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OSCE > Lower Limb Neuro Exam > Flashcards

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
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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
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3
Q

What around the bed may suggest neurological problems?

A
  • Wheelchair
  • Walking aids
  • Catheter
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4
Q

What menmonic can help with a neuro visual inspection?

A

A SWIFT

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5
Q

What does the mnemonic A SWIFT mean?

A

A - Asymmetry

S - Scars

W - Wasting

I - Involuntary movements

F - Fasciculations

T - Tremor

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6
Q

What are some involuntary movements to look for in neuro inspection?

A
  • Dystonia
  • Chorea
  • Myoclonus
  • Athetosis
  • (Fasciculations)
  • (Tremor)
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7
Q

What is an important distinction to make about tremors?

A

Resting vs Kinetic

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8
Q

Involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both

A

Dystonia

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9
Q

Random-appearing sequence of one or more discrete involuntary movements

A

Chorea

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10
Q

Slow, continuous, involuntary writhing movements often affecting the extremities

A

Athetosis

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11
Q

Repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles

A

Myoclonus

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12
Q

Rhythmic back-and-forth or oscillating involuntary movement about a joint axis

A

Tremor

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13
Q

Give 2 causes of dystonia

A
  • Parkinson’s Disease
  • Dyskinetic Cerebral Palsy
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14
Q

Give 2 causes of chorea

A
  • Dyskinetic Cerebral Palsy
  • Huntington’s Disease
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15
Q

Give 2 causes of athetosis

A
  • Dyskinetic Cerebral Palsy
  • Huntington’s Disease
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16
Q

Give a cause of myoclonus

A

Myoclonic epilepsy

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17
Q

What is a common cause of resting tremor?

A

Parkinson’s Disease

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18
Q

What is a common cause of a kinetic tremor?

A

Benign essential tremor

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19
Q

When inspecting a patient in a neuro exam, what clues may be seen in the face?

A
  • Hypomimia
  • Ptosis
  • Ophtalmoplegia
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20
Q

What is hypomimia?

A

Lack of facial expression

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21
Q

What is a common cause of hypomimia?

A

Parkinson’s Disease

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22
Q

What systemic neurological condition can cause ptosis and ophthalmoplegia?

A

Myasthenia gravis

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23
Q

What is shown here?

A

Muscle wasting

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24
Q

What function should be tested first in a lower limb neuro exam?

A

Gait

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25
Q

How is gait assessed?

A
  • Back and forth walking
  • Heel-to-toe walking
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26
Q

What are some abnormal types of gate?

A
  • Ataxic
  • Parkinsonian
  • High-stepping
  • Waddling
  • Hemiparetic
  • Spastic paraperesis
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27
Q

What are the features of an ataxic gait?

A
  • Broad based
  • Unsteady
  • Unable to heel-toe walk
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28
Q

What are the potential causes of an ataxic gait?

A
  • Cerebellar lesion
  • Sensory ataxia (proprioceptive loss)
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29
Q

What can differentiate a sensory ataxic gait from a cerebellar gait?

A

In a sensory ataxic gait they may stare intensely at their feet to make up for loss of proprioception

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30
Q

What are the features of a parkinsonian gait?

A
  • Shuffling steps
  • Stooped posture
  • Reduced arm swing
  • Several steps to turn
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31
Q

What is a high stepping gait?

A

Lifts one (or both) feet high to compensate for foot drop

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32
Q

What causes foot drop?

A

Weakness of ankle dorsiflexion

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33
Q

What is the most common cause of weak ankle dorsiflexion?

A

Peroneal nerve injury

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34
Q

What are the features of a high-stepping gait?

A
  • Shoulders sway side-to-side
  • Legs lifted off by tilting the trunk
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35
Q

What causes a waddling gait?

A

Weakness of the pelvic girdle muscles

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36
Q

What are the features of a hemiparetic (and spastic paraparetic) gait?

A
  • Stiff legs
  • Circumduction
  • -
  • (Bilateral and scissoring of feet)
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37
Q

What is circumduction of the legs when walking?

A

Swinging them in an arc with each stride

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38
Q

What is scissoring of the feet?

A

Inverted feet

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39
Q

What sort of lesion causes a hemiparetic or paraparetic gait?

A

UMN lesion

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40
Q

What is a common cause of hemiparetic or paraparetic gait?

A

Cerebral palsy

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41
Q

What disorders can cause problems with heel-toe walking?

A
  • Proprioception impairment
  • Cerebellar disorder
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42
Q

What test shoudl be performed after gait?

A

Romberg’s Test

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43
Q

How is Romberg’s test performed?

A
  • 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)
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44
Q

What is a positive Romberg’s test?

A

Swaying or falling over

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45
Q

What does a positive Romberg’s test suggest?

A

Sensory ataxia (loss of proprioceptive deficit)

46
Q

How is tone assessed in the lower limb?

A
  • 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
Q

What is clonus?

A

Rapid sustained jerking upon forced stretching of the muscles

48
Q

How is quadriceps clonus elicited?

A

Rapidly push the quads down towards the knee

49
Q

How is calf muscle clonus elicited?

A

Rapid dorsiflexion of the ankle

50
Q

How should power be assessed in the lower limbs?

A
  • 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
Q

Power in which joints should be assessed in a lower limb neuro exam?

A
  • Hip
  • Knee
  • Ankle
  • Big toe
52
Q

Power of which hip motions should be tested in a neuro exam?

A
  • Flexion
  • Extension
  • Abduction
  • Adduction
53
Q

What nerve roots provide power to hip flexion?

A

L1/2

54
Q

What nerve roots provide power to hip extension?

A

L4/S1

55
Q

What nerve roots provide power to hip abduction?

A

L4/5

56
Q

What nerve roots provide power to hip adduction?

A

L2/3

57
Q

Power of which knee movements should be tested in a lower limb neuro exam?

A
  • Flexion
  • Extension
58
Q

What nerve roots provide power to knee flexion?

A

S1

59
Q

What nerve roots provide power to knee extension?

A

L3/4

60
Q

Power of which ankle movements should be tested?

A
  • Dorsiflexion
  • Plantarflexion
61
Q

What nerve roots provide power to ankle dorsiflexion?

A

L4

62
Q

What nerve roots provide power to ankle plantarflexion?

A

S1/2

63
Q

Power of which big toe movement should be tested in a lower limb neuro exam?

A

Extension

64
Q

What nerve roots provide power to big toe extension?

A

L5

65
Q

Which deep tendon reflexes should be tested in a lower limb neuro exam?

A
  • Knee jerk
  • Ankle jerk
  • Plantar reflex (not really tendon)

*

66
Q

What nerve root supplies the knee jerk reflex?

A

L3/4

67
Q

What nerve root supplies the ankle jerk reflex?

A

L5/S1

68
Q

What nerve root supplies the plantar reflex?

A

S1

69
Q

How should tendon reflexes be tested?

A
  • 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
Q

How is the knee jerk tested?

A
71
Q

How is the ankle jerk reflex tested?

A
72
Q

How is plantar reflex tested?

A
  • 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
Q

What is a normal plantar reflex?

A

Flexion of the great toe and other toes

74
Q

What is an abnormal plantar reflex?

A

Extension of the big toe and spreading of the others

75
Q

What is an abnormal plantar reflex also known as?

A

Positive Babinski sign

76
Q

What does a positive Babinksi sign indicate?

A

UMN lesion

77
Q

If a reflex is absent, what should you ask the patient to do?

A

Clench their teeth and try again

78
Q

What sensory modalities should be tested in the upper limbs?

A
  • Pin prick
  • Light touch
  • Proprioception
  • Vibration
79
Q

Which tested sensory modality(s) are carried by the spinothalamic tracts?

A

Pin prick

80
Q

Which tested sensory modality(s) are carried by the dorsal columns?

A
  • Light touch
  • Proprioception
  • Vibration
81
Q

What should be used to assess light touch sensation?

A

A wisp of cotton wool

82
Q

What should be used to assess pin-prick sensation?

A

Sharp end of a neuro tip

83
Q

How should light touch and pin-prick sensation be tested?

A
  • 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
Q

What are some common distributions of sensory loss?

A
  • Dermatomal
  • Glove🧤 (and stocking)🧦
  • Loss of all sensation below a certain level
  • (Brown-Sequard syndrome)
    *
85
Q

What does a glove and stocking distribution of sensory loss commonly suggest?

A

Peripheral neuropathy

86
Q

Is glove and stocking distribution usually symmetrical or asymmetrical?

A

Symmetrical

87
Q

What does a dermatomal sensory loss suggest?

A

Radiculopathy (compression of the nerve root)

88
Q

What commonly causes complete loss of sensation below a certain level?

A

Complete cord transection

89
Q

What should be used to test vibration sensation?

A

128 Hz tuning fork

90
Q

How should vibration sense be tested?

A
  • 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
Q

How should proprioception be tested?

A
  • 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
Q

How is co-ordination assessed in the lower limb?

A

Heel to shin test

93
Q

How is the heel to shin test performed?

A
  • 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
Q

What can cause an inability to perform heel to shin test?

A
  • Cerebellar disorder
  • Loss of motor strength
  • Loss of proprioception
95
Q

How should a lower limb neuro exam be completed?

A
  • Thank patient
  • Wash hands
  • Summarise findings
96
Q

What further investigations/examinations can be performed following an upper limb neuro exam?

A
  • Cranial nerve examination
  • Upper limb neuro examination
  • Imaging e.g. CT/MRI if required
97
Q

Which region is innervated by T12-L1?

A

Inguinal/groin region

98
Q

Which region is innervated by L2?

A

Lateral and anterior thigh

99
Q

Which region is innervated by L3?

A

Medial thigh and anterior knee

100
Q

Which region is innervated by L4?

A

Medial leg

101
Q

Which region is innervated by L5?

A

Lateral leg and medial foot

102
Q

Which region is innervated by S1?

A

Lateral foot (including digits 4 and 5) and heel and Achilles’ tendon

103
Q

Which region is innervated by S2?

A

Posterior thigh, popliteal fossa and central triangle moving halfway down leg

104
Q

Which region is innervated by S3?

A

Outer buttock

105
Q

Which region is innervated by S4?

A

Inner buttock

106
Q

Which region is innervated by S5?

A

Ring around anus

107
Q

What sort of gait is shown here?

A

Parkinsonian

108
Q

What sort of gait is shown here?

A

Ataxic (on heel-toe walking)

109
Q

What gait is shown here?

A

Hemiparetic gait with circumduction

110
Q

What sort of gait is shown here?

A

Waddling gait

OSCE (19 decks)

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