Edna is a 70-year-old woman who just moved to Pittsburgh. She lives by herself, and suffers from chronic low back pain.
Edna's Health History
Edna's general health is good, with no weight loss, fever, or chills. She experiences normal urination and bowel movements.
- Lower back pain for three years. Edna says she was able to manage her pain at first and was able to do what sheeded to do. However, over the past six months, the pain has gotten much worse.
- Sitting, lying down, and taking warm baths help relieve her pain, although not for very long.
- Edna denies weakness with her pain, although she says the pain does make her feel tired.
- In addition to her back pain, Edna experiences pain in her right leg, but not both legs.
We need to learn more about Edna's health history. Let's begin by asking some questions.
QUESTION: You need to know more about Edna’s pain. How should you have her rate it?
QUESTION: A patient’s “pain signature is defined by limitations set by pain during specific activities. Pain might limit which of the following for Edna?
QUESTION: Edna’s chronic pain isn’t constant pain all the time. If it were, it could indicate which of the following?
QUESTION: Edna doesn’t complain of night pain, but many older adults do. If a patient says they wake up to night pain, what might be the cause?
Now that we've covered some health history questions regarding Edna's pain, we need to examine her. First, we'll perform a standing exam.
We need to check Edna's gait, spinal alignment, kyphosis, any leg length discrepancy, sacroiliac joints, and paraspinal musculature. We'll do so during the standing exam.
Standing Exam: Gait
Dr. Weiner asks Edna to walk back and forth across the examining room. Edna can be seen to clearly favor her right leg as she walks.
Standing Exam: Spinal Alignment
To check Edna’s spinal alignment, Dr. Weiner positions Edna standing with her back facing the viewer.
First, she pulls aside Edna’s exam gown to expose her back and notes that the exam should always be performed without clothing covering the patient’s back.
Second, Dr. Weiner visually examines Edna’s back and spine.
Third, Dr. Weiner places her left hand on Edna’s left scapula and her right hand on Edna’s right scapula and notes that Edna’s left scapula sits a little higher than her right scapula.
Fourth, Dr. Weiner positions her index finger and middle finger of her dominant hand, and physically traces Edna’s spine. Dr. Weiner notes Edna’s spine curves, an indication of scoliosis.
Standing Exam: Kyphosis
To check for symptoms of kyphosis, Dr. Weiner positions Edna in profile, perpendicular to the viewer, with her examining gown still exposing her back.
Dr. Weiner sweeps her hand down Edna’s back in a straight line, starting from the top of Edna’s spine, to see if any portions of the spine project further outward from the plane of the spine and back. Dr. Weiner notes no protrusions to indicate kyphosis in Edna.
Standing Exam: Leg Length Discrepancy
To determine whether Edna has functional leg length discrepancy, Dr. Weiner positions Edna with her back facing the viewer. Edna’s examining gown exposes her bare back and buttocks covered with undergarments, and bare upper legs.
Dr. Weiner places her hands around Edna’s sides, grasping lightly just above the iliac crest, with her thumbs pointing toward each other. Dr. Weiner then kneels down behind the patient to visually observe the effect of where her hands sit on Edna’s iliac crest by lining up her field of vision to Edna’s waist level. Dr. Weiner observes that her hands line up along Edna’s iliac crest, thereby indicating that Edna has no functional leg length discrepancy.
Standing Exam: Sacroiliac Joints
To examine Edna’s sacroiliac joints, Dr. Weiner positions her with her back to the viewer, with her back, waist, and buttocks exposed by the examining gown. Starting at eye level with Edna’s waist, Dr. Weiner tugs down Edna’s underwear about an inch to expose the sacral dimples, which are highlighted by the sacral dimples.
Dr. Weiner explains that if the sacral dimples cannot be found visually, the practitioner can locate the sacroiliac joints by placing each hand above Edna’s iliac crest on either side, with thumbs pointing toward each other.
By rotating the thumbs forty five degrees down, the sacroiliac joints can be located. To palpate the sacroiliac joints to discover whether the patient feels pain upon palpation, stand perpendicular to the patient, and brace them with an arm in front while using the opposite hand to palpate the sacroiliac joints. Edna shows no pain upon palpation.
Standing Exam: Paraspinal Musculature
To examine Edna’s paraspinal musculature, Dr. Weiner positions her with her back facing the viewer. Edna’s back is exposed by her examining gown. Dr. Weiner positions her hand flat with the palm facing Edna’s back, just below Edna’s scapula. She uses the first two fingers of her hand to palpate the muscle along Edna’s spine, while asking Edna if she feels any pain upon doing so. Edna denies any pain during palpation.
We need to check Edna's hip range of motion, piriformis musculature, iliotibial band, and perform Faber's Test. We'll do so during the lying exam.
Lying Exam: Hip Range of Motion
To perform the hip range of motion physical exam, Dr. Weiner has Edna lie down on an examining table. She walks to Edna’s left side to perform the test first on Edna’s non-painful left leg. Dr. Weiner lifts a light blanket that covers Edna and her examining gown to the knee to expose Edna’s left leg to the upper thigh.
Then Dr. Weiner grasps Edna’s upper calf, just under the knee with her left hand, supporting Edna’s calf with her left lower arm, while she bends Edna’s leg into a ninety degree angle at the knee and the hip.
Once positioned so, Dr. Weiner then gently pushes Edna’s lower leg toward the center of her body and asks if she feels any pain. Edna denies any pain. When Dr. Weiner repeats the same test on Edna’s right leg, Edna admits to pain within ten degrees of internal rotation, and cannot have the test continued.
Lying Exam: Faber's Test
To perform the hip range of motion physical exam, Dr. Weiner has Edna lie down on an examining table. She walks to Edna’s left side to perform the test first on Edna’s non-painful left leg. Edna is directed to take her left heel and place it just above her right knee, while she lies on an examining table. Then, Dr. Weiner tells Edna to let her leg fall back toward the examining table while her left heel still rests above her right knee. Dr. Weiner asks Edna if she feels any pain while doing so. Edna denies any pain. Therefore, Faber's test is negative.
Lying Exam: Piriformis Musculature
To perform the exam for piriformis musculature, Dr. Weiner asks Edna to bend her left knee as she lies on an examining table, and cross her left leg over her right after she bends the knee. While Edna stays in this position, Dr. Weiner places her right hand on Edna’s pelvis to stabilize it, and using her left hand, gently pushes Edna’s left knee toward the right to prepare for palpation by stretching out the piriformis musculature.
Lying Exam: Iliotibial Band
To perform the iliotibial band exam, Dr. Weiner examines Edna’s non-painful left leg while Edna lies on an examining table. She places both hands, palms down, on the lateral aspect of Edna’s thigh.
Using her thumbs, Dr. Weiner firmly presses down along the iliotibial band for the entire length of the lateral aspect of Edna’s thigh.
She asks Edna if she feels any pain while doing so. Edna denies any pain, giving a negative result for iliotibial band pain.