Anamnesis & Physical Examination of Spine & Extremities
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Transcript of Anamnesis & Physical Examination of Spine & Extremities
ANAMNESIS & PHYSICAL EXAMINATION
OF SPINE & EXTREMITIES
Fahmi Sisindra
June 2015
Anamnesis Pain (nyeri) Stiffness (kekakuan) Swelling Trauma Instability Weakness
(kelemahan) Loss of function
(hilangnya fungsi)
Deformity Other relevant
symptoms:Color changesNeurologic
disturbancesSystemic illnessFatigueSleep disturbanceDepressionFear
Pain
Aching pain (worse / better) Radiating pain (regio gluteus menjalar
ke genu s/d gastrocnemius susp. HNP)
Waking up at night due to pain
Degree of Pain Relation to Activity Relation to Analgetics
I Pain on vigorous activity
Over the counter drugs
II Pain walking outdoors
NSAIDs
III Pain walking indoors
Combine analgetics
IV Pain at night No response to analgetics, only
opiatesV Pain all the time
Pain severity
Deformity & Weakness
Activity daily living (ADL)? Difficulties:
Placing objects (menempatkan benda)Climbing stairs (naik tangga)
Neurologic abnormality? Loss of bowel or bladder function?
(gangguan BAB / BAK)
History (riwayat) Family history / Social history:
Social economyEmploymentFriends and familyRecreationSports
Trauma history:Chief complaint (keluhan utama)Mechanism of injury
Past history:Previous injuryPrevious operationMusculoskeletal diseasesPrevious general condition related to the
complaint (riwayat medis yg berhubungan dgn keluhan)
Guide for anamnesis
1. Introduce yourself.
2. Make sure your hands are clean.
3. Sit down, listen to the patient without interupting for a few minutes.
4. Identify what the patient want.
5. Ask simple questions.
Physical Examination
Look Feel Move Special test (bila perlu)
Look
Symmetry or asymmetry Side by side comparison (perbandingan
sisi kanan & kiri)Wound (luka)Swelling (oedema)DeformityShortening (pemendekan, ex. # femur)Displacement/malalignment (ke posterior,
anterior, lateral, medial terhadap fragment proximal)
Feel
Tenderness (nyeri tekan) Temperature changes
hangat infection / inflammationDingin shock, kematian jaringan
(necrosis), inflamasi kronik. Crepitation (not recommended) Abnormal movement
Move
Range of motion (ROM)Gerakan sendi secara aktif, bila tidak bisa,
gerakkan sendi secara pasif.
Special Test
Gait examination (cara berjalan) Muscle power examination Neurologic examination Regional examination (sesuai status
lokalis)
Gait
Muscle Power
Look
Posture
Feel (spine)
Palpasi sepanjang tulang belakang, dari cervical s/d sacrum:Tenderness (nyeri tekan)InstabilityBony prominence (penonjolan tulang)Crepitation Scoliosis
ROM
Special Test
EXTREMITIES
Shoulder
Apprehension test
Shoulder
Arm & Elbow
Tennis Elbow
Golfer’s Elbow
Forearm & Wrist
Colles & Smith type #
Hand
Gamekeeper’s thumb
Ulnar Collateral Lig.
Hip
ROM
Knee (Genu)
ROM
Stability test
Thompson Test Achilles tendon
Foot & Ankle
Stability test
Thank you
T H A N K Y O U