function tests are normal.
♦ What is your most likely diagnosis?
^ What is your next diagnostic step?
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