This is a giveaway exam so it’s important to do it properly.
Place the patients hands on a pillow, palms down. Feel down the hand with the back of your hand for any warmth. Ask then to lift them up looking for any obvious subluxation. Turn them over, feel again, then ask them to make a fist noting any deformities. Then ask them to make a prayer sign by pushing the open palms against each other and then reversing it – these manoeuvres look at the movements of the wrist. Then ask them to put their hands on their shoulders and take this opportunity to look at their elbows for plaques and nodules. Then ask then to put their hands behind their head and then behind their lower back.
Now go through each joint of the hand starting at the wrist and moving down testing for subluxation, tenderness and passive range of movement – yes it takes a while. Use two hands with finger at 90 degress to each other when palpating for boggy synovitis.
Then turn the hands over and feel for crepitus across the palm. Whilst you are doing that ask then to grip your fingers tight.
Then screen each of the nerves of the hand with motor first and then sensory tests i.e.
Median – Pen toching test, sensory over 2nd digit, also do Tinels test
Ulnar – Abduction of the fingers, sensory over 5th digit
Radial- Extension of the fingers, sensory over anatomical snuffbox
Now palpate the elbows for nodules and look behind the ears and at the hairline for psoaritic rash.
Now look for functional impact, grip strength, key grip, opposition strength and opening a button or using a key. It’s a good idea to have a key in a screw-lid jar to get the patient to undo and then use the key.
If the hands are rheumatoid then say something like “I would now like to go on to examine for other articular involvement, extra-articular features and drug complications of the underlying disease”. The examiners will probably direct you to listen to the pulmonary fibrosis for example.
If not go to the neck, feel for crepitus and test range of movement. Then go to the eyes looking for inflammatory change and signs of Sjorgens, then examine the lungs (all assuming that its rheumatoid)