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A 35 year old female presented with pain of her both hands of 4 weeks duration .
On examination she had contactures and skin lesions as shown .

The joint involvement was symmetrical and feet were also involved .
On evaluation she had Hb 9.4gm/dl ESR 70mm CRP= 48 (High)
RA factor = Positive , Anti CCP=Positive , ANA =Negative

What is the most likely diagnosis ?

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