Case 5 | Examination

General inspection

 

Muscular build, in obvious pain.

 

Observations

Pulse 50 reg.

BP 145/65.

Temp 36.1o

 

Back Inspection

Posterior – Obvious list of the lower back to the left.

Lateral – Loss of lumbar lordosis.

Gait – Pain on walking, but demonstrates good control.

 

Palpation

Pain on palpation of left sided paraspinal musculature.

No pain in midline or sacroiliac joints.

 

Movement

Modified Schobers Test for flexion:  5 cm but with pain.

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

5

5

Ankle plantarflexion

5

5

Great toe dorsiflexion

5

5

Great toe plantarflexion

5

5

 

 

 

Sensory

Normal.

 

Co-ordination

Normal.

 

Reflexes

Ankle – normal

Knee – normal

 

 

Nerve tension tests

Straight leg raising

Negative.

Lasegue’s test

Negative.

Bowstring test

Negative.

Femoral nerve stretch test

Negative.

 

 

Other Relevant Examinations

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

Peripheral pulses  -  Intact.

 

Abdominal examination– Normal.  No AAA or palpable bladder.