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