Case 4 | Examination

Examination

 

General inspection

Moderate build unsteady on feet while walking to examination couch.

 

Observations

Pulse 103 reg.

BP 171/70.

Temp 36.4o

 

Back Inspection

Posterior – Nothing obvious.

Lateral – Back held in flexion.

Gait – Unsteady.

 

Palpation

No bony tenderness.

No pain or swelling palpable in paraspinal musculature.

Movement

Modified Schobers Test for flexion:Limitedas flexion brings on pain in both legs.

Extension:  Normal.

Lateral movements:  Normal

 

Neurological examination

Motor power

 

Power (Lower Limb)

RIGHT

LEFT

Hip flexion

5

5

Knee flexion

5

5

Knee extension

5

5

Ankle dorsiflexion

4

4

Ankle plantar flexion

4

4

Great toe dorsiflexion

3

3

Great toe plantar flexion

4

4

 

Sensory

Patchy loss of sensation bilaterally in lower limbs but not following a specific dermatomal distribution. 

Normal perianal sensation and anal tone.

 

Co-ordination

Normal.

 

Reflexes

Ankle – absent bilaterallly.

Knee – normal.

 

Nerve tension tests

Not indicated as bilateral signs and multiple levels.

 

Other Relevant Examinations

Screening for hip problems - Full range of rotation, painless.

Peripheral pulses  -  Intact.

 

Abdominal examination - Palpable distended bladder.  Patient only feels minor discomfort on pressing.