Question
A 40-year-old lady complains of progressive deformities of her hands and fingers associated with stiffness which is present in both the hands and improves as the day progresses. On examination, there is symmetrical involvement of hands and fingers of both the upper limbs with flexion and ulnar deviation at the metacarpophalangeal joints. What is the most likely diagnosis in this lady?
The correct answer is
Rheumatoid arthritis
Rheumatoid Arthritis Key Features
The patient presents with several classic signs pointing towards Rheumatoid Arthritis (RA):
- Age and Gender: A 40-year-old lady is within the typical demographic for RA onset.
- Symmetrical Involvement: RA commonly affects joints symmetrically on both sides of the body.
- Joint Distribution: Involvement of hands and fingers, specifically the metacarpophalangeal (MCP) joints, is characteristic.
- Stiffness Pattern: Stiffness that improves as the day progresses ("morning stiffness") is a hallmark of inflammatory arthritis like RA.
- Deformities: Progressive deformities, such as flexion and ulnar deviation at the MCP joints (ulnar drift), are typical findings in advanced RA.
Differential Diagnosis Comparison
Let's briefly consider why other options are less likely:
- Osteoarthritis (OA): Usually affects DIP and PIP joints, often asymmetrical, and stiffness typically worsens with activity, not improves.
- Ankylosing Spondylitis (AS): Primarily affects the spine and sacroiliac joints; significant hand deformities like this are uncommon.
- Tenosynovitis: While it can occur in RA, it represents inflammation of tendon sheaths, not the primary systemic joint disease described.
Conclusion: Rheumatoid Arthritis
Given the symmetrical polyarthritis affecting the small joints of the hands (MCPs), characteristic stiffness pattern, and specific deformities (ulnar deviation), Rheumatoid Arthritis is the most likely diagnosis.
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