Rheumatologic Examination

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Rheumatologic Examination

• Walter Eisenhauer MMS PA-C

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Approach to Disorders of the Joints

• Etiologies of Joint Pain
• Traumatic
• Infectious
• Degenerative
• Metabolic
• Immunologic
• Neoplastic

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Diagnosis

• Based on
• History
• Physical
• Lab
• X-ray
• Origination of Joint Symptoms
• Synovium Cartilage Periarticular structures
• Inflammatory Non-inflammatory

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History

• Duration of Joint Symptoms
• Rapidity of Development
• Self Limited Symptoms Vs Persistent
• Number and Location of Affected Joints
• Pattern of Affected Joints
• Symmetric
• Asymmetric

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History

• Sequence of Joint Involvement
• Additive
• Migratory
• Pain at Rest/Following Exercise
• Gelling
• Precipitating Events-Illness
• Morning Stiffness

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History

• Symmetric Distribution of inflammatory changes-RA
• Weight Bearing Joints After Exercise-DJD
• Migratory-Rheumatic Fever
• Additive-RA
• Persistent Low Back Pain in Young Man-Ankylosing
  Spondylitis

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History

• Acute Inflammation-Infection/Crystal Deposition
  Disease
• Chills/High Fever
• Constitutional Sx-RA/Neoplasm/infections
• Medications-Pronestyl Induced Lupus

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Past Medical History

• Hepatitis
• Rubella, Mumps, Parvovirus
• Reynauds
• Iritis-Ankylosing Spondylitis
• Inflammatory Bowel Disease

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Social History

• Sexual Practices
• Work
• S/S Depression-Anxiety
• Stress
• Diet-CA/Purines

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Physical Examination

• Skin
• Nodules on extensor surfaces
• Psoriatic Rashes
• Nails
• Signs of Vasculitis
• Mucocutaneous lesions of Reiters Syndrome
• Eye Dryness

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Examination of the Joints

• Examine even Unaffected Joints
• Examine Peri-Articular Surfaces
• Atrophy Effusions Erythema
• Palpation
• Establish Range of Motion
• Palpate Exact Location of Tenderness
• Temperature
• Assess Muscle Strength/Tone

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Physical Examination

• History will help guide complementary exams
• Risk for CA and Assoc Wt Loss-Examine high risk
  systems
• Abdomen/Bowel Sx- Examine abdomen
• Fever-Cardiac
• Pulmonary Sx-Lung

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Classification of Joints

• Synarthrosis-No Movement
• Suture-Cranial
• Synchondrosis-Epiphysis/Diaphysis
• Amphiarthrosis-Slight movement
• Diarthrosis-Synovial
• Ball and Socket Saddle-Thumb Carpal/MC
• Hinge Gliding-intervertebral
• Pivot-Atlantoaxial
• Condyloid-Wrist

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Examination

• Waiting Room Diagnosis
• Inspect Gait
• Ability to Disrobe etc- good eval of ROM
• Inspect Muscles
• Goniometer for ROM

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Motor Examination

• S.I.T.S.
• Size-measure all major muscle groups
• upper/lower arms
• upper/lower legs
• Inspect for Involuntary Movements
• Evaluate Tone
• Strength Testing
• 0-4 grading

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Motor Strength Testing

• 0- No Movement
• 1-Slight Contraction
• 2-Full Range of Motion/No Gravity
• 3-Full Range of Motion/Gravity
• 4- Some resistance
• 5- Full Resistance

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Examination of the Upper Extremities

• Shoulder
• Inspect
• Contour
• Girdle
• Clavicles
• Scapulae
• Muscles-SITT/Biceps/Deltoid/Traps
• AC Joint
• Bicipital Groove

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Shoulder

• Shoulder Shrug-Inspect for symmetry
• Abduction-180
• Adduction-50
• Internal Rotation(behind small of back)-90
• External Rotation(behind neck)-90

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Elbow

• Inspection
• Contour
• Nodules
• Swelling
• ROM
• Flexion-160
• Extension-180
• Supination/Pronation-90

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Elbow

• Strength Testing
• Palpate surface landmarks
• Tenderness
• Swelling
• Crepidis-differentiate articular from tendinous
• Synovial Thickening
• Epicondyles
• Olecranon

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