Physical Exam Key Points

1. General appearance, including vital signs. Fever may occur with infectious, inflammatory, and neoplastic processes.

2. Skin. Observe for Still's rash in patients with JRA; Gottron papules in those with dermatomyositis; or cellulitis.

3. Musculoskeletal system. Check long bones for point tenderness (fracture, osteomyelitis). Check joints for warmth, tenderness, effusion, or restriction of full range of motion. Hip pathology manifests on exam with the hip joint flexed, abducted, and externally rotated to decrease mean articular pressure. Observe for muscle atrophy and leg length discrepancy.

4. Neurologic exam. Check for symmetric strength, reflexes, and tone. Watch gait for clue to pain or weakness. Running may intensify an abnormal gait.

5. Referred pain. Evaluate for areas of referred pain in abdomen, genital area, and spine.

B. Laboratory Data. Obtain CBC, ESR, and C-reactive protein (CRP). Abnormal findings help identify infectious or inflammatory etiology. Serial results help clinician track progress of treatment. Obtain culture of blood, joint fluid, or bone if septic joint or osteomyelitis is suspected. CRP is more sensitive than ESR for early osteomyelitis and therefore more likely to be abnormal earlier in disease process.

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