Rheumatic fever physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. Anthony Gallo, B.S. [2]


Physical examination of patients with rheumatic fever is usually remarkable for fever, Sydenham's chorea, cardiac murmurs, and erythema marginatum.

Physical Examination

General appearance

Patients present frequently with joint involvement and fatigue.[1][2]

Vital signs


  • Erythema marginatum is a pink-red rash frequently located on trunk, limbs, and seldom on the face, appearing as non-pruritic macules or papules extending centrifugally outwards with central clearing and raised outer margins[2]
  • Ruddiness of the skin secondary to rheumatic vasculitis
Erythema Marginatum



Cardiac involvement is the second most common complication of rheumatic fever. Signs include:[3][4][5][6]



  • Sydenham's chorea (St. Vitus' dance, occurring very late in the disease for at least three months from onset of infection; see video #1)[7]
  • Spooning sign (flexion of the wrists and extension of the fingers when the hands are extended)
  • Pronator sign (turning outwards of the arms and palms when held above the head)
  • Inability to maintain protrusion of the tongue
  • Milk maids sign (intermittent increase and decrease of hand grip pressure; see video #2)





  • Arthritis, often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints), and can be migratory in nature, affecting multiple joints at one time[8]
  • Affected joints may be swollen, erythematous, warm, and tender
  • Subcutaneous nodules in approximately 10% of rheumatic fever patients, usually appearing on extensor surface of limbs, and over bony prominences such as elbows, knees, ankles and knuckles, and are generally painless[1]
  • Pedal edema possible if congestive heart failure and hypervolemia are present


  1. 1.0 1.1 Ayoub EM (1992). "Resurgence of rheumatic fever in the United States. The changing picture of a preventable illness". Postgrad Med. 92 (3): 133–6, 139–42. PMID 1518750.
  2. 2.0 2.1 BURKE JB (1955). "Erythema marginatum". Arch Dis Child. 30 (152): 359–65. PMC 2011784. PMID 13249623.
  3. Dressler W (1968). "Precordial heave on the right related to left-atrial enlargement". JAMA. 205 (9): 642–3. PMID 4233112.
  4. Dray N, Balaguru D, Pauliks LB (2008). "Abnormal left ventricular longitudinal wall motion in rheumatic mitral stenosis before and after balloon valvuloplasty: a strain rate imaging study". Pediatr Cardiol. 29 (3): 663–6. doi:10.1007/s00246-007-9047-5. PMID 17786377.
  5. "Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association". JAMA. 268 (15): 2069–73. 1992. PMID 1404745.
  6. Ferrieri P, Jones Criteria Working Group (2002). "Proceedings of the Jones Criteria workshop". Circulation. 106 (19): 2521–3. PMID 12417554.
  7. SACKS L, FEINSTEIN AR, TARANTA A (1962). "A controlled psychologic study of Sydenham's chorea". J Pediatr. 61: 714–22. PMID 13975949.
  8. Olgunturk R, Canter B, Tunaoglu FS, Kula S (2006). "Review of 609 patients with rheumatic fever in terms of revised and updated Jones criteria". Int J Cardiol. 112 (1): 91–8. doi:10.1016/j.ijcard.2005.11.007. PMID 16364469.