Emily is a 45-year-old woman presenting to her GP with a three-week history of polyarthritis. She has swelling in all her fingers, with restricted finger flexion and very limited grip.
Her wrists, ankles and forefeet are swollen and tender. She has great difficulty in walking, dressing and feeding herself, and in the mornings she is so stiff and in such pain that she fears going to bed. She is utterly miserable, tearful, has lost weight and has a low-grade fever (37.8°C).
Emily works in an administrative position at a childcare facility, with some contact with the children. She has recently returned