CLIN NEURO Lower Limb Exam Flashcards
Process of peripheral NEURO exam.
- HH
- Greet pt
- Introduce yourself
- Identify pt
- Explanation of examination
- Discuss exposure
- Consent & confidentiality
- Ask if the pt is currently in any pain/discomfort
- Ask pt to properly exposure the area you want to examine
- General Inspection
a. Pain
b. Aids
c. Gait
d. General appearance
e. Presence of any abnormal movements
f. Posture - Gait – walk beside pt & check for loss of balance at t.p.s.
a. Ask pt to walk
i. A few metres
ii. Heel to toe
iii. On tiptoes S1
iv. On heels L4, 5 - Look
a. Skin changes
b. Gait
c. Arm drifting
i. Closed eyes
ii. Extended & supinated arms
d. Muscle bulk/wasting
e. Fasciculation
f. Abnormal movements/tremor/spasm/dystonia/chorea/hemiballismus
i. Ask if intermittent/constant. - Feel
a. Fasciculations
i. Tap lightly over muscles (i.e., quadriceps/calves). - Motor System Assessment
a. Proximal Muscle Strength Assessment
i. Ask pt to rise & stand from squat w/out assistance
b. Romberg’s Test – remain beside the pt at all times
i. Ask pt to stand w feet close & arms by their sides
ii. Watch if the pt sways when their eyes are open
iii. Ask the pt to close their eyes
iv. Watch if the pt sways
c. Trendelenburg Test
i. Inform pt that you will be standing behind them
ii. Ask pt to stand on one leg
d. Pull/Beam Test – be prepared to catch pt
i. Pt warning
ii. Stand behind pt
iii. Put your hands on their shoulders & pull back sharply.
e. Tone
i. Knee - Pulling heel up bed by knee
ii. Ankle - Turning foot around by ankle
f. Clonus
i. Patellar Clonus - Pt’s knee extended
- Hold pt’s patella btw thumb & index finger
- Sharply move patella downwards
- Repeat on the other knee.
ii. Ankle Clonus - Pt’s knee flexed
- Hip externally rotated
- Briskly dorsiflex pt’s foot.
- Repeat on the other ankle.
g. Power (do not assess at the same time unless underlined) – first ask pt to actively demonstrate movement you want to test and then apply resistive force
i. Hip - Abduction L4, L5, S1
- Adduction L2, L3, L4
- Flexion L2, L3
a. Ask pt to lift their leg off the body and not let you push it down with your hand on their knee. - Extension L4, L5, S1
a. Ask pt to keep their leg on the bed and not let you pull it up with your hand placed under the calf.
ii. Knee - Flexion L5, S1
- Extension L3, L4
a. Bridge under knee and stop you from bending it with your hand placed on their shin.
iii. Ankle - Plantar flexion S1, S2
- Dorsiflexion L4, L5
- Inversion L5, S1
- Eversion L5, S1.
iv. Big toe - Extension L5 (extensor hallucis longs mm).
h. Reflexes (need pt to relax)
i. Knee L3, L4 (w pt sitting & legs dangling/pt lying supine & knees bent/flexed and you squatting) - Strike patellar tendon just distal to patella w knee in bridge position.
- (Quadriceps contracts & leg extends in a kicking motion).
ii. Ankle S1, S2 (w pt lying supine, knee flexed & hip externally rotated) - Slightly dorsiflex pt’s foot
- Strike Achilles tendon
- If no reflex, tap over fingers when gripping toes of pt
- (Contraction of gastrocnemius & plantar flexion of the foot).
iii. Plantar reflex L5, S1, S2 - Inform pt you are scratching feet
- Hold pt’s ankle
- Nail of thumb/blunt key to stroke pt’s sole near its lateral border starting from the heel toward the metatarsal heads & curve medially along base of toes
- (Plantar flexion/Babinski sign involving great toe dorsiflexion & fanning of all toes).
a. NB: If no reflex, ask pt to clench teeth/jaw on count of 3.
i. Coordination (pt lying supine)
i. Heel-to-shin test (pt lying supine) - Run heel on opposite knee and slide down shin towards ankle
- Repeat on either side at moderate pace
ii. Toe-to-finger test - Ask pt to lift their foot & touch your finger with their great toe
- Look for tremor
- Change position of finger
iii. Foot tapping test (pt sole of foot tap on your hand & their heel on their opposite shin) - Sensory System Assessment – of each dermatome w eyes closed
a. Pain – pinprick w neuro-tips
i. Reference point – top of chest
ii. Bilateral dermatomes
b. Temperature (w tuning fork)
i. Reference point – top of chest
ii. Bilateral dermatomes
c. Vibration – w 128 tuning fork
i. Reference point - forehead
ii. Bony prominence (e.g., DIP)
iii. Ask pt to say when it stops (corresponds to when you grip it) - If pt can’t feel than, keep moving more proximally.
d. Proprioception (always w pt eyes closed)
i. Isolate DIP and grasp on either side
ii. Tell pt what movement corresponds with up/down
iii. Ask pt if pointing up/down after series of random movements
e. Light touch – w wisp of cotton wool
i. Reference point - chest
ii. Bilateral dermatomes
f. Two-point discrimination – w paper clip
i. Use a clean paperclip.
ii. Reshape the paper clip so you can have the two endings ready to touch the patient’s skin simultaneously or with one end alone.
iii. Adjust the distance between the two ends as required. (e.g. 0.4 – 0.6 mm for the tips of the fingers and 3cm for plantar surface of the foot.).
iv. Switch between using the two ends and one single end as the stimulus for touching the skin.
v. As the patient to report whether one or two points is felt.
vi. Decrease or increase the distance as required and note the shortest distance the patient is able to feel 2 points.
vii. Complete for one fingertip & palm
viii. Repeat bilaterally - Examine lower back & spine.
- Redress.
- Explain findings/results.
- Ask if pt has questions.
- Thank pt.
- HH.
General Inspection
a. Pain
b. Aids
c. Gait
d. General appearance
e. Presence of any abnormal movements
f. Posture
Gait
i. A few metres
ii. Heel to toe
iii. On tiptoes S1
iv. On heels L4, 5
Abnormalities in heel to toe walking may be a result of
Cerebellar lesions.
Look
a. Skin changes
b. Gait
d. Muscle bulk/wasting
e. Fasciculation
f. Abnormal movements/tremor/spasm/dystonia/chorea/hemiballismus
i. Ask if intermittent/constant.
Feel
a. Fasciculations
i. Tap lightly over muscles (i.e., quadriceps/calves).
Motor System Assessment
a. Proximal Muscle Strength Assessment
i. Ask pt to rise & stand from squat w/out assistance
b. Romberg’s Test – remain beside the pt at all times
i. Ask pt to stand w feet close & arms by their sides
ii. Watch if the pt sways when their eyes are open
iii. Ask the pt to close their eyes
iv. Watch if the pt sways
c. Trendelenburg Test
i. Inform pt that you will be standing behind them
ii. Ask pt to stand on one leg
d. Pull/Beam Test – be prepared to catch pt
i. Pt warning
ii. Stand behind pt
iii. Put your hands on their shoulders & pull back sharply.
e. Tone
i. Knee
1. Pulling heel up bed by knee
ii. Ankle
1. Turning foot around by ankle
f. Clonus
i. Patellar Clonus
1. Pt’s knee extended
2. Hold pt’s patella btw thumb & index finger
3. Sharply move patella downwards
4. Repeat on the other knee.
ii. Ankle Clonus
1. Pt’s knee flexed
2. Hip externally rotated
3. Briskly dorsiflex pt’s foot.
4. Repeat on the other ankle.
g. Power (do not assess at the same time unless underlined) – first ask pt to actively demonstrate movement you want to test and then apply resistive force
i. Hip
1. Abduction L4, L5, S1
2. Adduction L2, L3, L4
3. Flexion L2, L3
a. Ask pt to lift their leg off the body and not let you push it down with your hand on their knee.
4. Extension L4, L5, S1
a. Ask pt to keep their leg on the bed and not let you pull it up with your hand placed under the calf.
ii. Knee
1. Flexion L5, S1
2. Extension L3, L4
a. Bridge under knee and stop you from bending it with your hand placed on their shin.
iii. Ankle
1. Plantar flexion S1, S2
2. Dorsiflexion L4, L5
3. Inversion L5, S1
4. Eversion L5, S1.
iv. Big toe
1. Extension L5 (extensor hallucis longs mm).
h. Reflexes (need pt to relax)
i. Knee L3, L4 (w pt sitting & legs dangling/pt lying supine & knees bent/flexed and you squatting)
1. Strike patellar tendon just distal to patella w knee in bridge position.
2. (Quadriceps contracts & leg extends in a kicking motion).
ii. Ankle S1, S2 (w pt lying supine, knee flexed & hip externally rotated)
1. Slightly dorsiflex pt’s foot
2. Strike Achilles tendon
3. If no reflex, tap over fingers when gripping toes of pt
4. (Contraction of gastrocnemius & plantar flexion of the foot).
iii. Plantar reflex L5, S1, S2
1. Inform pt you are scratching feet
2. Hold pt’s ankle
3. Nail of thumb/blunt key to stroke pt’s sole near its lateral border starting from the heel toward the metatarsal heads & curve medially along base of toes
4. (Plantar flexion/Babinski sign involving great toe dorsiflexion & fanning of all toes).
a. NB: If no reflex, ask pt to clench teeth/jaw on count of 3.
i. Coordination (pt lying supine)
i. Heel-to-shin test (pt lying supine)
1. Run heel on opposite knee and slide down shin towards ankle
2. Repeat on either side at moderate pace
ii. Toe-to-finger test
1. Ask pt to lift their foot & touch your finger with their great toe
2. Look for tremor
3. Change position of finger
iii. Foot tapping test (pt sole of foot tap on your hand & their heel on their opposite shin)
What does swaying w eyes closed & eyes opened during Romberg’s test indicate?
Cerebellar lesions.
What does swaying with eyes closed during Romberg’s test indicate?
Loss of proprioception.
What does the presence of clonus suggest?
Upper Motor Lesions (e.g., stroke, MS, cerebral palsy).
Sensory System Assessment.
a. Pain – pinprick w neuro-tips
i. Reference point – top of chest
ii. Bilateral dermatomes
b. Temperature (w tuning fork)
i. Reference point – top of chest
ii. Bilateral dermatomes
c. Vibration – w 128 tuning fork
i. Reference point - forehead
ii. Bony prominence (e.g., DIP)
iii. Ask pt to say when it stops (corresponds to when you grip it)
1. If pt can’t feel than, keep moving more proximally.
d. Proprioception (always w pt eyes closed)
i. Isolate DIP and grasp on either side
ii. Tell pt what movement corresponds with up/down
iii. Ask pt if pointing up/down after series of random movements
e. Light touch – w wisp of cotton wool
i. Reference point - chest
ii. Bilateral dermatomes
f. Two-point discrimination – w paper clip
i. Use a clean paperclip.
ii. Reshape the paper clip so you can have the two endings ready to touch the patient’s skin simultaneously or with one end alone.
iii. Adjust the distance between the two ends as required. (e.g. 0.4 – 0.6 mm for the tips of the fingers and 3cm for plantar surface of the foot.).
iv. Switch between using the two ends and one single end as the stimulus for touching the skin.
v. As the patient to report whether one or two points is felt.
vi. Decrease or increase the distance as required and note the shortest distance the patient is able to feel 2 points.
vii. Complete for one fingertip & palm
viii. Repeat bilaterally
What does muscle wasting suggest?
Disuse or lower motor neuron lesion.
What does hyporeflexia/absent reflexes suggest?
Lower motor neuron lesion.
Distance of two-point discrimination fingers vs plantar foot
0.4 – 0.6 mm for the tips of the fingers and 3cm for plantar surface of the foot.
Babinski reflex suggests what kind of lesion?
Upper motor neuron lesion.
