Lower Limb Neuro Exam Flashcards
1
Q
What are some upper motor neurone signs?
A
- Hypertonicity (spasticity)
- “Pyramidal” pattern of weakness
- Hyper-reflexia
- Ankle clonus
- Babinski positive
Potentially:
- Disuse atrophy
2
Q
What are some lower motor neurone signs?
A
- Muscle wasting
- Fasciculations
- Hypotonia
- Varying patterns of weakness
- Hyporeflexia or areflexia
- Normal or absent planter reflex
3
Q
What around the bed may suggest neurological problems?
A
- Wheelchair
- Walking aids
- Catheter
4
Q
What menmonic can help with a neuro visual inspection?
A
A SWIFT
5
Q
What does the mnemonic A SWIFT mean?
A
A - Asymmetry
S - Scars
W - Wasting
I - Involuntary movements
F - Fasciculations
T - Tremor
6
Q
What are some involuntary movements to look for in neuro inspection?
A
- Dystonia
- Chorea
- Myoclonus
- Athetosis
- (Fasciculations)
- (Tremor)
7
Q
What is an important distinction to make about tremors?
A
Resting vs Kinetic
8
Q
Involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both
A
Dystonia
9
Q
Random-appearing sequence of one or more discrete involuntary movements
A
Chorea
10
Q
Slow, continuous, involuntary writhing movements often affecting the extremities
A
Athetosis
11
Q
Repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles
A
Myoclonus
12
Q
Rhythmic back-and-forth or oscillating involuntary movement about a joint axis
A
Tremor
13
Q
Give 2 causes of dystonia
A
- Parkinson’s Disease
- Dyskinetic Cerebral Palsy
14
Q
Give 2 causes of chorea
A
- Dyskinetic Cerebral Palsy
- Huntington’s Disease
15
Q
Give 2 causes of athetosis
A
- Dyskinetic Cerebral Palsy
- Huntington’s Disease
16
Q
Give a cause of myoclonus
A
Myoclonic epilepsy
17
Q
What is a common cause of resting tremor?
A
Parkinson’s Disease
18
Q
What is a common cause of a kinetic tremor?
A
Benign essential tremor
19
Q
When inspecting a patient in a neuro exam, what clues may be seen in the face?
A
- Hypomimia
- Ptosis
- Ophtalmoplegia
20
Q
What is hypomimia?
A
Lack of facial expression
21
Q
What is a common cause of hypomimia?
A
Parkinson’s Disease
22
Q
What systemic neurological condition can cause ptosis and ophthalmoplegia?
A
Myasthenia gravis
23
Q
What is shown here?
A
Muscle wasting
24
Q
What function should be tested first in a lower limb neuro exam?
A
Gait
25
How is gait assessed?
* Back and forth walking
* Heel-to-toe walking
26
What are some abnormal types of gate?
* Ataxic
* Parkinsonian
* High-stepping
* Waddling
* Hemiparetic
* Spastic paraperesis
27
What are the features of an ataxic gait?
* Broad based
* Unsteady
* Unable to heel-toe walk
28
What are the potential causes of an ataxic gait?
* Cerebellar lesion
* Sensory ataxia (proprioceptive loss)
29
What can differentiate a sensory ataxic gait from a cerebellar gait?
In a sensory ataxic gait they may stare intensely at their feet to make up for loss of proprioception
30
What are the features of a parkinsonian gait?
* Shuffling steps
* Stooped posture
* Reduced arm swing
* Several steps to turn
31
What is a high stepping gait?
Lifts one (or both) feet high to compensate for foot drop
32
What causes foot drop?
Weakness of ankle dorsiflexion
33
What is the most common cause of weak ankle dorsiflexion?
Peroneal nerve injury
34
What are the features of a high-stepping gait?
* Shoulders sway side-to-side
* Legs lifted off by tilting the trunk
35
What causes a waddling gait?
Weakness of the pelvic girdle muscles
36
What are the features of a hemiparetic (and *spastic paraparetic*) gait?
* Stiff legs
* Circumduction
* -
* *(Bilateral and scissoring of feet)*
37
What is circumduction of the legs when walking?
Swinging them in an arc with each stride
38
What is scissoring of the feet?
Inverted feet
39
What sort of lesion causes a hemiparetic or paraparetic gait?
UMN lesion
40
What is a common cause of hemiparetic or paraparetic gait?
Cerebral palsy
41
What disorders can cause problems with heel-toe walking?
* Proprioception impairment
* Cerebellar disorder
42
What test shoudl be performed after gait?
Romberg's Test
43
How is Romberg's test performed?
* Ask the patient to stand with feet together and eyes closed
* Place arms front and back of patient to reduce sway in a positive test
* Obsever for excessive swaying for 10 ~seconds (1 min is ideal but come on this is an OSCE)
44
What is a positive Romberg's test?
Swaying or falling over
45
What does a positive Romberg's test suggest?
Sensory ataxia (loss of proprioceptive deficit)
46
How is tone assessed in the lower limb?
* Ask the patient to let their legs go floppy
* Rolling the leg (tests hips)
* Leg lift at the knee (heel should remain in the bed)
* Move the foot at the ankle
* Quadriceps and calf clonus
47
What is clonus?
Rapid sustained jerking upon forced stretching of the muscles
48
How is quadriceps clonus elicited?
Rapidly push the quads down towards the knee
49
How is calf muscle clonus elicited?
Rapid dorsiflexion of the ankle
50
How should power be assessed in the lower limbs?
* Assess each function one side at a time, comparing like for like
* Stabilise limb to isolate the joint if needed
* Use MRC muscle power assessment scale
51
Power in which joints should be assessed in a lower limb neuro exam?
* Hip
* Knee
* Ankle
* Big toe
52
Power of which hip motions should be tested in a neuro exam?
* Flexion
* Extension
* Abduction
* Adduction
53
What nerve roots provide power to hip flexion?
L1/2
54
What nerve roots provide power to hip extension?
L4/S1
55
What nerve roots provide power to hip abduction?
L4/5
56
What nerve roots provide power to hip adduction?
L2/3
57
Power of which knee movements should be tested in a lower limb neuro exam?
* Flexion
* Extension
58
What nerve roots provide power to knee flexion?
S1
59
What nerve roots provide power to knee extension?
L3/4
60
Power of which ankle movements should be tested?
* Dorsiflexion
* Plantarflexion
61
What nerve roots provide power to ankle dorsiflexion?
L4
62
What nerve roots provide power to ankle plantarflexion?
S1/2
63
Power of which big toe movement should be tested in a lower limb neuro exam?
Extension
64
What nerve roots provide power to big toe extension?
L5
65
Which deep tendon reflexes should be tested in a lower limb neuro exam?
* Knee jerk
* Ankle jerk
* Plantar reflex (not really tendon)
*
66
What nerve root supplies the knee jerk reflex?
L3/4
67
What nerve root supplies the ankle jerk reflex?
L5/S1
68
What nerve root supplies the plantar reflex?
S1
69
How should tendon reflexes be tested?
* Ensure patient's limb is completely relaxed
* Hold hammer at end and use gravity to aim a good swing at the tendon
* Observe for absent or exaggerated reflexes
70
How is the knee jerk tested?
71
How is the ankle jerk reflex tested?
72
How is plantar reflex tested?
* Run a blunt object along the lateral edge of the sole of the foot, moving towards the little toe, then medially under the toes
* Observe the great toe
73
What is a normal plantar reflex?
Flexion of the great toe and other toes
74
What is an abnormal plantar reflex?
**Extension** of the big toe and spreading of the others
75
What is an abnormal plantar reflex also known as?
Positive Babinski sign
76
What does a positive Babinksi sign indicate?
UMN lesion
77
If a reflex is absent, what should you ask the patient to do?
Clench their teeth and try again
78
What sensory modalities should be tested in the upper limbs?
* Pin prick
* Light touch
* Proprioception
* Vibration
79
Which tested sensory modality(s) are carried by the spinothalamic tracts?
Pin prick
80
Which tested sensory modality(s) are carried by the dorsal columns?
* Light touch
* Proprioception
* Vibration
81
What should be used to assess light touch sensation?
A wisp of cotton wool
82
What should be used to assess pin-prick sensation?
Sharp end of a neuro tip
83
How should light touch and pin-prick sensation be tested?
* Demonstrate sensation on the sternum
* Ask the patient to close their eyes
* Assess each dermatome in turn
* Ask patient to say yes when touched
* Compare left to right and ask for any differences
* Assess distal sensation at the tips of the big and little toes, move more proximally gradually until sensation is identified
84
What are some common distributions of sensory loss?
* Dermatomal
* Glove🧤 (and stocking)🧦
* Loss of all sensation below a certain level
* (Brown-Sequard syndrome)
*
85
What does a glove and stocking distribution of sensory loss commonly suggest?
Peripheral neuropathy
86
Is glove and stocking distribution usually symmetrical or asymmetrical?
Symmetrical
87
What does a dermatomal sensory loss suggest?
Radiculopathy (compression of the nerve root)
88
What commonly causes complete loss of sensation below a certain level?
Complete cord transection
89
What should be used to test vibration sensation?
128 Hz tuning fork
90
How should vibration sense be tested?
* Tap tuning fork
* Place on sternum to confirm feeling
* Ask patient to close their eyes
* Place on distal phalanx and ask if they can feel vibration and when it stops
* If not felt move to the next most proximal joint (if felt can leave it there)
* Compare both sides
91
How should proprioception be tested?
* Demosntrate movement of the distal phalanx upwards and downwards with the patient watching
* Ask patient to close their eyes
* Ask them to identify the position of the big toe as you move it
* If unable to do so, move more proximally
92
How is co-ordination assessed in the lower limb?
Heel to shin test
93
How is the heel to shin test performed?
* Ask patient to put their heel on the opposite knee
* Run heel down shin towards foot
* Repeat this numerous times
* Perform on both sides
94
What can cause an inability to perform heel to shin test?
* Cerebellar disorder
* Loss of motor strength
* Loss of proprioception
95
How should a lower limb neuro exam be completed?
* Thank patient
* Wash hands
* Summarise findings
96
What further investigations/examinations can be performed following an upper limb neuro exam?
* Cranial nerve examination
* Upper limb neuro examination
* Imaging e.g. CT/MRI if required
97
Which region is innervated by T12-L1?
Inguinal/groin region
98
Which region is innervated by L2?
Lateral and anterior thigh
99
Which region is innervated by L3?
Medial thigh and anterior knee
100
Which region is innervated by L4?
Medial leg
101
Which region is innervated by L5?
Lateral leg and medial foot
102
Which region is innervated by S1?
Lateral foot (including digits 4 and 5) and heel and Achilles' tendon
103
Which region is innervated by S2?
Posterior thigh, popliteal fossa and central triangle moving halfway down leg
104
Which region is innervated by S3?
Outer buttock
105
Which region is innervated by S4?
Inner buttock
106
Which region is innervated by S5?
Ring around anus
107
What sort of gait is shown here?
Parkinsonian
108
What sort of gait is shown here?
Ataxic (on heel-toe walking)
109
What gait is shown here?
Hemiparetic gait with circumduction
110
What sort of gait is shown here?
Waddling gait
