Rheumatoid: Examination
Systemic
- Environment, general appearance
- Head, eyes, mouth
- Chest, abdomen, pelvis
Joints
- Hands, wrists
- Elbows, shoulders
- TMJ, neck, spine, SIJ
- Hips, knees, ankles, feet
During each step of examination, compare one side of body to the other.
- Cane.
- Crutches, walker, wheelchair, hoist.
- Bent spoons, double handled cups.
- Utensils with large diameter handles.
- Gait, if entering room.
- Posture, hump.
- Abnormal mental state (SLE).
- Chorea (Rheumatic fever arthritis).
- Systemic rash (Rheumatic fever arthritis, SLE).
- Fatigue, breathlessness.
- Weight loss (scleroderma, RA).
- Visible deformities.
- Cushingoid (steroid Rx for RA).
- Allopecia, lupus hairs [short, broken] (SLE).
- Psoriasis on scalp (psoriatic arthritis).
- Butterfly rash (SLE).
- Salt-and-pepper pigmentation (scleroderma).
- "Face lift" face (scleroderma).
- Parotid swelling (Sjogren's).
- Dry eyes (Sjogren's).
- Red eyes, painful eyes (seronegatives).
- Pale conjunctivits (anemia: 2° to many arthritis complications).
- Scleritis (RA nodule in eye).
- Unilateral loss of visual acuity (seronegatives).
- Pt. can't completely shut eye on command (scleroderma).
- Fundus hyperviscosity, cytoid bodies [white swollen nerve fibres] (SLE).
See Fundus Examination.
- Mouth ulcers (Reiter's, SLE).
- Dry mouth (Sjogren's).
- Dental caries (Sjogren's).
- Thickened chest wall skin (scleroderma).
- Lung: fibrosis, effusion signs (RA, SLE, etc).
- Heart: AR (RA nodule on valve, AnS).
- Heart: pericardial rub (RA, SLE, etc).
- Spenomegaly (RA, SLE).
- Hepatomegaly (SLE).
- Biliary cirrhosis signs (scleroderma).
- Inguinal nodes (RA).
- If indicated, Rectal Examination for IBD
signs (IBD-associated arthritis).
- Sphincter control loss (cord compression 2° to AnS).
- Psoriasis in lumbrosacral area (psoriatic arthritis).
- Genital irritation (Reiter's).
- Prostatitis (Reiter's).
- Inspection:
• Subcutaneous nodules (RA, gout).
• Enlarged bursa (fluid).
• Colour of nodules (yellow: gout).
• Swelling (joint effusion).
• Psoriasis on elbows (psoriatic arthritis).
- Palpation:
• Warmth.
• Lateral epicondyle tenderness (tennis elbow).
• Medial epicondyle tenderness (golfer's elbow).
• Enlarged bursa (fluid).
• Nodules: hard (RA) or firm (gout).
- Motion:
• Flexion [normal: 150°].
- Inspection:
• Swelling.
- Palpation:
• Warmth.
• Tenderness: localized or diffuse.
• Swelling.
• Axillary nodes (RA).
- Motion, asking if painful:
• Abduction [normal: 150°].
• Adduction [normal: 50°].
• Flexion [normal: 180°].
• Extension [normal: 60°].
• External rotation [normal: 60°].
• Internal rotation [normal: 90°].
- Pain during movement:
• All directions (intra-articular).
• One direction (inflamed tendon).
• No pain, only weakness (lesion to tendon or nerve).
- Inspection:
• Swelling.
• Closer examination of parotid (Sjorgen).
• Grating, other noises as pt. moves.
- Palpation:
• Feel mandible as it moves.
• Tenderness (RA inflammation).
- Inspection:
• Head tilt (RA atlanto-axial subluxation).
• Compensatory hyperextension (ankylosing spondylitis).
• Thyroidectomy scar (calcium imbalance 2° to lost parathyroids).
- Motion:
• Flex: pt. touches chin to chest [normal: 45°].
• Extend. pt. tries to look backward [normal: 45°].
• Rotation. pt. looks to shoulder [normal: 70°].
• Lateral. pt. touches ear to shoulder [normal: 45°].
- Inspection:
• Exaggerated kyphosis (AnS).
• Loss of lordosis (AnS).
- Palpation:
• Vertebral bodies: spasms, tenderness.
• Bilateral palm pressure over sacro-iliac joint elicits pain:
bilateral (AnS, Reiter's [Reiter's may be unilateral]).
- Motion:
• Flexion: pt. touch toes.
• Extension: pt. stretches backward.
• Rotation: pt twists upper body.
• Lateral bending: pt. slides arm down leg.
- Lasegue's sign: lift straightened leg (reduced in slipped disc).
- Schober test:
• Pt. standing.
• Mark 5th lumber spine and a point 10cm superior.
• Pt flexing waist.
• Mark will normally increase to >15cm (reduced flexion: AnS).
- Inspection:
• Only obvious deformities, like fracture, since hip joint is so
deep.
• True leg length: ASIS to medial malleolus (hip dz).
• Apparent length: umbilicus to medial malleolus (pelvic tilt).
- Palpation:
• Joint tenderness.
- Motion:
• Abduction [normal: 50°].
• Adduction [normal: 40°].
• Flexion.
• Extension [normal: 30°].
• External rotation [normal: 45°].
• Internal rotation [normal: 45°].
- Trendelenburg test:
• Pt. stands on 1 leg
• Non-standing hip should rise (if sags: proximal myopathy).
• Note: there's a different Trendelenberg
test for varicose veins.
- Inspection:
• Deformities: bow leg, knock-knee.
• Swelling.
• Psoriasis on knees (psoriatic arthritis).
• Abnormal fixed flexion when legs laid flat (flexion deformity).
- Palpation:
• Warmth.
• Wasting.
• Swelling.
• Popliteal fossa for Baker's cyst [knee capsule hernia].
- Motion, noting pain, grating:
• Flexion [normal: 135°].
• Extension [normal: 5°].
- Ligament motion.
- Inspection:
• General deformities.
• Swelling.
• Ulcerations (Felty's).
• Peripheral neuropathy signs (spinal cord compression).
• Foot drop (RA).
• Ankle edema (steroid use).
• Clawing of toes.
• Tophi (gout).
• Hallux valgus [great toe lateral deviation]
• Crowded toes (RA).
• Calluses on deformed joints (RA).
• Flattened arches (RA).
- Palpation:
• Warmth.
• Peripheral neuropathy (spinal cord compression).
• Achilles tendon: tendonitis (AnS), nodules (RA).
• Heel tenderness (seronegatives' plantar fasciitis).
• Squeeze all metatarsophalangeal joints together for tenderness
(RA).
- Motion:
• Dorsiflexion [normal: 20°].
• Plantarflexion [normal: 50°].
• Eversion.
• Inversion.
• Individual toe movements.
- Many hand observations can also be seen in toes. See Hand
Examination.