The document provides guidance on performing a rheumatological examination. It describes examining various joints including the temporomandibular joint, hands, wrists, elbows, knees, cervical spine, shoulders, and neck. For each joint, it outlines inspecting for abnormalities, palpating for tenderness, swelling, and crepitus, and testing the range of motion. The examinations are to be performed systematically and carefully with the patient's comfort in mind.

1. Rheumatological Examination
By
ASHRAF OKBA
PROF. OF INTERNAL MEDICINE
AIN SHAMS UNIVERSITY

2. History
1. What are your occupation and hobbies? Patients who work at a desk, type, or who perform
other repetitive activities that involve simultaneous wrist and finger flexion are prone to develop carpal tunnel syndrome.
2. Where is your pain?
3. Is the pain and swelling symmetrical? rheumatoid
4. What is the quality of your pain and/or symptoms (e.g., sharp, electric,
dull, aching, numbness, tingling, etc.)?
5. When did your symptoms begin?
6. Have you ever had a history of trauma? Z joint disease
7. Have you noticed any weight loss or systemic symptoms, such as flushing
or fever? rheumatoid
8. Do you ever have symptoms at night that awaken you from sleep? carpal tunnel
syndrome.
9. Have you tried any treatments for your pain and have they Helped?

3. Examination

4. 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.

5. Upper limb

6. Wrist and hand

7. Inspection

8. Inspection
Inspect the hand & wrists for:
• Swelling,
• Deformity,
• Nodule (heberden's nodes, Bouchard nod, tc),
• Muscle wasting,
• Skin abnormality
• Nail abnormality.
(heberden's nodes, Bouchard nodes

9. Palpation
Palpate the hand for
– tenderness
– synovial thickening
– increased warmth
– sweating.
Perform
– Metacarpal squeeze test

10. palpate
– Metacarpophalangeal joints
– Proximal interphalangeal joints
– Distal interphalangeal, joints

11. Movement
• Ask the patient to open and
spread the fingers, of both
sides
Close the fingers (power grip),
of both sides

12. • Pinch the tip of index
finger and thumb
(precision pinch). of
both sides and feel its
power
(precision pinch)

13. • Ask the patient to put
his hands together in
the position of prayer
and then to lower the
hands keeping the
palms together.
This demonstrates the range of dorsiflexion of the wrists

14. • Ask the patient to place
the back of his hands
together and to raise
the arms upwards.
This demonstrates the range of flexion of wrists

15. Elbow

16. Examination of the elbow
Inspection
Inspect for:
• Deformity,
• Nodule,
• Muscle wasting,
• Skin abnormality

17. Palpation
– Tenderness
– Swelling
– Increased warmth.
Three bony landmarks - the medial epicondyle, the lateral
epicondyle, and the apex of the olecranon - form an equilateral
triangle when the elbow is flexed 90°, and a straight line when
the elbow is in extension

18. Movement
• Instruct the patient to bend and
straighten both elbows
simultaneously (0-150°),
• With elbows flexed to 90° turn
hands palm up (supination 0-90°)
and then palms down (pronation
0-90°).

19. Shoulder

20. Examination of the shoulders
Inspection
Inspect for
o Deformity,
o Nodule,
o Muscle wasting,
o Skin abnormality from the front and the back
Marked atrophy of infra and supraspinous fossae.

21. SHOULDER JOINT
• Sternoclavicular joint (SC)
• acromioclvicular joint
(AC)
• glenohumeral joints

22. Sternoclavicular joint (SC)
A swelling with bruising over The right sternoclavicular joint

23. Acromioclvicular joint (AC)

24. PALPATION OF SHOULDER JOINT
observe for
– Tenderness
– Swelling
– Temperature
– Crepitus.

25. Palpate both shoulder joints in a
systematic approach.
1) Sternoclavicular joint
2) Clavicle
3) Acromioclavicular joint
4) Humeral head
5) Coracoid process
6) Deltoid muscle
7) Spine of scapula
8) Supraspinatus muscle
9) Infraspinatus muscle
10) Trazpezus muscle
(then repeat on the other side)

26. Ask the patient to point to the site where they are
experiencing discomfort.
Instruct the patient to inform you if he experience any
pain during the examination.

27. Movement
• Ask the patient to put both hands behind
the head with elbows pointing laterally
(flexion, abduction and external rotation),
• To put the arms down and reach up behind
the back (extension, adduction and full
internal rotation).

28. Ankle and feet

29. Examination of ankles and feet
Inspection:
Inspect the ankles and feet joints for:
• Swelling,
• Deformity,
• Nodule
• Muscle wasting,
• Skin abnormality and
• Nail abnormality.
Bilateral rheumatoid nodule at
the ankle with superficial bursitis

30. Palpation
Palpate joints for:
• Tenderness,
• Swelling
• Increased warmth.

31. Perform Metatarsal squeeze test

32. Movement
Ask 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 the
ankles in neutral.

33. Knee

34. Examination of the knees
Inspection
Inspect the knee joints for:
• Swelling,
• Deformity,
• Muscle wasting and
• Skin abnormality.

35. Palpation
• Palpate for:
o tenderness
o swelling
o increased warmth

36. Examine for knee effusion
Patellar tap test:
Slide your hand down the
patient's thigh, pushing down
over the suprapatellar pouch, so
that any effusion is forced
behind the patella.
- When you reach the upper pole of the
patella, keep your hand there and
maintain pressure
Using the index & middle finger of the
other hand push the patella down
gently.
- Does it bounce? If so this may indicate
the presence of an effusion.

37. Bulge test (massage test)
- Using your thumb and index finger - milk
down any fluid from above the knee.
- Keep this hand in this position.
-Now with the other hand, stroke the
medial side of the knee to empty the
medial compartment of fluid then
stroke the lateral side.
- Observe the medial side of the knee for
any bulging? This may indicate an
effusion

38. Movement
• Ask the patient to flex each
knee in turn and observe the
range of movement (0-150°)
and any signs of pain.
• Ask the patient straightens
each knee, place a hand on
the knee to feel the crepitus.

39. Hip

40. Examination of the hip
Palpation
• Palpate the greater
trochanter area

41. Movements
FLEXION
Have the patient flex their
knees & move their hip joint
into the flexed position as fair
as possible. (Normal range ~
120 degree)
• If you keep the knee extended
the range of movement in the
hip joint is limited by tension
in the hamstring muscles

42. ABDUCTION
Make sure you stabilize the
pelvis by placing a hand on
the opposite anterior iliac
crest and holding the ankle
with the other hand. The hip
is abducted until the pelvis
tilts. (Normal range of
movement ~ 45 degrees)

43. ADDUCTION
Cross one leg over the other until
pelvis begins to tilt. (Normal
range of movement ~ 30
degrees)

44. INTERNAL ROTATION
• Flex the hip and knee to 90 degrees.
Now move the leg laterally. (Normal
range of movement ~ 45 degrees)

45. EXTERNAL ROTATION
• With the hip and knee flexed
move the patient's leg medially.
(Normal range of movement ~ 60
degrees)

46. EXTENSION
Have the patient lie prone on the
couch. Immobilize the pelvis with
one hand while extending the hip
with the other hand.

47. Temporomandibular joint

48. Examine the temporomandibular
joint
• Places first two fingers of
each hand in front of tragus
of ear and instruct patient
to open and close mouth.

49. Spine

50. Examination of the spine and posture
• Inspect the standing patient's spine and posture
from behind and the side for:
– abnormal kyphosis
– lordosis
– flattening of the longitudinal arch of the foot.

51. Palpation of the spine
• Tenderness
• Swelling
• Increased warmth

52. Movement
• Cervical spine:
Ask the patient to look right, left,
and then tilt the head sideways
aiming to touch each ear on the
shoulder.

53. Thoracic spines
• Measure the chest expansion by a
tape at the level of nipple.

54. Lumbar flexion
• Try to touch your toes
without bending knees

55. Lumbar extension
Lean back

56. Lateral lumbar flexion
(Both sides)
• Slide your hand down
your leg

57. Thoracolumbar rotation
• “Sit down and turn round,
looking over your shoulder”
(Sitting down helps fix the
patients pelvis)

58. Schober's test
• Firstly identify the Dimples of Venus (2)
Now in the midline, use a tape measure
and 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 “touch
their toes” (i.e Flexing their lumbar
spine).The distance between these
two marks should be measured
when the patient’s spine is flexed
maximally
• The distance should increase to
more than 21cm in a normal patient.
In lumbar spine flexion, hip flexion can compensate to a considerable extent for a loss of spinal flexion. You
may want to consider performing Schober’s test to objectively measure the degree of spinal flexion.

59. Schober's test

60. Good Luck

61. 1) The temporomandibular joint examination:
رقم الطالب
Marks
Getting Ready: (2 marks)
1. Greeted the patient with
kindness
2. Introduced himself/herself
to the patient
3. Explained the procedure to
the patient
1
0.5
0.5
Palpation:
Placed the finger over the
joint while the patient
opened and closed the
mouth; notice if there any
crepitus, tenderness

62. 2) Inspect the Hand and the Wrist
رقم الطالب
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the
patient
3. Explained the procedure to the
patient
4. Ensured the wrist and hand are
free of clothing
0.5
0.5
0.5
0.5
Inspection Hands and Wrists:
a) Deformity
b) Swellings
c) Nodules
d) Skin abnormalities
e) Nail abnormalities
f) Muscle state (thenar,
hypothenar, interossei,
forearm)
(6)
1
1
1
1
1
1
Compare both sides 2

63. رقم الطالب
3) Wrist joint examination
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the patient
3. Explained the procedure to the patient
4. Ensured the wrist and hand are free of
clothing
0.5
0.5
0.5
0.5
Palpation of Wrists: (4 marks)
a) Tenderness
b) Temperature
c) Synovial thickening
d) Crepitus
1
1
1
1
(4 marks)
a) Dorsiflexion of wrist
Ask the patient to put his hands together in the
position of prayer and then to lower the hands
keeping the palms together
a) Flexion of wrists
Ask the patient to place the back of his hands
together and to raise the arms upwards.
2
2
Compare active with passive if active
range limited
1
Compare both sides 1

64. 4) Elbow joint examination:
رقم الطالب
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the patient
3. Explained the procedure to the patient
4. Ensured both upper limbs are free of
clothing
0.5
0.5
0.5
0.5
Inspection: (2 marks)
a) Nodules
b) Deformity
c) Skin abnormality
d) Muscle state of arm & forearm
0.5
0.5
0.5
0.5
Palpation (2 marks)
a) Tenderness
b) Temperature
c) Swelling
d) Crepitus
0.5
0.5
0.5
0.5
Range of movement
Active movements:
-Asked the patient to actively move the
elbow, Flexion, Extension.
- With elbow flexed to 90 to turn hands
palm up (supination) and then palm down )
pronation).
2.5
Compare active with passive if active
range limited
0.5
Compare both sides 1

65. رقم الطالب
5) Examine for knee effusion:
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the patient
3. Explained the procedure to the patient
4. Made sure that both knees are fully exposed.
0.5
0.5
0.5
0.5
Patellar tap test: (4 marks)
a) Slide hand down the patient's thigh, pushing
down over the suprapatellar pouch, so that
any effusion is forced behind the patella.
b) On reaching the upper pole of the patella,
keep hand there and maintain pressure.
c) Using the index & middle finger of the other
hand push the patella down gently.
Bulge test (massage test) (4 marks)
a) Using thumb and index finger - milk down any
fluid from above the knee.
b) Keep this hand in this position.
c) Then with the other hand, stroke the medial side
of the knee to empty the medial compartment of
fluid then stroke the lateral side.
d) Observe the medial side of the knee for any
bulging.

66. رقم الطالب
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the
patient
3. Explained the procedure to the
patient
4. Ensured the neck and upper chest are
free of clothing
0.5
0.5
0.5
0.5
Range of movement: (8marks)
a) Flexion:
Instructed the patient to try to touch the
chest with the chin
b) Extension:
Asked the patient to move the head
backward and to look up
c) Rotation
- With the head looking forward, asked the
patient to look to the right and then to the
left
- Compared the movement in both
directions
d) Lateral bending:
Started while the head was in the neutral
position, asked the patient to try to touch
the shoulder by the ipsilateral ear, without
moving the shoulders
Repeated on the other side
2
2
2
2
6) Cervical spine movement

67. رقم الطالب
Marks
Getting Ready: (2 marks)
1. Greeted the patient with kindness
2. Introduced himself/herself to the
patient
3. Explained the procedure to the patient
4. Ensured both upper limbs are free of
clothing with exposure of upper chest
0.5
0.5
0.5
0.5
Palpation (7 marks)
a) Observe for any signs of tenderness,
1 swelling, temperature or crepitus
Palpate for
1) Sternoclavicular joint
2) Clavicle
3) Acromioclavicular joint
4) Humeral head
5) Coracoid process
6) Deltoid muscle
7) Spine of scapula
8) Supraspinatus muscle
9) Infraspinatus muscle
10) Trazpezus muscle
6
1 Compare sboth ides
7) Shoulder joint examination