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.
- For detailed exam, See Knee Examination.
- 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.