Lower limb neurological examination


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in neurology outpatient clinic

Patient: 40 year old patient

Task:
Your consultant has asked you to perform a full upper limb neurology examination and they will observe you
– Please provide a running commentary whilst you are examining
– After 6 minutes you will be asked a series of questions by the examiner

You are a 40 year old patient who has come to a neurology outpatient clinic. The consultant as asked if you are happy for a junior doctor to examine you and you are delighted by this. You have been asked not to give a history but to confirm your name and date of birth.

Please feel free to stop the examination is the patient causes pain or discomfort to yourself.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


Étique Examination étique
Washes hands
Exposes patient appropriately
Patient positioned at 45 degrees
Examination from left hand side


Inspection General inspection
Muscle symmetry
Muscle wasting
Muscle fasciculation
Involuntary muscle movements
Use of walking aids e.g walking frame


Tone Tone
Assesses tone by asking patient to ‘let the leg go floppy’
Roll single leg from side to side
Sudden pull of pull superior from behind knee
Attempts to illicit clonus (sudden pull of foot to dorsiflexion)
Repeats on other side


Power 1 Power 1 - Hip. Please state nerve root when assessing power
Hip flexion (L1/L2)
Hip extension (L5/S1)
Both nerve roots correct when examining


Power 2 Power 2 - Knee. Please state nerve root when assessing power
Knee flexion (L5/S1)
Knee extension (L3/L4)
Both nerve roots correct when examining


Power 3 Power 3 - Ankle. Please state nerve root when assessing power
Ankle dorsiflexion (L4)
Ankle plantarflexion (S1)
Both nerve roots correct when examining


Power 4 Power 4 - Big toe. Please state nerve root when assessing power
Big toe extension (L5)
Nerve root correct when examining


Power overall Power overall
Assess power in a “like for like” - test your muscle against the patients
Stabilises and isolates the joint


Reflex 1 Reflex 1 - Knee. Please state nerve root when assessing reflexes
Attempts knee jerk
Root L3/L4


Reflex 2 Reflex 2 - Ankle. Please state nerve root when assessing reflexes
Attempts ankle jerk
S1


Reflex 3 Reflex 3 - Plantar reflex
Plantar reflex (Babinski)
States direction of movement (up / down / no movement)


Coordination Coordination
Tested by movement from heel to shin
Tests on both sides


Sensation 1 Sensation 1 - light touch
Asks patient to close eyes
Demonstrates on sternum sensation
Compares sides directly by comparing each nerve root


Sensation 2
Sensation 2 - light touch. Please state nerve root when examining

Antero-medial thigh
Nerve root L2


Sensation 3
Sensation 3 - light touch. Please state nerve root when examining

Medical thigh just above knee
L3


Sensation 4
Sensation 4 - light touch. Please state nerve root when examining

Medical malleolus
L4


Sensation 5
Sensation 5 - light touch. Please state nerve root when examining

Dorsal 1st web space
L5


Sensation 6
Sensation 6 - light touch. Please state nerve root when examining

Lateral heel
S1


Proprioception Proprioception
Eyes closed
Hallux used
Immobilise by holding by sides only
Randomly move tip up / down
Repeat on other side


Vibration Vibration
Eyes closed
128 Hz fork
Placed on sternum and confirms patient can feel vibration
Test on hallux (move proximal if not felt)


Special test Special test - Romberg’s sign
Examines with patient standing upright
Support patient appropriately and asks to close eyes
If unsteady positive result


Closing Closing examination
Invites patient to get re-dressed
Washes hands


Patient Patient score
Candidate did not cause any pain to patient
Candidate was polite throughout examination


Question What investigations may be useful in guiding you to a diagnosis?
Nerve conduction studies
Imaging CT head / MRI spine


Question
Review the following video. What sign is shown? What type of lesion is this?

Foot drop
Right sided
Lower motor neurone lesion


Question What nerve roots are commonly effected in foot drop?
Nerve root L4/5


Question What are the clinical features of an lower motor neurone lesion?
Normal (or reduced) tone
Decreased power
Reflexes reduced
Plantars down-going
Co-ordination normal
Inspection (wasting / fasciculations)


Question What are the common differentials for unilateral leg weakness?
Stroke
Tumour
Multiple sclerosis
Root lesion
Nerve lesion
Other appropriate answer



Score