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A twenty six year old woman with no prior medical history, present with a three week history of joint swelling and stiffness. She points to all her proximal inter-phalangeal joins and as well as metacarpo-phalangeal joints and wrists. She informs you that she had stiffness for two hours every morning since these symptoms started and symptoms improve as the day progress. She denies of back stiffness. She has fatigue and low grade fever also. On examination the wrist, inter-phalangeal joints and metacarpo-phalangeal joints are tender and swollen of both hands. The distal inter-phalangeal joints are not involved. There is fluid in the joints.

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