EXAMINATION OF OF BACK
Posted by nazishg on May 15, 2009
EXAMINATION OF BACK (ANKYLOSING SPONDYLITIS):
INSTRUCTION: EXAMINE THIS GENTLEMANS BACK.
TO PATIENT:
HELLO MR.SAM. MY NAME IS DR. NAZISH. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.
MAY I PLEASE EXAMINE YOU? THANK YOU.
LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.
COULD YOU PLEASE TAKE OFF UR TROUSERS KEEPING UR UNDERWEAR ON? CAN U PLZ STAND WITH UR BACK TO ME.? THANK U.
ARE YOU COMFORTABLE SIR?
DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?
I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.
ACT: LOOK AT PTS BACK.
TO EXAMINER:
THERE IS ON INSPECTION IN THIS GENTLEMAN NO EVIDENCE OF ANY CAFÉ AU LAIT SPOTS, ERYTHEMA, SCARS OF PREVIOUS THORACOTOMY OR TRAUMA, HAIRY PATCH (SPINA BIFIDA), SWELLING OR SCOLIOSIS.
FIG. 8, 9 MC RAE PG 131.
TO PT:
NOW SIR COULD U PLZ TURN TO UR SIDE.
TO EXAMINER:
THIS YOUNG MAN HAS LOSS OF NORMAL LUMBAR LORDOSIS AND INCREASED THORACIC KYPHOSIS WITH FORWARD THRUST OF NECK PRODUCING A STOOPED QUESTION MARK POSTURE.
FIG. 1, 4, 6 PG 130 MC RAE.
I WOULD LIKE TO DETERMINE WHETHER THIS KYPHOSIS IS FIXED OR MOBILE.
NOTE:
MOBILE KYPHOSIS IS FOUND IN POSTURAL KYPHOSIS WHILE FIXED KYPHOSIS IS PRESENT INS ENILE KYPHOSIS, ANKYLOSING SPONDILITIS.
TO PT:
COULD U PLZ BEND FORWARDS? I AM CHECKING FOR FLOW OF MOVEMENT IN SPINE AND WHETHER THE CURVATURE INCREASES. THANK U. U MAY STRAIGHTEN UP NOW. NOW STANDING UPRIGHT PLZ BRACE BACK UR SHOULDERS. I AM CHECKING FOR MOBILITY OF KYPHOSIS. THANK U. U MAY RELAX NOW.
FIG. 2, 3, 4 PG. 130 MC RAE.
TO EXAMINER:
A FIXED KYPHOSIS IS PRESENT.
TO PT:
COULD U PLZ SIT ON THIS CHAIR WITH UR BACK TO ME AND LEAN FORWARDS. I AM NOW GOING TO GENTLY FEEL UR BACK. I WILL BE VERY GENTLE.
ACT:
CHECK TEMP WITH BACK OF HAND FROM TOP TO DOWN IN MIDLINE OF BACK.
TO EXAMINER:
THE OVERLYING SKIN IS NOT WARM.
ACT:
CHECK FOR TENDERNESS: BW SPINES OF LUMBAR VERTEBRAE AND LUMBOSACRAL JUNCTION, OVER LUMBAR MUSCLES, OVER SACROILIAC JOINT.
FIG. 15, 16 PG 132 MC RAE.
TO PT:
PLZ LET ME KNOW IF IT HURTS AT ALL.
NOW SIR PLZ STAND UP WITH UR BACK TO ME. I AM JUST GOING TO SLIDE MY FINGERS DOWN LUMBAR SPINE ON TO THE SACRUM TO FEEL FOR A PALPABLE STEP AT LUMBOSACRAL JUNCTION.
FEATURE OF SPONDYLOLITHESIS.
FIG. 17 PG. 132 MC RAE.
TO EXAMINER:
TENDERNESS IS PRESENT OVER SPINE AND SACROILIAC JOINTS. I CANNOT FEEL A PALPABLE STEP AT LUMBOSACRAL JUNCTION.
TO PT:
COULD U PLZ BEND FORWARDS? I AM JUST GOING TO GENTLY TAP OVER UR SPINE WITH MY FIST FROM THE NECK TO SACRUM. PLZ LET ME KNOW IF IT HURTS.
FIG. 18, PG. 132 MC RAE.
TO EXAMINER:
THERE IS NO MARKED PAIN ON PERCUSSION OVER SPINE.
TO PT:
I AM NOW GOING TO ASSESS MOVEMENTS. CAN U PLZ LEAN FORWARDS AS FAR AS U CAN KEEPING UR KNEES UNBENT, TRY TO TOUCH UR TOES. THANK U.
FIG 20 PG 133 MC RAE
NOTE:
MAJORITY CAN REACH WITHIN 7 CMS OF FLOOR. (NORMAL).
NOW COULD U PLZ ARCH UR BACK. LET ME HELP U BY PLACING MY HAND ON THE SMALL OF UR BACK TO STEADY PELVIS. WITH MY OTHER HAND I WILL GENTLY STEADY PELVIS. WITH MY OTHER HAND I WILL GENTLY PULL BACK UR SHOULDERS. PLZ DO LET ME KNOW IF IT HURTS AT ALL. THANK U.
FIG 26 PG 134 MC RAE
THIS TESTS EXTENSION WHICH IS NORMALLY ABOUT 30 DEGREES.
AND NOW PLZ STAND UP STRAIGHT AGAIN AND REST UR HANDS AGAINST THIGHS. NOW LEAN TO LEFT AND SLIDE UR HAND DOWN THE SIDE OF UR LEFT LEG. DO NOT LEAN FORWARDS OR BACK.
AND NOW THE RT SIDE. THANK U.
FIG 27 PG 134 MC RAE
THIS TESTS LATERAL FLEXION WHICH IS NORMALLY ABOUT 30 DEGREES.
NOW COULD U PLZ SIT DOWN SO AS TO FIX THE PELVIS. CROSS UR ARMS OVER UR CHEST AND NOW TWIST UR SHOULDERS AS FAR BACK AS U CAN. FIRST TO THE RT AND NOW TO THE LT. THANK U.
THIS CHECKS ROTATION WHICH IS NORMALLY ABOUT 40 DEGREES.
FIG 29 PG 134 MC RAE
TO EXAMINER:
THE RANGE OF MOVEMENT OF SPINE IS REDUCED IN ALL DIRECTIONS ESPECIALLY EXTENSION.
TO PT:
I WOULD LIKE TO ASSESS MOVEMENTS AT THE NECK.
COUL U PLZ BEND UR HEAD FORWARDS AND TRY TO PUT UR CHIN TO UR CHEST. THIS TESTS FORWARD FLEXION. THANK U.
FIG 7 PG 32 MC RAE
AND NOW TILT UR HEAD BACKWARDS AS FAR BACK AS IT CAN GO. THIS TEST EXTENSION. THANK U.
FIG 8 PG 32 MC RAE
NOW PLZ TILT UR HEAD AND TRY TO TOUCH UR EARS TO UR SHOULDER. AND NOW THE OTHER SIDE. THANK U. THIS TESTS LATERAL FLEXION.
FIG 11 PG 32 MC RAE
NOW PLZ LOOK OVER UR SHOULDER. LET ME JUST PUT ONE HAND ON SHOULDER TO RESTRICT ITS MOVEMENT. AND NOW THE OTHER SIDE. THANK U. THIS TESTS ROTATION.
TO EXAMINER:
THERE IS LOSS OF CERVICAL EXTENSION.
TO PT:
NOW I WOULD LIKE TO PERFORM WALL TEST. PLZ STAND WITH UR BACK AGAINST THE WALL. HEELS, BUTTOCKS, SCAPULA AND OCCIPUT MUST ALL TOUCH WALL SIMULTANEOUSLY.
TO EXAMINER:
THE WALL TEST IS POSITIVE AS REDUCTION IN SPINE EXTENSION MAKES ABOVE IMPOSSIBLE.
TO PT:
NOW I WULD LIKE TO TEST FOR IRRITATION OF ROOTS OF SCIATIC NERVE WITH THE STRAIGHT LEG RAISING TEST (SLR).
PLZ LIE DOWN COMFORTABLY STRAIGHT ON THIS BED. CAN U PLZ STARIGHTEN UR LEG.? LET ME JUST LIFT IT. WATCH PTS FACE. PLZ LET ME KNOW WHEN U FEEL PAIN.
ACT: KEEPING KNEE STRAIGHT LIFT LEG BY HEEL.
TO PT:
PLZ LET ME KNOW WHEN U FEEL BACK OR LEG PAIN.
FIG 31 PG 135 MC RAE
NOTE:
BACK PAIN SUGGESTS CENTARL DISC PROLAPSE WHILE LEG PAIN SUGGESTS LATERAL PROTRUSION.
TO PT:
NOW WITH THE STRAIGHT LEG STILL RAISED, I AM JUST GOING TO BEND UR FOOT FORWARDS (TOWARDS UR LEG). PLZ LET ME KNOW IF IT INCRESES PAIN.
ACT:
PASSIVELY DORSIFLEX FOOT.
NOTE:
THIS INCREASES TENSION ON NERVE ROOTS INCREASING PAIN.
FIG 33 PG 135 MC RAE
TO EXAMINER:
SCIATIC NERVE IS NOT INVOLVED AND THERE IS NO EVIDENCE OF PROLAPSED INTERVERTEBRAL DISC.
TO PT:
THANK U SIR. U MAY WEAR UR TROUSERS. LET ME HELP U WITH IT. THANK YOU AGAIN.
TO EXAMINER:
TO COMPLETE MY EXAMINATION I WOULD LIKE TO EXAMINE CHEST (AS CHEST EXPANSION IS DECREASED BC OF INVOLVEMENT OF COSTOVERTEBRAL JOINTA), DO A FULL NEUROLOGICAL EXAMINATION OF LEGS, CHECK FEMORAL PULSES TO EXCLUDE VASCULAR CAUSE, EXAMINE ABDOMEN AND PERFORM DRE TO EXCLUDE INTRA ABDOMINAL AND PELVIC PATHOLOGY THAT MAY CAUSE BACK PAIN.
ALSO I WOULD LIKE TO CHECK ESR AND AP AND LATERAL THORACIC AND LUMBAR SPINE XRAYS.
DIAGNOSIS IS ANKYLOSING SPONDYLITIS.
I WOULD LIKE TO WASH MY HANDS.
FOR DIAGRAM: APLEY PG 58.
