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Cheatography

Neurological Examination of the Lower Limbs Cheat Sheet (DRAFT) by

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This is a draft cheat sheet. It is a work in progress and is not finished yet.

Preper­ation and Equipment:

W
Wash Hands
I
Introduce Yourself + Patient's Identity
P
Permission
P
Patient Position + Pain
E
Explai­­nation
Patient must be placed at 45° and limbs exposed

Equipment:

 
Cotton Wool
Neurotips
Tendon Hammer
128Hz Tuning Fork

General Inspec­tion:

•Postural abnorm­alities and deform­ities
•Leaning or facial asymmetry
•Muscle wasting, fascic­ula­tions, or tremor
•Abnormal movements
•Obvious discomfort or pain
•Medical paraph­ern­alia:
Walking aids, Calipers

Tone:

Check for pain
Check tone:
Roll the relaxed leg from side to side and watch foot
Extra movement => Decreased tone

Less movement => Rigidity
 
Flex and extend knee
+ check for clonus at knee
Check for clonus:
Rotate ankle
Ensure no pain
Relax foot
Hold lower leg with one hand and extend the ankle joint with the other
Suddenly dorsiflex ankle and hold in position
Compare with other leg
Clonus is seen in upper motor neuron lesions

Power:

Test both left and right limbs, directly comparing each movement in turn.

The patient should perform each movement on their own and then attempt with the examiner resisting the movement
Hips:
•Flexion
•Abduction
•Adduction
•Extension
Patient straig­htens leg, raises leg off the bed, lowers it to the bed
Knee:
•Flexion
•Extension
Patient flexes hip and knee, secure thigh with one hand, ask patient to kick out towards the end of the bed, pull in heel towards bum
Ankle:
•Dorsiflexion
•Plantarflexion
Leg flat on bed, secure leg, dorsiflex foot, planta­rflex foot
Big Toe:
•Flexion
•Extension
Hold foot secure, flex big toe (towards patient), extend (away from patient)

Coordi­nation:

Heel-shin test:
Place heel on one knee and run up and down the shin
Toe Tapping:
Patient taps floor/your hand with their foot
Must be completed for both sides and the patient should be asked to perform the actions as quickly as possible

Tendon Reflexes:

Limb must be totally relaxed
Knee:
Support the leg above the knee, with the knee flexed, strike directly below the patella
L3/4
Ankle:
Leg flat on the bed, laterally rotate leg, flex knee, hold the foot dorsif­lexed. Strike Achilles Tendon
S1/2
Plantar Response:
Hold ankle with one hand.
Warn the patient this may tickle.
Scratch the sole of the foot with a tongue depressor, starting at the lateral side of the heel, up lateral sole, across base of toes.
Must be first movement of the big toe

Negative Babinski sign (normal except in the case of LMN disease): Flexion of the toes and pull away

Positive Babinski sign: Extension (upwards movement) of the toes Indicates UMN damage
Muscle may just contract, may not be an obvious movement

Reflex may be presen­t/a­bsent, or reduce­d/brisk

Sensation:

Light Touch:
Important to touch rather then stroke

Lightly touch sternum first using cotton wool.
Ask patient to close eyes and tell you when they feel the touch.
Ask if touch feels the same on both sides
 
Proximal anterior upper thigh
L1
 
Proximal anterior upper leg, between thigh and knee
L2
 
Anterior surface of knee
L3
 
Medial aspect of lower leg
L4
 
Lateral aspect of lower leg
L5
 
Lateral side of foot/small toe
S1
 
Posterior vertical midline of leg
S2
Pain:
Repeat same process as for light touch.

Tested using a new neurotip.
Must be disposed of in the sharps bin.
Temperature:
Tested the same way as pain/light touch, rarely done.

Tested using a cold tuning fork.
Vibration Sense: (128Hz)
Strike tuning fork and hold to patient's sternum.
Ask patient to close eyes.
 
Begin on most distal bony prominance (Big toe of each foot)
Proprioception:
Ask patient to close eyes.
Hold big toe at the sides, distal to the DIP joint. Stabilise the toe proximal to the tested joint.

Demonstrate up/down for the patient, then repeat in a random direction, asking the patient to say which direction the toe is moving.

Repeat 3 times
If normal, end here. If patient is unable to feel, move proximally up the joints.

PIP, Ankle, Knee, etc.

Gait and Balance:

Examine Gait:
Examine Balance:
Romberg's Test:
Patient stands with their feet together and close their eyes.

If they become unsteady -> Positive test

Completing the Examin­ation:

Thank the Patient
•Consider Upper Limbs Examin­aiton
•Consider Cranial Nerves Examin­ation
•Consider Examining Anal Tone
Wash Hands

Common Disorders

B12 deficiency:
Commonest cause of dorsal column problems - sub acute combined degene­ration of the spinal cord
Cerebellar disease is ipsila­teral and causes horizontal nystagmus - Fast phase towards the side of the lesion

MRC Muscle Power Scale:

Lower Limbs Dermatome Map: