Examination of the Back

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