OnExam

Inspection

  • Generally inspect patients in standing and sitting positions. Examine patients from an anterior, posterior and lateral angle
  • Note
    • Gait
    • Posture and alignment
      • Lateral: alignment of ear, shoulder, hip, knee and malleolus
      • Posterior: alignment of spinous processes and paravertebral muscles
    • Muscle atrophy, hypertrophy, spasm, fasiculation or increased tone (eg. torticollis) and trigger point locations
    • Note integumentary findings (lesions, sinus tracts, tufts of hair, signs of trauma, etc.)
    • Measure leg length with the true leg length test
  • Cervical Spine
    • Note cervical curvature
      • Postural deformities (head forward/loss of cervical lordosis)
    • Landmarks: C7/T1 most prominent spinous process
  • Thoracic Spine
    • Note thoracic curvature
      • Postural deformities (increased kyphosis, scoliosis)
    • Shoulder height and symmetry
    • Scapulae (resting position, winging, anterior shoulder posture/abducted scapula)
    • Height (spinal level) where hands hang
  • Lumbosacral Spine
    • Note lumbar curvature
      • Postural deformities (increased lumbar lordosis, flattening)
    • Landmarks: Posterior superior iliac crest (L4 vertebrae), PSIS/sacral dimples (S2 vertebrae)
    • Gluteal fold height and symmetry
    • Iliac crest height and symmetry
    • Approximate leg length discrepancy

Palpation

  • Generally note any areas of pain, swelling, spasm, atrophy, deformity or crepitus when palpating:
  • Cervical Spine
    • Each spinous process C2-C7
      • Note any step-offs
      • Tenderness: fracture, infection, arthritis, metastatic disease
    • Facet joints deep in the trapezius muscle C2-C7
    • Paravertebral muscles
    • Trapezius muscle
    • Sternocleidomastoid
  • Thoracic Spine
    • Each thoracic spinous process T1-T12
      • Note any step-offs
      • Tenderness: fracture, infection, arthritis, metastatic disease
    • Facet joints deep in paraspinal muscles T1-T12
    • Paravertebral muscles
    • Scapulae
      • Place hand on each scapula when approaching the patient posteriorly. Have patient flex thoracic spine to 45 degrees, if height of hands becomes asymmetrical it is suggestive of scoliosis

Percussion

  • Percuss each vertebrae with the hypothenar aspect of a closed fist to detect possible malignancy, degenerative disease or osteomyelitis
  • Malignancy
    • Post-test probability if positive: 86%
    • Specificity for malignancy: 60%
  • Osteomyelitis
    • Post-test probability if positive: 10.0% (LR+ = 2.1)
    • Post-test probability if negative: 1.2% (LR- =0.2)

Range of Motion

  • Cervical Spine
    • Forward flexion (normal= 45°), "chin to chest"
      • Assesses for MS, cervical nerve impingement and B12 deficiency
    • Extension (normal= 50°), "look up at ceiling"
    • Lateral bending (normal= 45°), "ear to shoulder"
      • Assesses for impingement of cervical root and radicular pain
    • Rotation (normal= 70°), "turn head from side to side"
  • Thoracic Spine
    • Note: stabilize hips
    • Forward flexion (20°-40°), "lean upper body forward"
    • Extension (normal= 30°), "lean upper body backwards"
    • Lateral bending (normal= 35°), "lean upper body side to side"
    • Rotation (normal= 30°), "rotate upper body from side to side"
  • Lumbosacral Spine
    • Foward flexion (variable), "touch toes"
    • Extension (normal= 30°), "bend backwards"
      • Have patients place hands on their hips for stability
    • Lateral bending (normal= 35°), "bend side to side"
    • Rotation (normal= 30°), "turn, looking over each shoulder"

Special Tests

References

  1. Baxter, S. & McSheffrey, G. (2010). Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. (2013). Bates Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
  3. Filate, W., Leung, R., Ng, D. & Sinyor, M. (2005). Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto; 2005.
  4. Hurley, K. (2005). OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  5. Pawa, J., Lesniak, D. & Lott, A. (2011). Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.