Lower Limb Neurological Examination

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1. Note the stem (important to commit to memory)
2. Walk into room
3. Wash hands
4. Introduce yourself to the patient. Make sure you shake the patient's hand (grip myotonia)
   1. Hello. My name is Dr Nanayakkara, thank you for letting me examine your (legs, lower limbs etc)
5. Place briefcase and open it up 
6. Ensure that the patient has adequate exposure - in the lower limb examination this means asking to expose the patient to their underwear or shorts. The examiner's may stop you to protect modesty. Make sure you obtain consent from the patient to proceed
7. Step back and make a general inspection
   1. signs of neurofibromatosis
   2. distribution of weakness
   3. myopathic facies
   4. Movement disorders
   5. Presence of walking aides
   6. Make a show of examining the patient's  
8. Ask the patient to stand and look at the quadriceps, this is the best position to assess quadriceps muscle bulk
9. Check the lower spine for scars and signs of spina bifida (lipoma, tuft of hair)
10. Ask the patient to walk. If this is difficult, make sure that your bulldog is there to help with this. The patient may 
    1. Assess normal walking first in one direction
    2. Assess tandem walking in the other direction - if you think this is dangerous for the patient tell the examiners that you would like to perform heel-to-toe testing
    3. Assess walking on heels - testing for foot drop
    4. Assess walking on toes - testing integrity of gastrocnemius muscle
    5. Aim to be able to characterise the gait
       1. eg high-stepping gait due to unilateral foot drop
       2. causes of bilateral foot drop include peripheral neuropathy such as CMTD, motor neuron disease, bilateral common peroneal nn palsy
       3. broad based gait
       4. trendelenburgs gait (or waddling gait) secondary to weakness of glut medius. If significant waddling gait then patient may have a myopathy or osteoarthritis of the hip
       5. If one leg is held stiffly and makes an arc around the other leg, with the foot scaping the ground with lack of arm swing on the side and flexed elbow this is a hemiparetic gait
       6. Scissor gait if both legs are held stiffly and show circumduction
       7. Parkinsonian gait with festination (hurrying), tendency to run forwards (propulsion) or backwards (retropulsion), getting suddenly stuck and unable to move (freezing) - ask to do the righting test where you suddenly tug backwards on the patients shoulder and observe the patient running backwards uncontrollably
       8. Marche a' petits pas' - like parkinsonian but also broad based --> normal pressure hydrocephalus
       9. Antalgic gait due to pain
11. Assess proximal muscle strength by asking the patient to squat
12. Perform Rombergs test by asking the patient to put their feet together and shut their eyes (proprioceptive testing of the integrity of the dorsal columns - as you take away visual input from the balance centre) - causes include tabes dorsalis, sensory neuropathy, spinocerebellar degeneration, subacute combined degeneration of the cord, multiple sclerosis
13. Move the patient to the bed and lie them down, making sure that they are adequately exposed
14. Maintain patient's modesty by placing towel covering sensitive area
15. Test for fasciculation's by flicking on the muscle - they are a lower motor neurone sign
16. Assess muscle bulk and outline any clinically relevant scars
17. Inspect soles of feet, noting pes cavus which is generaly a sign of a chronic disease such as CMT, freidrich's ataxia
18. Test tone (it is either normal or increased) - an upper motor neurone sign
    1. Roll the patients leg from side to side to first check if they have pain, look to see if there is a normal delay in 
    2. Lift the knee up quickly so that they are in 60 - 90 degree flexion - if their foot also lifts up then this could mean that they have increased tone
    3. Test for ankle clonus, if greater than 5 beats this indicates increased tone
    4. Patella clonus can also be elicited however this is often painful for the patient
19. Test power with special attention to pattern of weakness (eg pyramidal vs myotomal vs peripheral)
    1. Hip flexion (L1, L2)
    2. Hip extension (L4, L5)
    3. hip abduction (L4, L5, S1)
    4. hip adduction (L2, L3, L4) - obturator nn function vs femoral nerve function. If just hip flexion but not adduction then femoral nerve pathology, if hip adduction and not flexion then obturator. If both then above plexus
    5. Knee flexion (L5, S1) - holding knee at 60 degrees
    6. Knee extension (L3, L4) - holding knee at 60 degrees
    7. Foot dorsiflexion (L4, L5) - Hold foot in 10 degree dorsiflexion
    8. Foot plantar flexion (S1) - Push against me like you are driving a car
    9. Ankle inversion (L4, L5) - Move into inversion for the patient
    10. Ankle eversion (L5, S1, common peroneal nerve) 
        1. If dorsiflexion + eversion weakness then common peroneal nn
        2. If dorsiflexion + eversion + inversion then L5
    11. Great toe extension (L5) 
20. Test Reflexes
    1. Knee Jerk (L4, L5)
    2. Ankle jerk (S1, S2) 
    3. Plantar response
21. Test co-ordination
    1. lift your leg, place heel onto knee and slide down shin then LIFT IT again and
       repeat”. (Don’t let them just slide up and down the shin)
    2. Touch my finger with your big toe
22. Test sensation
    1. Quickly assess if they have a sensory level by running a cold tuning fork up their leg until they can feel it turn cold - especially important if there are upper motor neuron signs
    2. test on their forehead first so that the patient knows what to expect
       1. Check spinothalamic integrity by pin-prick testing and temperature in the dermatomal areas
       2. Check dorsal columns by testing vibration, proprioception and light touch
    3. If there is a clear deficit aim to map out that area
23. Tell the examiner that you would like to complete the examination by performing a full neurological examination of the upper limbs and cranial nerves
24. Cover and thank the patient

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