History & Examination in Rheumatoid Arthritis

Rheumatoid History

1. Presenting complaint
2. Pain: joints, limbs, elsewhere
3. Stiffness, swelling
4. Deformity, Raynaud's
5. Eyes, mouth
6. Systemic
7. Past medical, surgical history
8. Family, social, disability, drug history
Presenting complaint
· What is the problem lately?
Pain: joints
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associatedsymptoms
· Site: number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· Timing: acute/ chronic.
· Exacerbating factors: rest, exercise.
Pain: limbs
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associated
symptoms
· Bone pain.
· Severe pain of sudden onset (vascular disease).
· Nerve entrapment.
· In amputated limb (phantom pain).
Pain: elsewhere
· Site, onset, duration, character, radiation aggravating & relieving factors, severity, associated
symptoms
· Back is common.
· Spinal cord: localize to dermatome.
Stiffness
· Generalized or specific to certain joints.
· Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· Worse in morning (RA, other inflammatory).
· Duration before wears off (severity).
Swelling
· Number of joints, symmetrical/ asymmetrical, large/ small joints, sequence affected.
· When first noticed.
· Getting larger or smaller.
Deformity
· Misshapen joints.
· Time course of the deformity.

Raynaud's
· Assess Raynaud's phenomenon (scleroderma).
Eyes, mouth
· Dry eyes, mouth (Sjogren's).
· Red eyes, painful eyes (seronegatives).
· Unilateral loss of visual acuity (seronegatives).
Systemic
· Rash (SLE).
· Fatigue, breathlessness.
· Fever (connective tissue disease).
· Weight loss (dysphagia or malabsorption 2° to scleroderma).
· Abdominal pain, GI bleeding (NSAID s/e).
Past medical, surgical history
· Time of menopause [if applicable].
· Current problem in past.
· Trauma in past.
· Fractures, sprains.
· Infections:
• Gonorrhea [especially if monoarticular, young].
• Staphylococcus
• Streptococcus
• Hepatitis
• TB
• Dysentery
· Gout (gouty arthritis).
· IBD (IBD-associated arthritis).
· Psoriasis (psoriatic arthritis).
· Thyroid problems (osteoporosis).
· Tick bites (Lyme disease) [usu. USA only].
· Arthritis as a child.
· Depression [common in chronic disability].
· Seen a rheumatologist before?.
· Physiotherapy, occupational therapy.
· Joint surgery, bone surgery.
Family history
· The current complaint in parents/ siblings/ children: health, cause of death, age of onset, age of
death.
· Hereditary disease suspected: do a family tree.
· IBD.
· Gout.
· Rheumatoid arthritis.
· Osteoarthritis.
· Seronegatives: PAIR:
• Psoriasis
• Anklyosing
• IBD-associated
• Reiter's

Social history
· Smoking: ever smoked, how many per day, for how long, type [cigarette, pipe, chew] (increases
NSAID risk).
· Alcohol: do you drink. If yes: type, how much, how often (fall risk, increases NSAID risk).
· Present occupation.
· Any other factors that you wish to mention?
Disability
· Who is with you there at home [important for managing daily activities].
· Describe your home: stairs, if apartment what floor, handles (fall risk).
· Difficulties with cooking, dressing, bathing.
· How interrupts life.
· Home aids, utensils, appliances.
Drug history
· Prescriptions currently on [gold, etc], noting side effects.
· Over-the-counters, esp. NSAIDs.
· Steroids.
· Recreational drugs [most rheumatoid pt's are older than this, but may use for pain escape].
· Estrogen replacements [if menopausal], other hormones.
· Calcium supplements.
· Allergies: if allergic to drug, make sure not an allergy, not just a common side-effect.

Examination in Rheumatoid

1-Knee Examintion:
1- Inspection:* While lying: swelling, scars, redness, muscle waisting.
* Standing: valgus, varus, post aspect for bakers cyst
* While walking: limping to the side of the problem.
2- Palpation:[/LEFT]* Temprature
* Effusion
* Patellofemoral compartment (push the patella and press)
3- Movement:
* Range of movement
* Pain while moving
* Stability: ant and post cruciate ligaments , lateral and medial collateral ligaments.
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2- Spine Examination:
1- Inspection:
At rest: for deformities.
While moving: rotation , lateral flexion, ant and post flexion.
cervical spine is always examined while the patient is sitting BUT lumbosacral spine is examined while the patient is standing.
2- Palpation:
palpate paraspinal muscles and spine for tenderness.
Every time you Examine the spine U should perform a full neuro-exam for the lower limbs.

# Special examination in the spine:

1- Lumbosacral spine:

straight leg raising test ( Thomson's test):
while the patient is lying in the supine position. In normal individuals maximum stretch is at 70 degrees in patients with lumbosacral involvement nerve root stretches at 30 degrees and patient feels the pain.

2- Sacroiliac joint:
sacroilitis occrs in: seronegative arthrits such as Ankylosing spondylitis, or inflammatory bowel disease.

Manouvers to stress the sacroiliac joint:
pain is felt in the joint in the following cases:

1- open a book:
while the patient lying supine hold his both iliac bones and press on them as if U R opening a book.

2- lateral position ( close the book):
while the patient is lying on his lateral postion press the iliac bone as if U R closing a book.

3- Faber test ( Patrik test)
faber stands for
F: flexion
Ab: abduction
ER: External Rotation
all these movement at the hip joint.
******************
3- Hand:

1- Inspection:
At rest:
1- finger tips for pitting scars in scleroderma
2- nails for pitting nails in psoriasis, psoriatic changes, clubbing, splinter hemorrage...... etc.
3-muscles for wasting
4- skin for scaling, loss of hair, discoloration, atrophy.... etc
5- deformities

While moving:
for range the movement
for painful movement
ask the patient to flex his fingers extend them, make a fist.
opposition, adduction, abduction, extension and flexion of the thumb.
extension and flexion of the wrist joint.

Examine for carpal tunnel syndrome:
tap along the distribution of the median nerve.
phalen's test:
ask the patient to dorsiflex his both wrists
if positive patient will feel tingling along the distribution of the nerve.

2- Palpation:
palpate each interphalengeal joint medially lateraly anteriorly and posteriorly and passively flex and extend each joint looking for tenderness and effusion.

palpate each carpophalengeal joint and flex and extend each joint again looking for tenderness and effusion.

again palpate the wrist joint in the middle and extend and flex the joint looking for tenderness and effusion