clinical approch to rheumatological examination

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Clinical approch to rheumatological examination

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  • 1. Rheumatological ExaminationByASHRAF OKBAPROF. OF INTERNAL MEDICINEAIN SHAMS UNIVERSITY

2. Getting Ready Greet the patient with kindness. Introduce yourself to the patient. Explain the procedure to the patient. Expose the area to be examined and ensure that it is not covered by clothes. 3. Gait Observe for Rhythm Symmetry 4. Upper limbsInspection 5. C5T2 dermatomes. 6. Upper limbsInspectionInspect the hand & wrists for: Swelling, Deformity, Nodule (heberden's nodes, Bouchard nod, tc), Muscle wasting, Skin abnormality Nail abnormality.(heberden's nodes, Bouchard nodes 7. PalpationPalpate the hand for tenderness synovial thickening increased warmth sweating.Perform Metacarpal squeeze test 8. palpate Metacarpophalangeal joints Proximal interphalangeal joints Distal interphalangeal, joints 9. Movement Ask the patient to open andspread the fingers, of bothsidesClose the fingers (power grip),of both sides 10. Pinch the tip of indexfinger and thumb(precision pinch). ofboth sides and feel itspower Compare active withpassive if active rangelimited,(precision pinch) 11. Ask the patient to puthis hands together inthe position of prayerand then to lower thehands keeping thepalms together.This demonstrates the range of dorsiflexion of the wrists 12. Ask the patient to placethe back of his handstogether and to raisethe arms upwards.This demonstrates the range of flexion of wrists 13. Examination of the elbowInspectionInspect for: Deformity, Nodule, Muscle wasting, Skin abnormality 14. Palpation Tenderness Swelling Increased warmth.Three bony landmarks - the medial epicondyle, the lateralepicondyle, and the apex of the olecranon - form an equilateraltriangle when the elbow is flexed 90, and a straight line whenthe elbow is in extension 15. Movement Instruct the patient to bend andstraighten both elbowssimultaneously (0-150), With elbows flexed to 90 turnhands palm up (supination 0-90)and then palms down (pronation0-90). 16. Examination of the shouldersInspectionInspect foro Deformity,o Nodule,o Muscle wasting,o Skin abnormality from the front and the backMarked atrophy of infra and supraspinous fossae. 17. SHOULDER JOINT Sternoclavicular joint (SC) acromioclvicular joint(AC) glenohumeral joints 18. Sternoclavicular joint (SC)A swelling with bruising over The right sternoclavicular joint 19. Acromioclvicular joint (AC) 20. glenohumeral jointsNormally, it is possible to raise the arm to90 while maintaining the scapula fixed.Scapula pivots before glenohumeralabduction takes place giving thisaspect of raising of the shoulder 21. PALPATION OF SHOULDER JOINTobserve for Tenderness Swelling Temperature Crepitus. 22. Ask the patient to point to the site where they areexperiencing discomfort.Instruct the patient to inform you if he experience anypain during the examination. 23. Palpate both shoulder joints in asystematic approach.1) Sternoclavicular joint2) Clavicle3) Acromioclavicular joint4) Humeral head5) Coracoid process6) Deltoid muscle7) Spine of scapula8) Supraspinatus muscle9) Infraspinatus muscle10) Trazpezus muscle(then repeat on the other side) 24. Movement Ask the patient to put both hands behindthe head with elbows pointing laterally(flexion, abduction and external rotation), To put the arms down and reach up behindthe back (extension, adduction and fullinternal rotation). 25. Examination of ankles and feetInspection:Inspect the ankles and feet joints for: Swelling, Deformity, Nodule Muscle wasting, Skin abnormality and Nail abnormality.Bilateral rheumatoid nodule atthe ankle with superficial bursitis 26. PalpationPalpate joints for: Tenderness, Swelling Increased warmth. 27. Perform Metatarsal squeeze test 28. MovementAsk the patient to dorsiflex (20)and plantar flex (30) each ankle(wide range of normal).Passively evert (10) and invert(20) the subtalar joints with theankles in neutral. 29. Flex and extend the MTP joints. 30. Examination of the kneesInspectionInspect the knee joints for: Swelling, Deformity, Muscle wasting and Skin abnormality. 31. Palpation Palpate for:o tendernesso swellingo increased warmth 32. Examine for knee effusionPatellar tap test:Slide your hand down thepatient's thigh, pushing downover the suprapatellar pouch, sothat any effusion is forcedbehind the patella.- When you reach the upper pole of thepatella, keep your hand there andmaintain pressureUsing the index & middle finger of theother hand push the patella downgently.- Does it bounce? If so this may indicatethe presence of an effusion. 33. Bulge test (massage test)- Using your thumb and index finger - milkdown any fluid from above the knee.- Keep this hand in this position.-Now with the other hand, stroke themedial side of the knee to empty themedial compartment of fluid thenstroke the lateral side.- Observe the medial side of the knee forany bulging? This may indicate aneffusion 34. Movement Ask the patient to flex eachknee in turn and observe therange of movement (0-150)and any signs of pain. Ask the patient straightenseach knee, place a hand onthe knee to feel the crepitus. 35. Examination of the hipPalpation Palpate the greatertrochanter area 36. MovementsFLEXIONHave the patient flex theirknees & move their hip jointinto the flexed position as fairas possible. (Normal range ~120 degree) If you keep the knee extendedthe range of movement in thehip joint is limited by tensionin the hamstring muscles 37. ABDUCTIONMake sure you stabilize thepelvis by placing a hand onthe opposite anterior iliaccrest and holding the anklewith the other hand. The hipis abducted until the pelvistilts. (Normal range ofmovement ~ 45 degrees) 38. ADDUCTIONCross one leg over the other untilpelvis begins to tilt. (Normalrange of movement ~ 30degrees) 39. INTERNAL ROTATION Flex the hip and knee to 90 degrees.Now move the leg laterally. (Normalrange of movement ~ 45 degrees) 40. EXTERNAL ROTATION With the hip and knee flexedmove the patient's leg medially.(Normal range of movement ~ 60degrees) 41. EXTENSIONHave the patient lie prone on thecouch. Immobilize the pelvis withone hand while extending the hipwith the other hand. 42. Examine the temporomandibularjoint Places first two fingers ofeach hand in front of tragusof ear and instruct patientto open and close mouth. 43. Examination of the spine and posture Inspect the standing patient's spine and posturefrom behind and the side for: abnormal kyphosis lordosis flattening of the longitudinal arch of the foot. 44. Palpation of the spine Tenderness Swelling Increased warmth 45. Movement Cervical spine:Ask the patient to look right, left,and then tilt the head sidewaysaiming to touch each ear on theshoulder. 46. Thoracic spines Measure the chest expansion by atape at the level of nipple. 47. Lumbar flexion Try to touch your toeswithout bending knees 48. Lumbar extensionLean back 49. Lateral lumbar flexion(Both sides) Slide your hand downyour leg 50. Thoracolumbar rotation Sit down and turn round,looking over your shoulder(Sitting down helps fix thepatients pelvis) 51. Schober's test Firstly identify the Dimples of Venus (2)Now in the midline, use a tape measureand pen to mark a point 10 cm superior(1), and another mark 5 cm inferior (3)to this line Ask the patient to attempt to touchtheir toes (i.e Flexing their lumbarspine).The distance between thesetwo marks should be measuredwhen the patients spine is flexedmaximally The distance should increase tomore than 21cm in a normal patient.In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. Youmay want to consider performing Schobers test to objectively measure the degree of spinal flexion. 52. Schober's test 53. Good Luck