Scleroderma Examination
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  1. Introduce yourself and thank patient
  2. Make sure patient is sitting on bed, position height adequately and expose patient at least to elbow
  3. Place a pillow on the patient's lap
  4. Make a show of standing back and inspecting the room
    1. cup may be present to perform the sip test
    2. gloves to ward of raynaud's phenomenon
    3. mobility aides
    4. look for scleroderma facies, telangiectasia, obvious sclerodactyly, pigmentation, cushingoid appearance, raynauds
  5. Inspect carefully the nails, hands and arms for the following scleroderma features
    1. raynauds phenomenon
    2. thickening
    3. periungal erythema
    4. digital pitting and ulceration
    5. tapering of the fingers
    6. loss of digital pulps
    7. pseudo clubbing
    8. calcinosis
    9. telangiectasias
    10. joint swelling
  6. Test capillary return
  7. Palpate the radial and ulnar arteries
  8. Palpate carefully up the arms first to show extent of skin thickening: start from finger tips, hands, elbows, proximal arms, chest
    1. helps determine if scleroderma is diffuse or limited
  9. Perform the hand functionality exam testing for restricted movement
    1. supination
    2. Pronation
    3. wrist flexion (prayer sign)
    4. Wrist extension (reverse prayer sign)
    5. Elbow flexion
      1. inspect elbows for rheumatoid nodules
    6. elbow extension
    7. hands behind head
    8. hands behind back
  10. Formally test wrist flexion at the ulnar styloid if the hand functionality test was positive
  11. Palpate the CMC, MCP, PIJ, DIJ systematically, as 20% of patients with scleroderma have active joint synovitis
  12. Turn the patients hand over to expose the palm
  13. Palpate for thickening of the flexor tendons
  14. Test for finger crepitus
  15. Check for functional movements
    1. grip strength
    2. pincer strength
    3. Opposition
  16. Check for practical movements
    1. Ask patient what their dominant hand is
    2. Get patient to open jar, pull out key and make a motion as if they are turning on the ignition of a car
  17. Ask to check the patients blood pressure
  18. Check for proximal myopathy by asking patient to abduct shoulders against resistance
    1. checking for associated myositis, disuse atrophy or steroid effect
  19. Inspect hair for alopecia
  20. Inspect eyes for anaemia
    1. aetiology is gastric antral vascular ectasia, GI telangiectasia, anaemia of chronic disease, medication related
    2. Pull down eye lids slowly, they should not easily evert
  21. Inspect face for telangiectesia
  22. Inspect mouth for ulcers
  23. Measure oral aperture with tape or fingers (<3 fingers is limited opening)
  24. Perform sip test
    1. Positive if regurgitation or aspiration is evident
  25. Check for signs of pulmonary hypertension
    1. JVP with systolic v waves
    2. Pulsatile liver
    3. RV heave
    4. Palpable P2
    5. Pulmonary thrill
    6. Loud P2
    7. TR murmur
    8. PR murmur
  26. Check for signs of ILD
    1. fine end-inspiratory velcro like crackles predominantly at the bases
    2. Note the predominant pattern is NSIP > UIP 
  27. Measure chest expansion if diffuse skin thickening is observed
  28. Move on to the lower legs and expose them, testing for skin thickening
  29. Palpate the distal pulses
  30. Feel for pitting oedema
  31. Palpate peripheral pulses
  32. Squeeze MTP joints

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