Q63) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. The most appropriate next step in management :
A. Start etanercept
B. Start Ibuprofen and follow-up in one month.
C. Start Ibuprofen and Methotrexate
D. Obtain plain x-rays of hands and wrists
E. Obtain anti-nuclear antibodies