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
History
- 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