Title: The Arthritic Hand: Evaluation of Chronic Joint Pain
Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
Location: General Practice or Outpatient Rheumatology Clinic
Learning Objectives
- Primary: Conduct a focused, time-efficient bilateral hand examination.
- Secondary: Perform functional assessments using provided equipment.
- Clinical Reasoning: Differentiate between Osteoarthritis (OA) and Rheumatoid Arthritis (RA) through pathognomonic physical signs.
Patient Profile
- Name: Mrs. Eleanor Rigby
- Age: 68 years old
- Ethnicity: Caucasian
- Occupation: Retired Florist
- Social History: Lives alone; enjoys knitting and gardening but has recently struggled with these hobbies.
Presenting Complaint
Mrs. Rigby presents with a 12-month history of worsening pain and stiffness in both hands, particularly “knobby” changes in her fingers and difficulty opening jars.
Contextual Information
- HPC: Pain is worse at the end of the day after gardening. Morning stiffness lasts about 15 minutes.
- PMHx: Hypertension (controlled), Mild Gastritis.
- Medications: Amlodipine, occasional Paracetamol. No NSAIDs due to stomach sensitivity.
- Allergies: Penicillin (Rash).
- Family History: Mother had “gnarled” hands in her 80s.
Exam Instructions
Candidate Instructions
Mrs. Eleanor Rigby has come to see you regarding chronic hand pain.
- Perform a focused physical examination of both hands.
- Assess her functional capacity using the items provided on the tray.
- Discuss your preliminary findings and the impact on her daily life with her.
Note: You do not need to take a full history. Focus on the physical exam and functional assessment.
Standardized Patient (SP) Instructions
- Affect: Cooperative but frustrated by your loss of dexterity.
- Physical Signs: You have visible Heberden’s nodes (DIP) and Bouchard’s nodes (PIP). You have a positive “Grind Test” at the base of your thumb. You do not have ulnar deviation or “boggy” swelling of the wrists.
- Opening Statement: “Doctor, my fingers are getting so stiff and lumpy, I can’t even open my jam jars anymore.”
- Key Trigger: If the doctor is too rough during palpation, say: “Ouch, that specific joint is quite tender, please be gentle.”
Examiner Checklist Items
- Introduces self and gains informed consent.
- Inspection: Identifies Heberden’s and Bouchard’s nodes (must use these terms or describe them accurately as DIP/PIP nodes).
- Palpation: Systematically checks all small joints and performs the Thumb Grind Test.
- Movement: Assesses active range of motion (fist and finger extension).
- Functional Assessment: Uses the tray items (Key, Paperclip, Bottle) to test grips.
- Communication: Explains the diagnosis of Osteoarthritis in lay terms.
Key Clinical Findings
- Vital Signs: Stable (BP 135/85, HR 72).
- Inspection: Hard, bony swellings at the DIP joints (Heberden’s) and PIP joints (Bouchard’s). Squaring of the CMC joint. No “Sausage digits,” no ulnar drift, no psoriasis plaques.
- Palpation: Bony crepitus. Tenderness at the base of the thumb (1st CMC joint). No “boggy” synovitis.
- Functional: Reduced power grip; unable to fully unscrew the specimen bottle.
Communication Triggers (Murtagh’s Approach)
- Open-Ended Start: “To help me understand how this affects you, could you describe what tasks have become the most difficult lately?”
- Summarizing: “So, it sounds like the pain is mostly at the tips of your fingers and the base of your thumb, making it hard to garden. Is that correct?”
- Lay Language: Avoid “Carpometacarpal joint degeneration.” Instead, use: “The wear-and-tear is affecting the hinge at the base of your thumb.”
- Empathy: “I can see how frustrating it is to lose the ability to do the things you love, like your gardening.”
Assessment & Marking Guide
| Domain | Critical Competency |
| Physical Exam | Identified specific nodes (H-D, B-P) and performed Thumb Grind test. |
| Functionality | Crucial: Candidate specifically asked the patient to use the key and open the bottle. |
| Differential | Correctly prioritized OA over RA based on the lack of morning stiffness and node location. |
| Professionalism | Handled the arthritic joints with physical care and empathy. |
Sample Answers / Model Performance
Suggested History Clarification:
“Mrs. Rigby, when you wake up, how long does the stiffness last? Does the pain get better or worse the more you use your hands?” (Differentiates inflammatory vs. degenerative).
Explaining the Diagnosis:
“Based on the bony lumps on your finger joints and the way your thumb is moving, it looks like you have Osteoarthritis. This is a ‘wear-and-tear’ condition of the cartilage. Unlike some other types of arthritis, this isn’t an ‘internal’ disease, but it clearly affects your ability to do daily tasks. I’d like to refer you to an Occupational Therapist to look at some tools that can make opening jars and gardening easier for you.”