The Virtual Joint Exam Save

The virtual joint exam. Hi, I'm Jack Cush with RheumNow. The joint exam has changed. You're now doing them remotely. If you're lucky, can do them by video and actually garner a lot of good and useful information from the patient if you have a plan.

This is the joint exam that I've been doing since I started doing telemedicine. First, begin by asking the patient directly while talking to them by on camera, is there anything that you need to show me especially in your hands, elbows and shoulders? Turns out those joints are much more easily examined by video. Feet, ankles, knees, not so much. But ask them, do you have any joints that are newly red, swollen, or hurt, or unable to move, or where there's been a change in a knuckle, or a finger, or your wrist?

And let them show you. It's always better to show one joint at a time like this hand and don't let them get too close like this. Have them stand back and show you their hand and ask them what you'd like them to do, rotate it, move it up and down, whatnot. While you're at it, ask them if they have any rashes they can show you either on their upper extremity, behind their ears, nape of their neck, forehead, face, etcetera. And also nail changes, ask about their nails, tell them get closer to the camera, let me see your nails, they look pretty good today.

Again, it's useful. Begin any joint exam with inspection. Okay? And then after that, you can take them through a range of motion. And while you're doing that, you'll be looking for things like redness, swelling, limitation of motion, etcetera.

But it's basically a game of Simon Says. While I do advocate for examining one joint at a time, you can start off with the hands together in a game of Simon Says. Simon Says, put your hands together and let's see if we have a prayer sign. You can do this, you can do this, and ask them to come down. So no evidence of, flexion problems at the DIPs and PIPs.

Move the hands away. Simon says, flex your fingers on themselves without making a fist. Now make a fist. Now rake your nut your your thumbs across the front to see how the CMC one moves. Then one at a time, ask them to show you their fist so you can see their knuckles, whether the space between the MCPs are full or edematous or red or abnormal.

Same thing with the neck the other hand. Okay? Once you have them in this position, then you can ask them, please flex your wrist down. Okay? Extend them up.

Now ask them to put their their hands down, their hands on their ears and elbows out. You're looking at elbow flexion and shoulder, abduction and rotation. To better examine the elbows, ask them to extend their arm out to see that they don't have a flexion contracture or to show you the elbow you're looking at nodules, look, I fell off my bicycle, and if they have any nodules or swelling in the elbow. Then you can have them sit back and do forward flexion over their head. You have put their arms down and do abduction out to the side going at least 90 degrees.

And then having their arm at their side, hand forward at a 90 degree angle, they can rotate out and you can show shoulder, external rotation. While you're looking at the shoulder and examining the shoulder, you may be concerned that there might be neck issues that are radiating causing shoulder pain. You want to do forward flexion, extension, lateral bending, and rotation going both ways, to assess the neck. You can also assess the TMJ by just having them open their mouth as far as they can. Other joints, you really are gonna have a harder time.

You may need another person to take the video of their knee, ankle or hip or foot problem or you can have the patient shoot, turn the camera and shoot the video of their own foot and ankle in a mirror to get a better view of those joints should they happen to be the ones of interest to the patient. That's my short two minute video virtual joint exam. I'd like to hear your modifications of it.