Apparently this is a confirm station!
So better spend more time on perfecting the osce.
I like Loco examinations coz it is very clear cut. No hidden rubbish.
Exposed hand up to shoulder, beyond elbow.
I think of Look from the superficial down to the inner structure. and compare with the other hand. for symmetry.
So it would be starting with: Deformity-Skin changes/Subcutaneous Nodules-Scar-Swelling-Muscle wasting.
1. Deformity. Ulnar deviation of the hand at the wrist joint. Z thumb deformity. Swan neck deformity and Boutonnière's deformity. and Subluxation of the MCP. Prominence of ulnar styloid.
Boutoneire's deformity. PIP flexion and DIP extension
Ulnar deviation of the hand at the wrist joint and Z thumb deformity
Prominence of ulnar styloid
Swan neck deformity
2. Skin Changes - Palmar Erythema (It helps me remember and wont forget. I appreciate that palmar erythema is not skin changes) Redness
3. Scar - Carpal Tunnel Syndrome Scar. I just realised it is on the palm area near wrist quite distally not on the wrist where we take ABG.
4. Swelling - Spindling of the PIP join, loss of valley at the knuckles - MCP joint (can ask the patient to make a fist)
Spindling of proximal interphalangeal joints
5. Muscle wasting - check the thenar eminence for wasting, comparing side by side. And also dupuytren's contracture.
6. Look at the Nails. Pitting and Onycholyis = psoriasis.
Also, ask the patient to make a fist to check MCP (as stated above), looking for triggering when he/she release the fist sign of tenosynovitis as well as diabetes and RA, and how much the patient can flex the fingers.
Also, ask the patient to make a praying position to look for again the boutoniere's or fixed flexion deformity
Check elbow and behind the ear. For RA nodes or psoriatic plaque. Ear also might have tophi for gout.
Next, FEEL and MOVE
Temperature of wrist and MCP. Takkan wanna feel each joints meh.
And squeeze for tenderness, each and every joint. I would do from distal towards proximal.
While squeezing, move it, flex and extend.
and then do the function thingy.
1. Squeeze ur two fingers. Assessing grip.
2. Pinch testing precision.
3. Piano movement for fine finger movement.
4. Pick up objects or do and undo button. To assess precision and hand function.
and then the books said do some arm function, quickly.
So stretch the whole arm out. bend the elbow. turning taps. Cock wrist up and down. Hands behind head and hands doing bra.
I like the way they suggest presenting the findings:
There is a symmetrical, deforming polyarthropathy of the small joints of the hands in a rheumatoid pattern. The differentials would be RA and psoriatic arthropathy.
And as you can see from the picture, I think I have RA.