The examination room   

The examination is the fundamental part of all rheumatology. The process is more important than blood tests or X-rays, all of which might be completely normal in the face of abnormality or disease.

Undressing the patient

Do not be surprised if your doc might insist on you getting undressed.

I usually request female patients to take their clothes off except bra and panty and put a gown on - open to the back.

If I feel it is relevant, I may ask a patient to remove the bra, in order to perform a breast examination to exclude breast malignancy. Breast malignancy is a potential cause of secondary bone cancer, and not examining the breasts may boccasionally required.

In addition there are issues relating to hormone therapy, that may require breast examination.

Maintain dignity                             

Once undressed the patient MUST be properly covered - with gown (for females) and covered with a sheet.                          

General examination                     

I perform a full general examination.
This includes :

Pulse, Blood pressure and peripheral circulation.

Examination for Glands (lymph nodes), skin rashes, pallor or anemia, oxygenation of the tissues, examination of nails and the peripheries, examination for fluid retention - oedema.

System examination

Examination of the Ear, nose, throat and lungs.

Examination of the heart.

Examination of the abdomen.

Examination of the neurological system - A VITAL examination.

Examination of the urine.                           

Muscle/joint examination

Clearly this is the most important aspect of the examination, but does not exclude the doctor from the full general and system examinations.
All the joints should be systematically examined and charted.

We examine ALL the joints.
We apply a principal of LOOK, FEEL and MOVE.

It is absolutely vital to differentiate between articular - i.e. joint problem, versus extra-articular disease - i.e. soft tissue / ligament / tendon or muscle disease. The presence of joint disease is usually more serious than soft tissue disease.

Look - joint inspection

Inspection of the joints for obvious swelling.
Inspection and charting of deformities.

Feel the joints

One by one - we examine each joint lining - for:
Swelling of the soft tissues. This is a doughy feel and it is this softness that is searched for - and reflects swelling of the lining of the joints - the synovium.
Damage is also felt as a rough or crackling feeling known as crepitus. Patients often complain that they can hear their joints cracking on movement. It is for this that damage must be excluded by feeling for crepitus. 

Move the joints

We take each joint through it's range of movement. Assessment is made of damage and contracture, as well as induction and reproduction of pain.

We also feel for crepitus on movement of the joints.

Active movement - is tested by making the patient move the joint through it's range of movement. This utilises joint and the soft tissue, and therefore acts as a screen for a musculoskeletal problem. 

Passive movement - is movement WITHOUT the patient contracting the muscles. The movement is conducted without patient assistance. If pain is induced - then the problem is NOT muscle or soft tissue origin, but lies within the joint itself

Resisted movement - is movement of the limb or joint in a specific direction upon request and against the resistance of the examiner. This therefore makes the patient contract a specified muscle structure. It is therefore the best test of disease of the soft tissue around the joint - such as muscles.

Make a provisional diagnosis

Once the examination is concluded, the suspicions obtained by the history, are confirmed or further suspected, and a diagnosis or potential diagnosis should already have been made by the doctor. A list of potential diagnoses - the differential diagnosis, should already be in the mind of the doctor, and it is only to confirm or assist in coming to a definitive diagnosis, that blood tests or X-rays may be requested.



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