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Rheumatology Clinical Examination

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					   Rheumatology
Clinical Examination
              Dr Javed Hussain
            ST2 Rheumatology
                     Overview
•   Spine
•   Shoulder
•   Hand and Wrist
•   Hip
•   Knee
•   Ankle and Foot
•   History Taking
Spine
   Inspection
   Exposure
   Sitting and standing
   Kyphosis/lordosis/scoliosis
   Back against the wall
   Occiput, shoulders,
      buttocks and heels
   Scars
   Rashes
                           Spine
Palpation                     Measure
Vertebra Prominens            Schobers Test
Spinous Processes
Facet Joints (1cm lat to
   spinous processes)
SI Joints
Paraspinal Muscles
                    Spine
Straight Leg Test      Movements
                       Cervical – flex/ext/lat
                         flex/lat rot
                       Thoracic & Lumbar –
                         Flex/ext/lat flex/lat rot

                       * When assessing lat rot
                         stabilise pelvis
                       Shoulder
4 joints                        Palpation
GAST                            Temperature with dorsum of
                                   hand
• Inspection                    Sternoclavicular Joint
Exposure                        Clavicle
Asymmetry/wasting/              AC Joint
  posture/swelling/scars/brui   Acromial Process
  sing/deformity/ level?        Head of Humerus
Axillae                         Coracoid process
                                Spine of Scapula
                                Greater tuberosity of Hum
                                Observe patients face
                    Shoulder
Movements
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
             Hand and Wrist
        PLACE HANDS ON PILLOW!!
Inspection                  Nails
Posture                     Pitting
Scars                       Hyperkeratosis
Skin changes                Leuconychia
Deformities                 Kilonychia
Subluxation                 Onycholysis
Muscle wasting              Ridging
Swelling-bony/soft/fluid?   Beau’s lines
Palmar erythema             Micro-infarcts
Sweating/tremor             Dilated capillary loops
                            Discolouration
                 Hand and Wrist
Deformities                    Palpation
Ulnar deviation                LOOK AT PATIENTS FACE
Subluxation of wrist/MCP
OA- Heberdens (DIP)/           Palpate wrist
   Bouchards (PIP)             Carpal bones
RA – Boutonniere(PIP)/         CMC
   Swan neck deformities/ Z
   shaped thumb                MCP
Gouty tophi                    PIP
Fixed flex contractures        DIP
Duputren’s contracture         Anatomical snuff box
   (little and ring fingers)   Squeeze MCP joints
                  Hand and Wrist
Movements                         Motor
Wrist – Pronation/Spination/      Radial – inverse prayer position
   Flexion/Extention/             Ulnar – Froments sign
   Abduction/Adduction
Digits –
   Thumb: flex/ext/ abd/add/opp
   Fingers: flex/ext/abd/ add
   Grip



                                  Median – Oppose thumb with
                                    index finger. Try to break circle
                Hand and Wrist
Sensory
ASK PATIENT TO CLOSE THEIR EYES
Test pinprick and light touch
Radial – anatomical snuff box
Ulnar – medial one and half fingers on palm (little and
  med half of ring finger)
Median – lateral three and half fingers on palm
                              Hip
Inspection                      Measure
Exposure – down to              USE MEASURING TAPE:
  underwear
Observe from all sides with     Apparent length:
  patient standing                xiphisternum to medial
Level of IC                       malleolus
Gait/Pain                       True length :ASIS to medial
                                  malleolus

                                ? Joint overload if > 2cm
                                   between sides
Hip
  Movements
  Flexion
  Extension
  Abduction
  Adduction
  Internal rotation
  External rotation
Hip
Hip
                        Knee
EXAMINE BOTH KNEES           Palpation
                             Temperature – use dorsum
Inspection                      of hand – compare sides
Exposure                     Quadraceps tendon –
                                abnormal anatomy
Varus/valgus
                             Joint line
Gait
                             Patello-femoral joint
Scars/cysts/muscle wasting
                             Popliteal fossa –
Bend knees - ? Tibial sag
                                aneurysm/cyst
  (PCL damage)
                         Knee
Bulge test
Index and middle fingers
  as a unit, sweep along
  medial aspect of knee
  (1). Then sweep along
  lateral side of knee (2).

Watch to see if a bulge
 occurs on medial side as
 fluid moves back
                            Knee
Patella tap test                  Measure
Using curve formed by             Measure circumference of
   extended thumb and              quadriceps bulk and
   index finger, milk down         compare bilaterally.
   any fluid above knee.
Using index and middle            Movements
   fingers of other hand
   push down patella firmly.      Flexion
A “tap” will be felt as patella   Extension
   bounces off lateral            ? Hyperextension
   femoral condyle.
                  Knee
Testing MCL/LCL      Testing ACL/PCL




                     Pulling tests ACL. Pushing tests
                       PCL
                                  Knee
Testing Menisci                          Neurovascular State
                                         Peripheral pulses




Patient prone
Flex knee 90 degrees
Stabilise lower leg with left hand and
   grip heel of foot with right.
Grinding motion.
                        Ankle and Foot
Inspection                                 Palpation
Exposure                                   Temperature – feel with dorsum of hand
Gait                                       Bony prominences – lat/med malleoli,
Appearance – swelling/muscle                  MTP, IP. Squeeze across MTP joints. ?
    wasting/deformity                         Pain
Posture – foot flat and tip toes           Achilles tendon - ? Ruptured tendon
Arches – Longitudinal/ metatarsal. ? Pes
    cavus ? Pes planus                     Movements
Heel – callosities/ulcers                  Active and passive movements
Nails - ? Ingrowing                        Dorsiflexion, inversion, eversion, flexion,
                                               extension and abduction/adduction of
Toes – mallet toe, bunion (1st MT),            toes
    bunionette (5th MT)
                                           Neurovascular
                                           Dorsalis pedis and post tibial pulses
                                           Fine touch
               History Taking
• 10 mins
• Systematic approach
• Likely scenario: back pain/shoulder pain/ hand
  swelling
• SAME approach
• PC, HxPC, PMHx, SHx, FHx, DHx, Allergy? RoS
• Focus on pain
• Characteristics, grading, radiation.
• Know characteristics:
  neuro/mechanical/inflammatory
Thank you

Good Luck

				
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