On examination she looked very ill, icteric, pale and dehydrated. She had severe neck stiffness and bilateral symmetrical large and small joint arthritis with distal interphalangeal joint sparing. Careful physical examination on admission did not reveal skin rash, oral ulcers or lymphadenopathy. Abdominal examination was unremarkable except for a non-tender enlarged liver 2 cm below the right costal margin. She had tachycardia of 100 beats/min and blood pressure of 110/60 mmHg with no cardiac murmurs. She was not tachypneic, and her lungs were clear. Vaginal examination was unremarkable.