IM7.8-10 | Rheumatologic Clinical Evaluation — Summary & Reflection

KEY TAKEAWAYS

The rheumatologic clinical evaluation is a three-part skill: history, examination, and differential synthesis.

History — seven domains:
1. Onset and joint pattern (number, distribution, migration, symmetry)
2. Morning stiffness duration (≥1 hour = inflammatory; <30 min = mechanical)
3. Aggravating/relieving factors (exercise improves inflammatory back pain; worsens mechanical)
4. Extra-articular/systemic symptoms (skin, eyes, mouth, bowel, GU, constitutional)
5. Past history, medications, family history
6. Functional impact
7. Occupational/social history

Examination — GALS screen + regional detail:
- Look: deformities, rash, swelling, muscle wasting
- Feel: warmth (dorsum of hand), synovial thickening vs effusion vs bony swelling, MCP squeeze test, joint line tenderness
- Move: ROM (active + passive), special tests (Schober's, FABER, MCP/MTP squeeze, Finkelstein)
- Skin/nails/muscles: Gottron's papules, psoriasis, nail pitting, proximal power assessment

Differential synthesis (IM7.10) — ranked by pattern:
- Symmetric MCP/PIP/wrist + morning stiffness ≥1 h → RA
- Axial pain + SI tenderness + Schober's <20 cm + HLA-B27 features → axial spondyloarthropathy
- Acute first MTP monoarthritis + tophi → gout
- Fever + acute monoarthritis → septic arthritis (urgent)
- Butterfly rash + polyarthritis + proteinuria → SLE
- Proximal weakness + Gottron's papules → dermatomyositis

Priority rule: Septic arthritis must always be excluded first in any acute hot monoarthritis.

REFLECT

Return to Priya from the opening hook. You have now taken her history: bilateral MCP and wrist pain for 3 months, morning stiffness lasting 2 hours, fatigue, no rash, no dry eyes. On examination: positive MCP squeeze test bilaterally, boggy synovial thickening at MCPs 2–3, warmth at the wrists. No deformity yet. How would you present this case in one minute to your supervising consultant? What is your working diagnosis, and which investigation would you prioritise? Now consider a second patient — a 25-year-old man with 9 months of lumbar back pain, worse at night, better after exercise, with restricted forward flexion on the Schober test and SI joint tenderness on FABER. How does the examination presentation differ? What does the Schober test add that the history alone could not confirm? Reflecting on these contrasts sharpens the clinical skill this module aims to build.