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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateMusculoskeletal investigationsRheumatoid arthritisSCE Rheumatology

A 42-year-old woman has 4 months of symmetrical pain and early morning stiffness in the small joints of both hands. Examination shows bilateral MCP and PIP synovitis with reduced grip. Investigations show anti-CCP is positive and CRP is raised. The consultant wants the next test most likely to confirm the suspected process or guide treatment. The result will change diagnosis, staging or immediate treatment. What is the most appropriate investigation?

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Correct answer: C — Plain radiographs of hands

Plain radiographs of hands is the best answer because plain radiographs of hands is the investigation most likely to resolve the immediate diagnostic or monitoring question in rheumatoid arthritis. CRP and ESR is a plausible distractor, but it does not account for the key discriminator in the stem. MRI scan and DXA scan would be more appropriate in a different clinical pattern or at another point in the pathway, while ENA profile is suboptimal for this presentation. Clinical pearl: autoantibodies are supportive tests and should be interpreted alongside phenotype, inflammatory markers, urinalysis and imaging.

Reference: BSR hot swollen joint guideline; NICE NG100; EULAR imaging recommendations