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CME / ABIM MOC Released: 10/20/2021
Valid for credit through: 10/20/2022, 11:59 PM EST
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Anna is a 26-year-old graduate student who presents to her primary care physician after a 1-month history of morning stiffness in the joints of her fingers, particularly in her dominant hand. The stiffness usually lasts a few hours and is accompanied by polyarticular pain and swelling. She reports some fatigue but no other symptoms and has no significant medical or family history. She does not smoke or drink alcohol. Laboratory studies are significant for an erythrocyte sedimentation rate (ESR) of 40 mm/h (normal range, 0-20 mm/h), C-reactive protein (CRP) of 5 mg/dL (normal range, 0.08-3.1 mg/dL), and positivity for rheumatoid factor (RF) and anticitrullinated protein antibodies (ACPA). Ultrasonography shows inflammation in both hands. In her dominant hand, there is significant synovitis (swelling and tenderness) across her proximal interphalangeal (PIP) joints, her metacarpophalangeal (MCP) joints, and in her carpal bones and wrist. The findings are similar in her nondominant hand, but the inflammation is not quite as severe. X-ray also shows well-defined bony erosions in the carpal bones and metacarpal bases. Based on these findings, a diagnosis of rheumatoid arthritis (RA) is made. She is started on oral methotrexate, 15 mg weekly, as well as 2 capsules of celecoxib 200 mg daily.