Fahmi Sisindra

ANAMNESIS & PHYSICAL

EXAMINATION OF SPINE
& EXTREMITIES
June 2015

Anamnesis

Pain (nyeri)
Stiffness (kekakuan)
Swelling
Trauma
Instability
Weakness
(kelemahan)
Loss of function
(hilangnya fungsi)

Deformity
Other relevant
symptoms:

Color changes
Neurologic

disturbances
Systemic illness
Fatigue
Sleep disturbance
Depression
Fear

Pain

Aching pain (worse / better)

Radiating pain (regio gluteus menjalar
ke genu s/d gastrocnemius susp.
HNP)
Waking up at night due to pain

Pain severity
Degree of Pain

Relation to Activity

Relation to
Analgetics

Pain on vigorous
activity

Over the counter

drugs

II

Pain walking
outdoors

NSAIDs

III

Pain walking
indoors

Combine
analgetics

IV

Pain at night

Pain all the time

No response to
analgetics, only
opiates

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 economy
Employment
Friends and family
Recreation
Sports

Trauma history:
Chief complaint (keluhan utama)
Mechanism of injury

Past history:
Previous injury
Previous operation
Musculoskeletal diseases
Previous general condition related to the

complaint (riwayat medis yg berhubungan

dgn keluhan)

Guide for anamnesis

1.
2.
3.
4.
5.

Introduce yourself.
Make sure your hands are clean.
Sit down, listen to the patient without
interupting for a few minutes.
Identify what the patient want.
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)
Deformity
Shortening (pemendekan, ex. # femur)
Displacement/malalignment (ke posterior,

anterior, lateral, medial terhadap fragment

proximal)

Feel

Tenderness (nyeri tekan)

Temperature changes
hangat infection / inflammation
Dingin 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)
Instability
Bony prominence (penonjolan tulang)
Crepitation
Scoliosis

ROM

Special Test

EXTREMITIES

Shoulder

Apprehension test

Shoulder

Arm & Elbow

Tennis Elbow

Golfers Elbow

Forearm & Wrist

Colles & Smith type #

Hand

Gamekeepers thumb

Ulnar Collateral Lig.

Hip

ROM

Knee (Genu)

ROM

Stability test

Thompson Test Achilles tendon

Foot & Ankle

Stability test

THANK YOU

Thank you