<prompt> Please answer with one of the option in the bracket. Write reasoning in between . Write answer in between .Q:A 61-year-old woman comes to her physician for a burning sensation and numbness in her right hand for 4 weeks. The burning sensation is worse at night and is sometimes relieved by shaking the wrist. In the past week, she has noticed an exacerbation of her symptoms. She has rheumatoid arthritis and type 2 diabetes mellitus. Her medications include insulin, methotrexate, and naproxen. Her vital signs are within normal limits. Examination shows swan neck deformities of the fingers on both hands and multiple subcutaneous nodules over bilateral olecranon processes. There is tingling and numbness over the right thumb, index finger, and middle finger when the wrist is actively flexed. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next best step in management?? A: Physiotherapy, B: Initiate sulfasalazine therapy, C: Initiate azathioprine therapy, D: Volar splinting, E: Vitamin B6 supplementationn,  <response>: This is a clinical vignette describing a 61-year-old woman with longstanding rheumatoid arthritis who now presents with symptoms and exam findings consistent with carpal tunnel syndrome. The history of rheumatoid arthritis along with the physical exam findings of swan neck deformities and subcutaneous nodules confirm the diagnosis. The tingling, numbness, and exacerbation of symptoms with wrist flexion suggest carpal tunnel syndrome, likely related to synovial inflammation and thickening compressing the median nerve. The question asks for the most appropriate next step in management. Options include physiotherapy, DMARDs like sulfasalazine and azathioprine, volar splinting, and vitamin B6. However, the new and acute finding is the carpal tunnel syndrome. Therefore, the next step should address this issue rather than escalation of rheumatoid arthritis management. Volar splinting can provide symptomatic relief and is less invasive than surgery. Vitamin B6 is not indicated.D: Volar splinting 