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

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

• Fever
• Normotension or Hypotension (if pericardium is involved)
• Tachycardia
• Tachypnea (if heart valves, pericardium or myocardium are involved leading to cardiac dysfunction)

• 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

• Epistaxis (usually accompanying severe carditis)
• Streptococcal pharyngitis
• Dysphagia

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

• Tachycardia
• Jugular venous distension, S₃ or occasionally a summation gallop may be noted if the patient demonstrates congestive heart failure secondary to valvular or myocardial involvement
• Parasternal heave
• Cardiac murmurs if heart valves are involved; commonly regurgitant murmurs in acute rheumatic fever and valve stenosis in chronic rheumatic fever, and include:
  • Mitral insufficiency (holosystolic murmur) (usually accompanied by aortic insufficiency and early diastolic murmur)
  • Aortic stenosis (systolic ejection murmur)
  • Mitral stenosis (mid diastolic murmur)
• Pericardial friction rub and low intensity heart sounds (if pericarditis or pericardial effusion are involved)

• Dull on percussion in presence of pleural effusion
• Decreased breath sounds may be noted in presence of an accompanying pleural effusion
• Basilar crackles may be heard on auscultation, suggestive of pulmonary edema

• 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)

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• Ascites (if heart failure and hypervolemia are present)

• 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