What are the key components of a comprehensive examination for a 30-60 year old adult suspected of having rheumatoid arthritis?

Comprehensive Rheumatoid Arthritis Examination

The examination for suspected rheumatoid arthritis must focus on identifying definite clinical synovitis in at least one joint not better explained by another disease, which is the cornerstone of RA diagnosis. 1

Essential Clinical Examination Components

Joint Assessment - 28-Joint Count Evaluation

Perform a systematic 28-joint count examining for both tenderness and swelling in the following joints: 1

• Proximal interphalangeal (PIP) joints - look for soft, boggy swelling from synovitis, not hard bony enlargement 1
• Metacarpophalangeal (MCP) joints - symmetric involvement is characteristic 1
• Wrists - commonly affected early in disease 1, 2
• Elbows 1
• Shoulders 1
• Knees 1, 2

Apply the "squeeze test" across MCPs and metatarsophalangeal (MTP) joints to assess for clinical synovitis - tenderness with this maneuver strongly suggests inflammatory arthritis. 1

Pattern Recognition

Symmetric involvement of small joints, particularly MCPs, PIPs, wrists, and MTPs, is the hallmark pattern. 1 Large joints including shoulders, elbows, hips, knees, and ankles may also be affected. 1

Notably, distal interphalangeal (DIP) joints, first carpometacarpal joints, and first metatarsophalangeal joints are typically spared - involvement of these joints should prompt consideration of alternative diagnoses like osteoarthritis or psoriatic arthritis. 1

Morning Stiffness Assessment

Document the duration of morning stiffness - stiffness lasting more than 30 minutes before maximal improvement is characteristic of RA and correlates with disease activity. 2, 3 This is a subjective finding, so carefully explain the difference between pain and stiffness to the patient. 2

Hand Examination Specifics

Examine hands for joint deformities characteristic of rheumatoid arthritis, Raynaud phenomenon, and splinter hemorrhages underneath the nails. 4 Early hand involvement shows tender swelling on palpation with severe motion impairment but no radiologic bone damage initially. 2

Extra-Articular Manifestations

Skin examination: 4

• Look for rheumatoid nodules (typically over extensor surfaces)
• Assess for facial changes consistent with rosacea or seborrhea
• Check for scleroderma features
• Examine for vasculitic lesions

Ocular examination: 4

• Assess for dry eyes (sicca symptoms occur in 15-30% of RA cases, particularly with secondary Sjögren's syndrome) 1
• Document tear film quality and stability
• Evaluate conjunctival and corneal changes

Pulmonary assessment: 3

• Auscultate for interstitial lung disease

Constitutional Symptoms

Document presence of: 2, 5

• Fatigue
• Fever
• Weight loss
• Malaise

These systemic features are frequent and may indicate more active disease.

Disease Activity Measurement

Calculate a composite disease activity score using one of the validated measures: 4, 1

Simplified Disease Activity Index (SDAI)

SDAI = Tender Joint Count (0-28) + Swollen Joint Count (0-28) + Patient Global Assessment (0-10 cm) + Evaluator Global Assessment (0-10 cm) + CRP (mg/dL) 1

Target thresholds: 1

• Remission: ≤3.3
• Low disease activity: ≤11
• Moderate disease activity: ≤26
• High disease activity: >26

Clinical Disease Activity Index (CDAI)

Use CDAI when acute phase reactants are normal or near-normal - it relies purely on clinical assessment without incorporating CRP. 1

CDAI thresholds: 1

• Remission: ≤2.8
• Low disease activity: ≤10
• Moderate disease activity: ≤22
• High disease activity: >22

Patient-Reported Outcomes

Include the following assessments: 1

• Pain assessment (0-10 scale)
• Patient Global Assessment of Disease Activity (0-10 cm visual analog scale)
• Health Assessment Questionnaire Disability Index for functional status 4

Critical Examination Pitfalls to Avoid

Do not dismiss RA diagnosis based on absence of symmetric involvement - approximately 25% of patients present with acute or subacute monoarticular or oligoarticular onset. 2

Do not rely solely on inflammatory markers - acute phase reactants (ESR/CRP) can be normal even in active disease and are poor predictors of RA. 1 The physical examination finding of synovitis takes precedence over laboratory values. 1

Distinguish soft tissue swelling from bony enlargement - inflammatory arthritis produces soft, boggy joint swelling from synovitis, while osteoarthritis causes hard, bony enlargement from osteophytes. 1

Do not delay referral waiting for complete serologic workup - seronegative RA accounts for 20-30% of cases, and negative RF does not exclude RA diagnosis. 1 Any patient with joint swelling in more than one joint should be referred to rheumatology within 6 weeks of symptom onset. 6

Functional Assessment

Perform functional status assessment using a standardized, validated measure at least annually, but more frequently if disease is active. 4 Examples include the Health Assessment Questionnaire or PROMIS Physical Function instruments. 4

Neurological and Vascular Assessment

Evaluate cranial nerve function - specifically cranial nerve V (trigeminal) and cranial nerve VII (facial), as these may be affected in RA-associated complications. 4