Dr saif darif ( internal medicine ) 2022.

Rheumatoid hand examination

Checklist

Coordination examination checklist 0 1/2 1

(introduction and gains consent)
E: Exposure (hands ideally up to elbows)
L: Lighting
P: Positions correctly (supine or setting , ideally resting on a
desk or table)
asks if the patient is in any pain
Inspection ( student should mention ) 0 1/2 1
Nails: clubbing, splinter haemorrhages, pitting, onycholysis, nailfold vasculitis.
Skin: scars, color, rashes, thick ( SS) , thinning (steroid use), bruises,
Observes wrist/elbow for rheumatoid nodules
Joints: erythema, swelling, deformity
Muscle: wasting, fasciculation.
Posture: characteristic abnormalities (e.g. claw hand , dupuytren contracture )
Looks behind the ears for psoriatic plaques
Palpation 0 1 2
Prayer test ( for reversibility ).
Temperature & tenderness
Muscle bulk (thenar and hypothenar eminences , Palmar fascia )
Squeeze across metacarpophalangeal joints
Bimanual palpation of individual joints
Bony swellings & palpates the elbows for rheumatoid nodules
Sensation in radial, median and ulnar nerve territories
Movement (active and passive): 0 1 2
• Wrist:
• Pronation • Supination • Flexion
• Extension • Abduction • Adduction
• Digits:
• Flexion and extension at metacarpophalangeal and proximal interphalangeal joints
• Abduction and adduction (spread fingers apart)

• Grip (making a fist)

• Thumb: Abduction , Adduction , Extension , Flexion , Opposition with 5th digit
Special tests for lower limbs 0 1 2
Special tests: Tinel’s/Phalen’s tests , Froment’s sign.
Functional Assessment of gait 0 1 2
Pincer grip , Squeezing student’s fingers
Doing up buttons , Opening jar.
Thanks patient , help to cover & Wash hands 0 1/2 1
what do you like to examine else ? 0 1 2
Tell examiner to complete my exam I have to assess ( other joints , dryness of eye or
mouth , LAN , loud S2 p component or basal lung crepitation , splenomegaly )
Dr saif darif ( internal medicine ) 2022.
Comment :- Tell finding by fluent presentation 2 4 7
There is no evidence of psoriatic changes or ischemic changes
No splinter bleeding or periungal teleangectasia.
No erythema or scars.
No evidence of skin changes of scleroderma.
There are multiple irreversible deformities in from of swan neck , boutonnière
and Z deformity not associated with hotness or swelling or tenderness.
There is no subcutaneous nodule but there is muscle weakness and wasting all
over the small muscle of the hands bilaterally
There are restrictions in joints movements due to deformity and weakness.
No evidence of nerve lesion & negative Phalen’ test.
What is your DD ? 0 2 3
1. Chronic Rheumatoid arthritis most likely in remission state cuz no tenderness
or swelling or nodules ( chronic because of wasting and deformity ).
2. Systemic lupus ( it is reversible Jacouds arthropathy )
3. Psoriatic arthropathy ( no skin changes or nail changes )
4. Gout arthritis ( no painful nodules )
5. Systemic sclerosis ( no skin changes or facial changes of SS)
What are investigations ? 0 1 2
CBC , ESR , CRP , ACCP , RF , JOINT X-ray , chest X-ray , echo , abdominal U/S.