Rheumatoid arthritis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Physical examination

Appearance of the Patient

• General fatigue and lassitude

Skin

• Rheumatoid nodule found over bony prominences, such as the olecranon, the calcaneal tuberosity, the metacarpophalangeal joints, or other areas that sustain repeated mechanical stress.
• Pyoderma gangrenosum, a necrotizing, ulcerative, noninfectious neutrophilic dermatosis.
• Sweet's syndrome, a neutrophilic dermatosis usually associated with myeloproliferative disorders
• Viral infections
• Drug reactions
• Erythema nodosum
• Lobular panniculitis
• Atrophy of digital skin
• Palmar erythema
• Diffuse thinning (rice paper skin), and skin fragility.
• Beading on the nails

Eyes

• Dry eyes
• Scleritis
• Keratoconjunctivitis sicca (dry eyes)
• Episcleritis and scleromalacia

Lungs

On Auscultation of lungs:

• • Decreased breath sounds on both sides.
  • Crackles may be present.

Abdomen

• On palpation:
  • Hepatomegaly
  • Splenomegaly

Extremities

• Inflammation in the joints manifests itself as a soft, "doughy" swelling, pain, tenderness to palpation and movement, local warmth, and functional impairment.
• In RA, the joints are usually affected in a fairly symmetrical fashion although the initial presentation may be asymmetrical.

Deformity

• The fingers are typically deviated towards the little finger (ulnar deviation) and can assume unnatural shapes. Classical deformities in rheumatoid arthritis are the Boutonniere deformity (Hyperflexion at the proximal interphalangeal joint with hyperextension at the distal interphalangeal joint), swan neck deformity (Hyperextension at the proximal interphalangeal joint, hyperflexion at the distal interphalangeal joint).
• The thumb may develop a "Z-Thumb" deformity with fixed flexion and subluxation at the metacarpophalangeal joint, and hyperextension at the IP joint.