Lower Limb

Question 1

General inspection

Answer 1

Walking aids, pain etc

Question 2

Inspection

Answer 2

Gait 
S
W
I
F - tapping on wasted muscle may elicit 
T - fast or slow? fine or coarse?

Question 3

Tone

Answer 3

Roll leg from side to side - watch for foot movements
Lift knee slowly and then quickly - if foot lifts off couch there is increased tone, if this is with quick movements there is spasticity
Clonus - rapidly dorsiflexion and look for clonus (spasticity). > 4/5 beats is pathological and suggests UMN pathology

Rigidity is increased tone that feels equal through all speeds of passive movements

Question 4

Power

Answer 4

Hip flexion (L1/ L2/ L3) and extension (L5/S1)
Knee flexion (L5/S1) and extension (L3/L4)
Ankle dorsiflexion (L4/L5) and plantarflexion (S1/S2)

Question 5

Sensation

Answer 5

Pin prick (superficial pain) - test in dermatomal pattern, compare legs

Vibration (128 Hz) - test on sternum then on bony prominences asking patient to say when they feel it stop

Question 6

Reflexes

Answer 6

Knee (L3/L4) - quads contraction
Ankle (S1/S2) - calf muscle contraction
Plantar (S1) - look for initial reaction of big toe, UP IS ABNORMAL (babinski) - UMN

Question 7

Finish

Answer 7

Thank patient and wash hands

I would also like to..

Question 8

Spastic paraperesis = Bilateral UMN signs

Answer 8

Sagittal sinus lesion
Bilateral strokes
Cord trauma
Cord compression: extradural tumour, disc prolapse, spondylosis
Intrinsic cord disease: tumour, vascular myelopathy, MS

Question 9

Flaccid paraperesis = Bilateral LMN signs

Answer 9

Polio
Guillan-Barre
Lead poisoning
Charcot-Marie-Tooth

Question 10

Unilateral Leg Weakness

Answer 10

UMN: stroke, tumour, MS

LMN: root lesion, nerve lesion

Question 11

Peripheral Neuropathy

Answer 11

Mostly sensory: diabetes mellitus, uraemia

Mostly motor: Guillan-Barre, lead poisoning

Mixed: Charcot-Marie-Tooth, B12 / folate deficiency, thiamine deficiency, alcohol, vasculitis / SLE, paraneoplastic, amyloid

Question 12

Positive Rhomberg’s test (sensory ataxia)

Answer 12

Dorsal column loss: tabes dorsalis (syphilis), SCDC, MS,

Sensory peripheral neuropathy

Question 13

SCDC (B12 / folate deficiency)

Answer 13

Spastic paraparesis 
Upgoing plantars
Reduced knee jerks
Loss of ankle jerks
Dorsal column loss: loss of vibration sense, loss of joint position sense, sensory ataxia

Question 14

Foot drop

Answer 14

Common peroneal nerve palsy
Stroke
L4 / L5 lesion
MND
CMT syndrome