Case 410 Medical history A 64-year-old female patient has been receiving medical care for 15 years by a rheumatologist due to pain and symmetrical polyarticular edema (proximal metacarpophalangeal and interphalangeal, wrists, knees, ankles and metatarsophalangeal) associated with morning stiffness of more than one hour, which improves over the course of the day and worsens at evening. Her condition has evolved to deformation in fingers and toes and functional incapacity of wrists and elbows, characterized by great restriction of motion. Image 1: Photograph of hands and wrists.Image 2: Photograph of the right hand and wrist.Image 3: Photograph of feet and ankles. Question:Considering the case above, which alternative contains the most likely diagnosis, as well as deformities and extra-articular manifestations potentially associated with it? Osteoarthritis - Joint instability - Coronary artery disease Rheumatoid arthritis - Boutonnière deformity - Interstitial lung disease Psoriatic arthritis - Telescoping of fingers - Inflammatory bowel disease Systemic lupus erythematosus - Jaccoud arthropathy - Diffuse proliferative glomerulonephritis Test question [Unified Selection for Medical Residency in the State of Ceará, 2020]Question: A 53-year-old woman reports pain and edema in her hands and wrists in the last four months. There was also adynamia throughout the period, in addition to morning stiffness of approximately one hour. Physical examination revealed: synovitis from the first to the fifth metacarpophalangeal and proximal interphalangeal joints of both hands, as well as heat and redness in the knees. She brought previous exams: rheumatoid factor ELISA 120 IU/ml (VR: <15 IU/ml). Based on the disease depicted, check the alternative with the most likely clinical hypothesis and a more specific exam for the clinical condition. Rheumatoid Arthritis and anti-citrullinated peptide. Systemic lupus erythematosus and antinuclear factor. Hepatitis C and C-reactive protein. Mixed cryoglobulinemia type II and x-ray of hands and wrists. Time is Up! Time's up
