Examination of the Back

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Note this is most likely going to be an ankylosing spondylitis examination. A relevent stem would be "This patient has had lower back pain and stiffness for 10 years, please proceed to the clinical examination"

Steps:

1. Wash hands
2. Introduce yourself to the patient and thank the patient
3. Place your case down, take out your stethescope (to listen for apical fibrosis and aortic regurgitation) and measuring tape (to perform the occiput to wall distance and modified shrober's test)
4. Remove the patient's gown exposing their spine
5. Inspect the patients shoes, make a show of inspecting the patient's walking aides if present
6. Inspect patient from the front, then from each sides, then from the back
   1. Clues include question mark posture, note loss of lumbar and cervical lordosis and exagerated thoracic kyphosis
   2. Patient may have features of cushing's syndrome
   3. Make sure you trace out the presence of an observed scoliosis (simple = C shaped, compound = S shaped)
7. Ask the patient if they are able to walk. If not ask the bull dog to help
8. Walk the patient, then make sure they walk on their heels and then their toes (testing lower limb strength)
9. Measure the occiput to wall distance
10. Perform the modified shober's test looking for loss of lumbar flexion
    1. Palpate the posterior superior iliac spine and locate dimples of venus
    2. Measure 5 cm below and 10 cm above with a measuring tape
    3. Ask the patient to lean forward as much as they can to try and touch their toes
    4. An increase of less than 5 cm in the distance between the two points indicates limitation of lumbar flexion
11. Palpate their entire spine for tenderness and muscle spasm
12. Palpate the sacroiliac joints
13. Measure lumber extension
14. Measure lumbar lateral flexion
15. Sit the patient at te end of the bed
16. Measure Thoracic rotation with the patient sitting at the bed
17. Measure chest expansion posteriorly
18. Measure cervical anterior posterior flexion extension
19. Measure cervical lateral flexion extension
20. Measure cervical rotation
21. Perform a screening hands examination
22. Inspect the nails and hands for deformities consistent with psoriatic arthropathy (shich can cause axial problems)
23. Inspect ear lobes and behind the ear for psoriatic scars
24. Inspect eyes for iritis and offer to perform a slit lamp examination to look for signs of anterior uveitis
25. Look in mouth for ulcers
26. Auscultate lung fields for apical fibrosis
27. Perform a limited cardiovascular examination looking for aortic regurgitation (RSE, LSE)
28. Move to the lower limbs and expose them adequately
29. Perform a screening examination of the hips, knee joints and ankles
30. Press directly on the anterior superior iliac spine on each side and apply lateral pressure to attempt to separate them to ilicit pain of sacroilitis
31. Palpate achilles for nodules and insertion point for evidence of enthesitis
32. Palpate plantar fascia insertion at heel for tenderness
33. Perform the MTP squeeze test
34. Turn to the examiner and tell them that you would like to complete the examination by examining all the peripheral joints and perform a detailed examination of the lower limbs
35. Cover and thank the patient