Mrs. B. looks ill, pale, tired, uncomfortable and disinterested.

T: 37 °C
P: 78 reg
BP: 148/76 mmHg

The musculoskeletal exam reveals:

• Multiple joint deformities in hands and feet
  
• Effusions of the left elbow and right knee, and on three left proximal interphalangeal (PIPs) joints and two right distal interphalangeal (DIPs) joints
  
• A 3 cm nodule over the left proximal ulna
  
• Marked dorsal kyphosis.
  

next: x-ray & lab tests