Case 6 – Hand Pain

You are seeing Mrs. Dawes, a 43 year old female, in your outpatient clinic today. She states that the pain in her right hand is becoming so severe that she can’t even hold a pencil or toothbrush. Take a focused history and perform the necessary physical exam


  • Identifies affected hand joints (MCPs, PIPs)
  • Onset of pain
  • Aggravating factors (activity)
  • Alleviating factors (rest, Advil)
  • Character
  • Radiation
  • Association with morning stiffness and duration of stiffness (lasts more than 1 hour)
  • Other affected joints, elsewhere in the body
  • Frequency (intermittent flare-ups)
  • Nighttime pain
  • Fever, night sweats, weight loss, or other systemic symptoms
  • Associated rash
  • Mouth ulcers, dry mouth
  • GI symptoms
  • Associated neurologic symptoms
  • Ophthalmologic symptoms: dry eyes, irritation
  • History of trauma
  • Current medications
  • Personal history of rheumatologic disease
  • Family history of diabetes, thyroid disease, or Celiac disease (autoimmune diseases)
  • Family history of rheumatologic conditions
  • Effect on daily activities

Physical Examination

Inspection of Hand joints, including Wrist

  • Comments on presence/absence of erythema and effusion
  • Comments on deformities, muscle wasting, and deviations

Palpation of hand joints, including the wrist

  • Warmth
  • Tenderness
  • Effusion
  • Crepitus
  • Instability
  • Neurologic exam of hand for power and sensation

Range of Motion

  • Assess active and passive range of motion of all joints in the hand

Extra-articular examination for autoimmune disease

  • General: presence/absence of edema, muscle wasting, cachexia
  • Oral examination: ulcers
  • Respiratory examination: effusions, interstitial disease
  • Musculoskeletal: other effused joints
  • Dermatologic: rashes, ulcers, petechiae
  • Ophthalmologic: iritis
Case 6 – Hand Pain