Examination of the Spine

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History Taking:

1 History Taking

Personal History:

2 Name Age Sex Occupation Residence Marital state, number of children Menstrual history in some cases Special habits of medical importance (e.g. smoking: number of cigarettes & duration) Social history Personal History

Complaint::

3 In the patient’s own words & duration Complaint:

History of the present illness:

4 Symptoms are analyzed in relation to each other and chronologically. Onset : Sudden ,acute or gradual. Course: - Progressive - Stationary - Regressive - Fluctuating - Responce to Tx Negative information in some cases may be important e.g. central chest pain not related to effort Review of other systems History of the present illness

Past history::

5 Previous illness Drugs Pregnancies. Family history: Similar disease DM Hypertension Allergy Trauma Surgery Blood transfusion Travel abroad Radiotherapy Past history:

Example of a symptom’s analysis:

6 Pain : ask about 1-Site: Midline pain arise from single structure ( heart -liver- pancrease -GIT). Localized or diffuse Diaphragmatic pleura --> tip of shoulder Myocardial ischemia --> retrosternal, Lt arm, Lt shoulder 3-Character of pain: aching, colicky, stabbing, burning……. 2- Radiation : Example of a symptom’s analysis

Pain (cont .):

7 4-Severity of pain 5-Duration: e.g. - Trigemimd neuralgia ( seconds) - Intestinal colic (minutes) 6-Frequency & Periodicity 7-Time of occurence: e.g. Morning headache in migraine & HTN After rising in frontal sinusits. At the end of the day in tension headache Pain (cont .)

Pain (cont .):

8 8- Aggravating factors : e.g. swallowing in esophagitis 9- Relieving factors: e.g. stop walking in ischemic pain 10-Associated phenomena: e.g. marked swaeting in cardiac pain Pain (cont .)

General Examination:

9 General Examination

Routine Data or Vital Signs ::

10 Temperature Pulse Blood pressure Respiratory rate Routine Data or Vital Signs :

Radial Artery:

11 Radial Artery

Pulse Examination:

12 Pulse Examination

Sphygmomanometer cuff:

13 Sphygmomanometer cuff

Length of the cuff:

14 Length of the cuff

Stethoscope:

15 Stethoscope

Brachial Artery:

16 Brachial Artery

BP measurement:

17 BP measurement

Temperature:

18 Normal: 36 .5 - 37.2 0 c -Diurnal variation -Age -Menstrual cycle variation Fever: T> 37.4 0 c -Infection -Tissue injury Temperature

Hyperpyrexia:T> 41.50c:

19 Neoplastic causes Collagen diseases Drugs Endocrine causes CNS causes Hyperpyrexia :T> 41.5 0 c

Hypothermia::

20 Shock. Hypothyroidism Panhypopituitarism Starvation Damage to anterior hypothalamus Old age Drugs e.g. phenothiazine Hypothermia:

Types of fever:

21 Types of fever Continuous Fever: Day & night changes < 1 0 C -Pneumonia -Meningitis Relapsing Fever: Brucellosis- spirochaetal relapsing fever- Bel Epstein fever (Hodgkin’s disease)- charcoat fever (biliary obstruction) Intermittent Fever: reaches base line during day - Malaria Remittent Fever : variation > 1 0 C -Septic conditions

Color changes:

22 Color changes Normal complexion depends on:- Thickness of skin Edema and Myxoedema  pallor Vascularity , Hb Reduced Hg > 5 gm  cyanosis Presence of pigments . Bilirubin ++ --> jaundice Caroten causes yellowish discoloration

Pallor:

23 Pallor Look for mucous membrane in inner aspect of lips Hb < 6 gm/dl --> pale palmar creases Causes of pallor: Anemia Anxiety Shock Edema

Cyanosis:

24 Bluish discoloration -Central ~~~ lateral aspect of under surface of the tongue (warm hands) -Peripheral ~~~ extremities (cold hands) D.D of central cyanosis: ++ methemoglobin N.B red cyanosis is due to CO poisoning Cyanosis

Cyanosis:

25 Cyanosis

Body Built1:

26 Body Built (weight & Hight) BMI = BW (kg) / Ht (m 2 ) Normal Over weight Obese Morbid Obesity 20-25 25-30 30-40 >40 Body Built 1

Body Built2:

27 Factors affecting the body built : Racial Familial Genetic Endocrine Malnutrition in young age Child hood disease. Body Built Body Built 2

Decubitus : :

28 Rigid dorsal decubitus Lateral decubitus Coild up Opisthotonus Orthopnea prayers posture Squatting Tri Pod position Decubitus :

Tri Pod position:

29 Patient with emphysema bending over in Tri-Pod Position Tri Pod position

Examination of the HEAD & FACE:

30 Examination of the HEAD & FACE

HEAD & FACE:

31 Head : Face : Size Shape Localized swelling Expression Edema and swelling Complexion Color change ( pallor - cyanosis - jaundice) Individual organs Asymmetry Malar flush ------ HEAD & FACE

Facial swelling causing asymmetry:

32 Facial swelling Facial swelling causing asymmetry

Facial swelling:Rt periorbital:

33 Facial swelling:Rt periorbital

Normal Eye:

34 Normal Eye

Jaundice:

35 Jaundice

Jaundice2:

36 Jaundice2

Eye Lids:

37 Edema Xanthelasma Dark ring Ptosis 3rd nerve paralysis - Horner’s syndrome Myathenia gravis Congenital retraction Thyrotoxicosis Eye Lids

Edema of the eye lids:

38 Edema of the eye lids

Eye ball:

39 Exophthalmus: Congenital Local condition Cavernous sinus A.V aneurysm Thyrotoxicosis Enophthalmus: dehydration ----- Eye ball

Pupils:

40 Pupils : size – equality - light reaction Small pinpoint pupils Mid position fixed pupil: (4-6mm) slightly dilated with no light reaction  Mid brain damage Bilateral small pupils Unilateral ( 1- 2.5 nm ) < 1mm Sympath. Damage Hypothalamic Metabolic pontine Hge Drugs: morphine, heroin , narcoti Horner syndrome Pupils

Horner syndrome:

41 Horner syndrome

Pupils2:

42 “Large” dilated pupils anoxia Bilaterally dilated pupils (fixed): drugs (atropine - phenothiazine- tricyclic antidepressants) (Reactive) Unilaterally dilated pupil ( Fixed dilated) Oculomotor paralysis Temporal lobe herniation ---Mid brain . Cocaine Amphetamine, LSD (Sympath. Agonists ) Pupils 2

Conjunctiva:

43 Hemorrhage Subconjunctivl haemorrage with severe cough Hypertension Septicaemia Bleeding tendency Conjunctiva Chemosis: edema

Conjunctivitis:

44 Conjunctivitis

Sclera:

45 Sclera Scleritis Episcleritis

Scleritis:

46 Scleritis

Nodular Episcleritis in a patient with CD:

47 Nodular Episcleritis in a patient with CD

Cornea:

48 Nose Ear Cornea Tophi Discoloration Cyanosis Ochronosis Dischrge

Parotid glands:

49 Unilateral enlargement as in acute parotitis Bilateral enlargement as in Sjogren Syndrome Parotid glands

Unilaterally enlarged parotid:

50 Unilaterally enlarged parotid

Mouth: Lips:

51 Color Angular stomatitis Chelitis Hypertrophy Herpes labialis Acromegaly Telangiectasia Myxoedema Trauma Angioedema Mouth: Lips

Breath:

52 Fetid breath (Fetor oris) Breath Alcohol Acetone : D.K.A Ammonia ---> uraemia Fetor hepaticus Local oral condition pyorrhea Suppurative lung syndrome Pyloric obstruction

Mouth : Dryness and increased salivation:

53 Dehydration Mouth breathing Anxiety Drugs, e.g. anticholinergics Sj ö gren syndrome Causes of Dry Mouth Ptyalism: increased salivation Mouth : Dryness and increased salivation

Normal oral cavity:

54 Normal oral cavity

Left peritonsillar abscess:

55 Left peritonsillar abscess

Teeth:

56 Loose teeth: - D.M - Hyperparathyroidism Wide spaced teeth: acromegaly Discoloration: Teeth Tobacco Poor oral hygiene Flourosis xxxxx

Tooth abscess:

57 Tooth Abscess Tooth abscess

Gums:

58 Pyorrhea Bleeding as in: Gums Hypertrophy as in: Addison Heavy metal ( lead and bisthmus) poisoning Drugs like epanutin Monocytic leukemia Pigmentation as in: Chronic liver disease Thrombocytopenia

Tongue1:

59 color Tongue 1 pale Bright red ( firy tongue- pellagra) Atrophic glossitis ( iron  , B12 , riboflavin  - pellagra) Black --> iron mixture coated --> dehydration Strawberry tongue scarlet feve Leukoplakia: precancerous Pigment : Addison’s disease

Tongue2:

60 Dry tongue (see causes of dry mouth) Scrotal tongue (mongolism) Tremors Tongue 2 Large tongue (macroglossia) as in acromegaly Anxiety Smoking Parkinsonism Chronic Alcoholism

Buccal mucosa1:

61 Buccal mucosa 1 Stomatitis (Red, swollen& tender) Catarrhal Ulcerative Monilia Aphthous Vincent’s angina Pigmentation Dark skinned Addison disease Intestinal polyposis Arsenic Hemochromatosis

Buccal mucosa2:

62 Buccal mucosa 2 Enanthema : Koplik’s spots Petechial Hge: Infective endocarditis - leukaemia Palate: Tonsils Deformity Paralysis Vesicles

Neck:

63 Neck Insepction Palpation Lymph Nodes Salivary glands Thyroid other swellings Deformity Asymmetry Position Limitation of movement Pulsations

Thyroid gland:anatomy:

64 Isthmus Thyroid gland:anatomy

Palpation of the thyroid gland:posterior approach:

65 Palpation of the thyroid gland:posterior approach

Palpation of the thyroid gland:anterior approach:

66 Palpation of the thyroid gland: anterior approach

Neck veins:

67 Jugular Vein Carotid Artery No pulsations palpable. Palpable pulsations. Pulsations obliterated by pressure above the clavicle. Pulsations not obliterated by pressure above the clavicle. Level of pulse wave decreased on inspiration; increased on expiration. No effects of respiration on pulse. Usually two pulsations per systole (x and y descents). One pulsation per systole. Prominent descents. Descents not prominent. Pulsations sometimes more prominent with abnominal pressure. No effect of abdominal pressure on pulsations Neck veins

Cervical lymph nodes:

68 Cervical lymph nodes

Examination of Axillae:

69 Examination of Axillae Lymph nodes Any swelling

Examination of the axilla1:

70 Examination of the axilla 1

Axillary lymphadenopathy:

71 Axillary lymphadenopathy

Examination of the axilla2:

72 Examination of the axilla 2

Examination of the Breast :

73 Examination of the Breast Gynecomastia: Physialogicl Drugs Liver cell failure Klinefelter Testiculr atrophy and tumors Adrenal tumors Estrogen Spironolactone Chloropromazine

Epitrochlear LN:

74 Epitrochlear LN

Examination of the Upper Limbs:Edema:

75 Examination of the Upper Limbs:Edema

DVT of the right arm:

76 DVT of the right arm

Cellulitis of the upper limb:

77 Examination of upper limbs:Cellulitis Cellulitis of the upper limb

Cellulitis of the upper limb 2:

78 Cellulitis of the upper limb 2

Examination of Hands:

79 Examination of Hands Shape & Size Wasting of the muscles Signs of peripheral vascular disease Staining of nails: as in heavy cig smokers White nails uraemia - liver cell failure Splinter Hg S.A.B.E See also joint examination

Acromegaly:

80 Acromegaly

Peripheral Vascular Disease of the UL:

81 Peripheral Vascular Disease of the UL

Wasting of the thenar eminance:

82 Wasting of the thenar eminance

Nicotine staining:

83 Nicotine staining

Wrist: Ganglion:

84 Wrist: Ganglion

Skin1:

85 Skin 1 Pigmentation Texture Elasticity Thickness Striae Eruption

Skin2:

86 Skin 2 Pigmentation Generalized Locaalized Addison’s disease Pellagra Hemochromatosis Ochronosis Arsenic Cloasma Sun burn Post- inflammatory X-ray Neurofibromatosis Leucoderma: -Vitiligo -leprosy - SLE - Pityriasis versicolor

Skin3:

87 Skin 3 2-Texture: Dryness Sweating Dehydration Myxedema Anxiety Thyrotoxicosis Respiratory failure Hyroglycaemia Toxemia

Skin4:

88 3.Elasticity : cutis loxa - old age - progeria 4.Thickness : -Acromegaly - Elephantiasis - Occupational 5.Striae: Pregnancy Obesity Cushing’s syndrome Skin 4

Skin5:

89 6-Eruption: Skin 5 Distribution: distribution of sensory nerve HZ Arrangement: Morphology: Linear  lymphangitis Annular  psoriasis Serpiginous  Syphilis Irregular  urticria Monomorphic Pleomorphic Type: Macule- papule- nodule- plaque- vesicles- bullae- pustule - wheals - scales - crust – erosion - fissure- ulcers – scar - atrophy - sclerosis.

Skin6:

90 Dilated Blood vessels Skin 6 Petechie 1-2 mm (Hess test) Purpura: e.g. thrombocytopenia , Senile purpura Ecchymosis > 5 mm Collaterals Telangiectsia. Haemangioma Vascular spiders Campbell de Morgan spots

Telangiectasia:

91 Telangiectasia

Skin-Hair:

92 Fall of hair : Look for Distribution: {head, face, axillae, and pubis) Skin-Hair Hirsutism: excessive growth of body hair of a female Idiopathic Racial Endocrine: Cushing- adrenogenital syndrome- polycystic ovary. Endocrine: Myxoedem - Addison’s disease - Sheehan’s syndrome- Eunchiadism Infection Localized fall of hair: Alopecia areata

Lymph nodes1:

93 Lymph nodes 1 Group {cervical (superfacial and deep) , scalene (Lt virchow), axillary, epitrochlear, inguinal }. Size Consistency Tenderness Matting Mobility Relation to surrounding structures.

Lymph nodes2:

94 Lymph nodes 2 Lymphadenopathy: Localized : Acute lymphadenitis T.B Hodgkin’ disease Generalized: Viral : glandulr fever Leukemia . Lymphoma Syphilis Sarcoidosis

Examination of the Lower Limbs:

95 Examination of the Lower Limbs

Peripheral pulsation :Dorsalis pedis:

96 Peripheral pulsation :Dorsalis pedis

Peripheral pulsations :Dorsalis pedis 2:

97 Peripheral puls ations :Dorsalis pedis 2

Peripheral pulsations :post tibial artery:

98 Peripheral pulsations :post tibial artery

Peripheral pulsations :posterior tibial artery2:

99 Peripheral pulsations : posterior tibial artery 2

Popliteal artery:

100 Popliteal artery

Acute vascular insufficiency:mottled appearance:

101 Acute vascular insufficiency: mottled appearance

Chronic arterial insufficiency:

102 Chronic arterial insufficiency

Digital gangrene:

103 Digital gangrene

Chronic Venous Insufficiency:

104 Chronic Venous Insufficiency

Neuropathic ulcer in a diabetic patient:

105 Neuropathic ulcer in a diabetic patient

Lower limbs: edema1:

106 Inspection Pressure over bony prominance for 5 to 30 sec just behind and below medial malleoli and sacrum For soft tissue edema: Lower limbs: edema 1 pinching  dimpling of skin ( Peou’d ‘orange) press with the stethoscope

Lower limbs:Edema2:

107 Edema may be: Lower limbs:Edema 2 Hard as in chronic. lymphatic obstruction. Soft Causes of Soft Edema: Localized edema: Inflammtory (hot, red, tender)- Angioneurotic - DVT- Paralysis --> paralyzed side Generlized edema: Renal Cardiac Nutritional Hepatic

LL edema:

108 LL edema

Pitting edema of the lower limb:

109 Pitting edema of the lower limb

Erythema nodosum:

110 Erythema nodosum

Onychomycosis:

111 Onychomycosis

Genitalia and Joints:

112 Genitalia Joints : Swelling Deformity Overlying skin Tenderness Atrophy of muscles Limitation of movement Hypermobility Eruption Genitalia and Joints

Rheumatoid arthritis:

113 Rheumatoid arthritis

RA: boutonniere finger:

114 RA: boutonniere finger

Rheumatoid arthritis 2:

115 Rheumatoid arthritis 2

Heberdens nodes:

116 Heberdens nodes Heberdens nodes

Gout: MCP joints:

117 Gout: MCP joints

Leprosy:

118 Leprosy

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