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Approach

• Expose hands and forearms to elbows (exam for rheumatoid nodules here later!)
• Place on white pillow

1. Look
   • Bilateral symmetrical polyarthropathy
   • Radial deviation of wrist
   • Ulnar deviation of finger
   • Volar subluxation of wrist joint
   • Swelling of proximal interphalangeal joint (Bouchard's nodes - cf Heberden's nodes)
   • Z-thumb appearance (flexion of interphalangeal joint and hyperextension of metacarpophalangeal joint)
   • Swan-neck deformity
   • Boutonniere deformity
   • Wasting of dorsal interossei, best seen in first dorsal webspace
2. Feel
   • Palpate over any swollen joints to detect warmth and tenderness of acutely inflammed joints
   • Palpate elbows (over subcutaneous border of the ulna) for rheumatoid nodules - present in 25% of patients, especially in active seropositive disease
3. Sensory / Motor assessment
   • Medial nerve may be affected (resulting in carpal tunnel syndrome)
   • Functional assessment - unbuttoning of shirt, writing

Completion

1. Ask for other joint involvment
2. Examine rest of patient for associated features of rheumatoid arthritis
   

   Ophthalmic	Episcleritis Scleritis Keratoconjunctivitis sicca
   Respiratory	Pleural effusions Pulmonary fibrosis
   Cardiac	Pericarditis
   Reticuloendothelial	Lymphadenopathy Splenomegaly Felty's syndrome
   Neurological	Multifocal neuropathies Carpal tunnel syndrome
   Vascular	Vasculitis

3. Ask how condition affects life

Investigation of Rheumatoid arthritis

1. Blood tests
   • Anaemia (1) of chronic disease (2) felty's (3) Autoimmune (4) bone marrow (5) iron deficiency from drugs
   • Immunological - Rheumatoid factor (75% cases), ANA (30%), HLA-DR3/4
2. X-rays

Treatment options for rheumatoid arthritis

1. Non-surgical
2. Surgical