Hand Examination
The
hands are most likely to have some rheumatological disease, however
keep it in mind that the condition might be neurological. If possible
ask the examiner if you can comment as you go through the examination,
as it is easy to forget specifically which deformities, and where, the
patient has by the time you have finished. If the patient has
rheumatoid arthritis the buzzphrase is "This patient has a symmetrical
deforming polyarthropathy, as evidenced by..." The examiner will also
like it if you comment on whether the disease is active or not.
Features suggesting activity include redness, heat and pain.
The routine
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Introduce yourself. Withhold the urge to shake the patient's hands as this may be painful.
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Ask "do you have any pain or stiffness in your hands"
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Position the patient with their hands palms down, resting on a pillow.
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Expose the patient's arms up to their sleeves.
Back of Hands
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Inspection
:
Look for: swelling of the joints, ulnar deviation, z-thumb, rheumatoid
nodules, boutonniere deformity, swan-neck deformity, redness, nail
pitting or other changes, fixed flexion, Heberdens nodes (DIP)
Bouchards nodes (PIP), wasting of muscles (guttering in hand)
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Get
the patient to flex their arms and stick their elbows out so you check
for rheumatoid nodules and psoriatic plaques. Make the point of feeling
this with your fingers.
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Palpate
the joints that are swollen feeling the warmth (active disease) and
looking at the patient's face to see if this is tender. Feel whether
the joint is soft (rheumatoid) or hard (osteoarthritis or gouty tophi).
Squeeze the MCP joints noting whether this is painful (active disease).
Some doctors recommend palpating all the individual joints. Reasons to
not do this include: there may not be enough time, and it may hurt the
patient, it does not give you very much more information.
Front of hands
-
Get the patient to turn his hands so the palms are facing up. Once again look for all the above features.
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Feel for Dupuytren's contracture by stroking with 2 fingers.
Functional assessment
Apart from inspection this is the second most important component of the exam.
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Pincer grip: the patient makes a ring with their first finger and thumb and you try and break it with your own.
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Power grip: the patient squeezes your finger
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Undo button
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Writing/holding a pen
Neurological Assessment
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Tone:
patient flexes/unflexes fingers in a wave. Ask them to open and close
their hands very quickly (is slow in myotonica dystrophica)
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Power:
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Median: patient sticks thumb in the air, you try and press it down in to teir hand towards their little finger
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Ulnar:
patient abducts all fingers, you abduct yours and try and adduct their
little finger with yours, and their thumb with yours (testing
"like-with-like"
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Radial: patient extends wrist and you try to flex it
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Sensation: check pinprick and light touch just in one area for each nerve
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Median: lateral thumb
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Ulnar: medial little finger
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Radial: anatomical snuffbox
Other
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Carpal tunnel syndrome: Tap on their wrist repeatedly to reveal tingling in the median nerve distribution
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Check behind ears for gouty tophi/psoriasis, and scalp for psoriasis
"I would like to"
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Investigations: FBC (anaemia), RF, ANA, dsDNA, complement (mixed connective tissue disease)
Common Conditions for OSCEs
