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Phase 2B Deck 1 > Lower limb neurological examination > Flashcards

Lower limb neurological examination Flashcards

1
Q

what are the overall steps of this examination?

A
  1. general inspection
  2. gait and Romberg’s test
  3. tone
  4. power
  5. reflexes
  6. sensation
  7. coordination
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2
Q

what equipment is required?

A
  • tendon hammer
  • neurotip
  • cotton wool
  • tuning fork (128Hz)
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3
Q

what clinical signs should be looked for in general inspection?

A
  • scars
  • muscle wasting
  • tremor
  • fasciculations
  • pseudoathetosis
  • chorea
  • myoclonus
  • tardive dyskinesia
  • hypomimia
  • ptosis and frontal balding
  • ophthalmoplegia
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4
Q

how should gait be assessed?

A
  1. normal gait
  2. tandem gait
  3. look at stance, stability, arm swing, steps, turning
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5
Q

what is ataxic gait?

A

broad-based, unsteady and associated with cerebellar pathology or sensory ataxia

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6
Q

what is Parkinsonian gait?

A

small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). several small steps to turn, rushed gait, getting stuck, hand tremor

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7
Q

what is high stepping gait?

A

can be unilateral or bilateral and is typically caused by foot drop; won’t be able to heel walk

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8
Q

what is waddling gait?

A

shoulders sway from side to side, legs lifted off ground with aid of tilting the trunk; commonly cause by proximal lower limb weakness

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9
Q

what is hemiparetic gait?

A

one leg held stiffly and swings round in an arc with each stride; associated with stroke

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10
Q

what is spastic paraparesis?

A

similar to hemiparetic gait but bilateral, with both legs stiff and circumducting; feet may be inverted and scissor; associated with hereditary spastic paraplegia

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11
Q

how is Romberg’s test performed?

A
  1. position yourself within arms reach of patient
  2. ask patient to put feet together and keep arms by sides
  3. ask patient to close eyes
  4. positive sign= falling without correction
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12
Q

what is a positive sign of Romberg’s test?

A

falling without correction; indicates unsteadiness due to sensory ataxia (deficit of proprioceptive or vestibular function)

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13
Q

what are causes of proprioceptive dysfunction?

A

joint hypermobility, B12 deficiency, Parkinson’s, ageing

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14
Q

what are causes of vestibular dysfunction?

A

vestibular neuronitis and Meniere’s disease

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15
Q

what movements are used to assess tone?

A
  1. leg roll and leg lift

2. ankle clonus

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16
Q

how is the leg roll and leg lift performed?

A
  1. assesses tone in muscles of hip, knee and ankle
  2. ask patient to keep legs fully relaxed throughout
  3. with patient lying on couch, roll each leg to assess tone in muscles responsible for rotation of hip
  4. lift each knee briskly off the bed (warn them first) and observe movement
  5. the knee should rise whilst the heel remains in contact with the bed
17
Q

what is clonus?

A

series of involuntary rhythmic muscular contractions and relaxations that’s associated with UMN lesions

18
Q

how is ankle clonus assessed?

A
  1. position the patient’s leg so the knee and ankle are slightly flexed, supporting the leg with your hand under their knee
  2. rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle
  3. keep foot in this position and observe for clonus; if more than 5 beats of clonus are present, this is abnormal
19
Q

what movements are used to assess power?

A
  1. hip flexion
  2. hip extension
  3. knee flexion
  4. knee extension
  5. ankle dorsiflexion
  6. ankle plantarflexion
  7. big toe extension
20
Q

what reflexes are assessed?

A
  1. knee-jerk reflex (L3,4)
  2. ankle-jerk reflex (S1)
  3. plantar reflex (L5, S1)
21
Q

how is the knee-jerk reflex assessed?

A
  1. remove weight from the patient’s lower limb by supporting it or asking them to hand their legs over the side of the bed
  2. tap patellar tendon with the hammer
22
Q

how is the ankle-jerk reflex assessed?

A
  1. with patient on exam couch, support their leg so their hip is slightly abducted, the knee is flexed and the ankle is dorsiflexed
  2. tap the Achilles tendon with hammer
  3. observe for contraction in the gastrocnemius muscle with associated plantarflexion of the foot
23
Q

how is the plantar reflex assessed?

A
  1. with patient on couch, explain you’re going to scratch the foot with a blunt stick and it will be uncomfortable
  2. fix foot in position by holding ankle
  3. run blunt object along lateral edge of the sole of the foot, moving towards the base of the little toe and turn medially to run across the transverse arch of the foot under the toes
  4. observe the big toe
  5. normal result = flexion of big toe and other toes
  6. abnormal result = Babinski sign
24
Q

where is the L1 dermatome located?

A

inguinal region and very top of medial thigh

25
Q

where is the L2 dermatome located?

A

middle and lateral aspect of the anterior thigh

26
Q

where is the L3 dermatome located?

A

medial aspect of knee

27
Q

where is the L4 dermatome located?

A

medial aspect of lower leg and ankle

28
Q

where is the L5 dermatome located?

A

dorsum and medial aspect of the big toe

29
Q

where is the S1 dermatome located?

A

dorsum and lateral aspect of the little toe

30
Q

what types of sensation are assessed?

A
  1. light touch sensation
  2. pinprick sensation
  3. vibration
  4. proprioception
31
Q

what joint is used to assess vibration and proprioception?

A

interphalangeal joint of the big toe

32
Q

how is coordination assessed?

A

heel-to-shin assessment

33
Q

how is the heel-to-shin assessment performed?

A
  1. ask patient to place left heel on their right knee and run it down their shin in a straight line
  2. ask them to return their left heel to the starting position over the right knee
  3. ask them to repeat these movements in smooth motion until you tell them to stop
  4. repeat on other side
34
Q

what further assessments and investigations should be suggested at the end of this examination?

A
  1. full neuro exam

2. neuroimaging

Phase 2B Deck 1 (9 decks)

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