Rheumatology Physical Examination

INSPECTION
1. What type of deformity & Which Swan neck Boutonniere
fingers/joints

Distal interphalangeal (DIP) joints

Proximal interphalangeal (PIP) joints
Metacarpals joints

Carpal (wrist) joints

Mallet Z- Deformity Ulnar deviation Swelling

Towards
ulnar

2. Inspect palm thenar & hypothenar 3. Inspect for nail changes (Psoriatic nail
muscle wasting (Carpal tunnel changes)
syndrome) Pitting nails

Hypothenar
wasting
Thenar Onycholysis Subungual
wasting
hyperkeratosis

4. Inspect extensor surface of arm, look

for:

Rheumatoid nodules Psoriatic plaques

PALPATION
1. Elicit warmness (inflammation) on each 2. Palpate each joints for swelling &
groups of joints (by using the back of tenderness (ask patient if theres any
your hands) pain)

3. Shake hand while the other hand PERCUSSION

palpating for rheumatoid nodules Percuss gently on the flexor part of wrist & ask
the patient whether theres tingling sense on the
palm (Tinels sign)(+ in Carpal tunnel syndrome).

ACTIVE MOVEMENT
1. Ask the patient to grip (flexion of 2. Ask the patient to extend fingers
Metacarpal, DIP, PIP)

3. Prayer sign (assess wrist joint) 4. Reverse prayer sign (Phalen test: tingling
on fingers suggest Carpal tunnel synd.)
assess wrist
PASSIVE MOVEMENT
Assess muscle tone of each joints & detect for any crepitation

POWER
1. Test Abduction & Adduction of 2nd 5th 2. Test abduction of thumb
finger (do to each fingers)

3. Pincer grip test ; assess every 2nd 4th 4. Gripping test: ask patient to pull your
finger gripping with the thumb index & middle finger.
FUNCTION
1. Doorknob test (ask the patient to grasp & 2. Pick up coins
rotate your grip just like a doorknob)

3. Button & Unbutton clothes 4. For female patient, ask to put their hand
backward (wearing bra)

What are other test to be done?

Look for generalized psoriatic plaques (to exclude psoriasis)

To suspect more signs for Rheumatoid Arthritis
Eyes examination: Conjuctival pallor (anemia) & Scleritis
Respiratory examination: look for signs of Pleural effusion or/and Pulmonary fibrosis
Abdominal examination: look for splenomegaly (Felty Syndrome = Splenomegaly + RA +
neutropenia)

Investigation

Rheumatoid factor
Anti-cyclic Citrullinated peptide (ACCP) Antibody
FBC neutropenia, thrombocytopenia, leukopenia (Feltys Syndrome)
CXR pulmonary fibrosis and/or pleural effusion
Joint X-ray erosion of joints (Caplans Syndrome)
ESR, CRP severity of inflammation