Lower limb Flashcards
Explanation of examination
Preexam checks
WIPER QQ -wash hands -introduce yourself -patient ID -explanation I'd like to examine your legs, this will involve an assessment of your muscles, sensation and reflexes -repositioning - standing and lying -questions - do you have any questions? are you happy for me to start my examination? do you have any pain or stiffness in your legs?
General inspection
- bedside
- patient
Bedside - mobility aids, orthotics, prescriptions
Skin
- scars
- pale/cyanosed/red, shiny, dry skin => autonomic loss?
- injuries, ulceration, rashes?
Joints
-deformities => proprioception loss? (Charcot’s joints of feet?)
Muscles
- wasting => motor loss?
- fasciculations => LMN sign?
- tremor, tics, chorea, clonus?
Walking
- gait
- stance, stability, arm swing, step, turning
- heel toe walking, stand on heels, toes
- Romberg
Gait
Hemiplegic - leg circumduction (extension) + elbow and wrist flexion => post stroke (due to ULF, LLE being stronger)
High steppage (foot slapping) - foot drop
Myopathic - waddling gait, promixal muscle weakness
Stance - wide base => cerebellar? Stability - unsteady => something is wrong Arm swing - loss => early PD sign Step - shuffling, festination => PD Turning - difficulty => PD
Heel toe walking - cerebellar ataxia
Stand on heels, toes - cerebellar, neuropathy, myopathic weakness
Romberg - eyes closed, exaggerated sway
-hold your arms infront and behind patient to steady them if they fall
Tone
- how would you assess this
- what are you looking for
Leg roll - foot loosely rotates
- too floppy - LMN
- too rigid - UMN
Leg raise from knee - foot stays on bed
-foot leaves bed => UMN
Support bended knee
-rapid dorsiflexion, foot eversion and hold => 5 rhythmic clonic mv
Compare each side
Power
Legs flat on bed, stabilise joint above
L1-2, L5-S1
Hip flexion, extension
-straight leg - push down/up on thigh
L3-4, L5-S1
Knee flexion, extension
-bent knee - push and pull leg
L4-5, S1
Ankle flexion, extension
-push against plantar, dorsal foot
Big toe extension - L5
-push down on big toe
How would you grade power
5 - normal 4 - active movement against gravity and resistance 3 - active movement against gravity 2 - active movement without gravity 1 - flicker/trace contraction 0 - no contraction
Reflexes
Knees L3-4
- bend knee, support their weight
- tap patellar tendon
- normal reflex causes quadricep contraction
Ankle L5-S1
- bend knee, dorsiflexed ankle resting on other shin
- tap Achilles tendon
- normal reflex causes gastrocnemius contraction and foot jerk in plantar direction
Plantar (Babinski)
-abnormal => fanning of toes, +ve
Coordination
Heel shin test
-lifting leg up from ankle => knee
-fast as possible
Repeat with opposite leg
Sensation
- light touch - dorsal
- pain - spinothalamic
Close eyes
Light touch - dorsal
-touch chest with cotton - central sensation
-dermatomal, alternate between legs
Pain - spinothalamic
- warn patient that you will use neurotip
- if suspecting peripheral neuropathy, test distally first and move proximally
Vibration - dorsal
Close eyes
128Hz on sternum - central sensation
Big toe ICP
-confirm if they feel the vibration and when it stops
If vibration sense impaired, test more proximal joints
Proprioception - dorsal
Close eyes
Hold sides of big toe
Familiarise with up and down
Ask them to identify up and down positioning
If proprioceptive sense impaired, test more proximal joints
Further examinations
Exam
-Upper motor, cranial, cerebellar
Testing
-Blood for diabetes
