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General Hand Script

 

Questions to answer:

  • Diagnosis

  • Disease activity

  • Function

  • Extra-articular features

  • Treatment

 

Thank you for asking me to examine Mr. X, who presented with painful hands.

 

The salient findings are of a symmetrical/asymmetrical deforming/non-deforming polyarthropathy of the hands involving the MCP/PIP/DIP joints with/without current disease activity, but functional impairment, as well as articular/extra-articular findings of....., which is consistent with specific diagnosis/or inflammatory arthropathy/crystal arthropathy, with differential of ____.

 

I will now present my findings in full with further commentary on the severity, extra-articular manifestations, complications, and differentials.

 

On general inspection, the patient was sitting comfortably in a chair with/without nil gait aids. There was/was not a Cushingoid appearance.

 

On inspection of the hands, there was evidence of symmetrical/asymmetrical deformity in the MCP/PIP joints with/without sparing of the DIP joints.

  • There was/was not Boutonniere’s deformity, Swan Neck deformity, Z-deformity of the thumbs, ulnar deviation of the MCPs, and volar subluxation.

  • There were / were not rheumatoid nodules, indicative of seropositive disease.

  • There was/was not Herberden’s or Bouchard’s nodes

  • There was / was not gouty tophi, both in the hands, and elbows and pinna of the ears.

  • There was / was not psoriatic rash (on extensor surfaces of joints, scalp and peri-umbilicus, dactylitis, pitting or onycholysis

  • There was / was not clubbing

  • There were / were not scars from previous surgery

 

This was / was not associated with small muscle wasting.

 

On palpation, there was / was not evidence of active synovitis, with no boggy tenderness or effusions, suggesting low / high disease activity.

 

There was / was not restriction in movement of the PIP, MCP, wrist flexion/extension and thumb movements.

 

Peripheral nerves were intact on brief screening.

 

Function was impaired / intact with/without deficits in grip strength, pincer grip, and opposition strength, and no difficulty / difficulty in opening a jar and undoing a button. MENTION COMPENSATION

 

 

In terms of other joints:

  • The feet showed... with/without enthesitis.

  • There was/was not reduced range of motion in the cervical spine

  • There was / was not axial involvement with positive/negative Schober’s and occiput to wall, and sacroiliitis

 

In terms of extra-articular features:

  • RA: There was / was not iritis or eye changes, parotitis, mouth ulcers, evidence of pulmonary fibrosis, cardiac involvement with aortic regurgitation or a pericardial rub, ulcerative changes or vasculitis, splenomegaly, or peripheral nerve entrapment

  • SLE: There was / was not a malar/discoid/photosensitive rash, mouth ulcers, pulmonary fibrosis, pericardial rub, hepatosplenomegaly, or evidence of renal complications

  • Gout: There was / was not evidence of an underlying aetiology with no hepatosplenomegaly (Haematological), evidence of renal disease, or fluid overload to suggest diuretic use. There was / was not evidence of metabolic syndrome with obesity, and evidence of insulin use.

  • PA: There was/was not psoriatic rash on the scalp, hairline and umbilicus.

 

In terms of findings suggestive of a particular treatment:

  • There was / was not signs of steroid complications, such as a Cushingoid appearance, bruising, skin atrophy, cataracts, or proximal myopathy.  

  • There were no particular injection marks suggestive of biological use

 

In summary, my findings are in keeping with _______.

  • Minimally/moderately active RA/PA/Gout/OA/SLE with severe/non-severe deformity, and impaired/intact function. There were/were not extra-articular manifestations. This likely required steroid and DMARD use, although I could/could not ascertain specific evidence for these.

 

Whilst my findings are consistent with ______, other differentials would include:

  • Inflammatory arthritis

    • RA

    • Seronegative - psoriasis

  • Osteoarthritis

  • Gout

  • Connective tissue disease

 

I would proceed from here by:

  • Completing my examination by examining other joints, and extra-articular manifestations.

  • Confirming my diagnosis with antibodies (RF, anti-CCP), urate and imaging

  • Completely an assessment of disease activity with CRP/ESR, anaemia, albumin, complement (SLE), urinalysis (SLE).

  • I would screen for complications of the disease and treatment side effects with basic bloods, HbA1c, osteoporosis investigations, and an assessment of CV risk factors.

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