Rheumatoid: Examination

Systemic

1. Environment, general appearance
2. Head, eyes, mouth
3. Chest, abdomen, pelvis

Joints

1. Hands, wrists
2. Elbows, shoulders
3. TMJ, neck, spine, SIJ
4. Hips, knees, ankles, feet

During each step of examination, compare one side of body to the other.

Environment

• Cane.
• Crutches, walker, wheelchair, hoist.
• Bent spoons, double handled cups.
• Utensils with large diameter handles.

General appearance

• 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).

Head, eyes, mouth

• 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).

Chest

• 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).

Abdomen, pelvis

• 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).

Hands, wrists

• See Hand Examination.

Elbows

• 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°].

Shoulders

• 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). 

TMJ

• Inspection:
  • Swelling.
  • Closer examination of parotid (Sjorgen).
  • Grating, other noises as pt. moves.
• Palpation:
  • Feel mandible as it moves.
  • Tenderness (RA inflammation). 

Neck

• 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°].

Spine, SIJ

• 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).

Hips

• 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.

Knees

• 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.

Ankles, feet

• 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.