Examination of lower limb in neurology-Short case approach for Final MBBS


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Examination of lower limb in neurology-medicine short case approach.
This document was prepared based on the teachings of Dr.Kahathuduwa.
Fonts in blue indicate sample way of presenting the case.

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Examination of lower limb in neurology-Short case approach for Final MBBS

  1. 1. Examination of lower limb in neurology-Short case approach Possible cases 1. Hemiplegia: flaccid or spastic 2. Paraplegia/ paraparesis: flaccid or spastic 3. Myopathy 4. Ataxia 5. Foot drop 6. Myasthenia/ NM In each & every step always think which category this pt best fits. Possible instructions at the exam 1. Examine the lower limbs of this pt 2. Inspect the gait & procede: pt may be wearing a diaper & catheter, then you must know that pt can’t walk 3. Inspect the lower limbs of this pt & procede Procedure “Time is money”. Cutdown all unnecessary steps/words Introduce briefly: I am a final year medical student & going to examine you. Arrange the setting  Cover the curtain  Lit the area if pt is placed in dark/ or atleast lit your torch to show the examiner that you want adequate light Commentry can be made at the end or it may be a running commentry Inspect the pt from the distance Is he 1. ill looking/ 2. in pain/ 3. comfortable/ 4. looks bed bound/ 5. features of urinary or fecal incontinence- Pt with pampers & catheter is likely to have both. Better not to say “smelly”) / 6. obvious bed sores/ 7. posture (if having decorticate, decerebrate)? “I am going to examine this young/old looking gentleman/lady who is lying comfotably on the bed. He looks well & not in pain. He is not having any bed sores or features of urinary or fecal incontinence. I would like to examine his LL.”  Age is particularly important (atleast a rough estimation) in CVS cases.  Use ONLY the terms “gentleman or lady” ( avoid other terms as examiners may unnecessarily cross ques you how do you know girl etc & waste your time) Yapa Wijeratne
  2. 2. Go near the LL Inspection of LL 1. Wasting/ 2. Fasciculations / 3. Contractures/ 4. Deformities/ 5. Trophic Ulcers/ 6. Rashes (Dermatomyositis)/ 7. Localized Inflammation (Myositis)/ 8. Muscle Biopsy Scars/tendon release scar in an infant On inspection there is no wasting /fasciculations/ contractures/deformities/ trophic ulcers Before you touch the pt ask whether there is any pain in the lower limb? (myositis) : without asking this you may touch the pt & he may scream in pain & this gives the impression of a good professional. Thre is no tenderness to touch Better approach would be asking pt to elevate LLs separately as high as they can This will elicit obvious  Proximal weakness  Hypotonia: dragging the foot in the bed  Foot drop  Disc prolapse: SLRT+. So you can easily observe as he would not raise above pain. Added advantages here are you are able to elevate limb upto the point of pain in disc prolapse & you need not to worry about the tone checking. But better not to comment about SLRT at that moment & you can perform with lesser force( you may use just 2 fingers to lift as at any moment pt can put his leg back easily). Focus pt’s face while noting the angle. In this pt’s SLRT was 90 degrees B/L Tone > Power > Then you can do clonus as it takes even a little time if done with tone >Reflexes You may roll one limb & suddenly lift & release the other limb. This will divert pt’s attention & reveal the signs well. Spasticity: initially there is a resistance to both sides. at one point resistance is gives away. clasp knifeLead pipe: Rigidity persisits throughout. Cog-wheel Checking for power should be done with one command word. It is always to better to comment as muscle power is reduced/ normal than comment with grading as incase of cross questioning, you don’t have an answer how you checked so. Power was reduced (flexors or the extensors at knee joint on R/S)/ normal (bilaterally) Reflexes Then you can do clonus depending on your findings. Plantar By this time you have already diagnosed common peroneal nerve palsy/ foot drop or root lesion Yapa Wijeratne
  3. 3. Then go by dermatomal pattern in sensory If find dermatomal pattern you go above till you find a sensory level. Once you find, check the back also. You must check the other limb also. Sir I would like to examine the posterior side as well. Periperal neuropathy, paralysis will be found. Superficial abdominal reflexes also can be done at this time. Superficial abdominal reflexes is a LMN sign. Umbilicus move to the side to the innervated/ intact group & opposing group is weak. Accurately localize the level You may use other side of the tooth pick. You must check the other limb also. As there can be a crossed hemiplegia (Brown Sequard). Once you get a sensory level, I would like to check for other sensory modalities also. (if time permits) Vibration is better than proprioception to check dorsal column. B/L Foot drop, only the weakness in plantar & dorsiflexion → sciatic nerve So check the sensory, check common peroneal & posterior tibial are affected. But the sural is intact (lateral border of foot). Foot drop+ affected eversion but big toe extension is preserved. → common peroneal So check deep & superficial branches of common peroneal. Prick the space between big toe & 2nd toe & check some other place also Lateral border Sole Either sides: lateral cutaneous/ obturator If time permits, check the back S2, S3 also. Foot drop+ affected big toe extension, but able to evert the foot→ L5 root If pt is in standing position, this can be done by asking the pt to stand with toes(L4,L5) & heel (S1,S2). If found root pattern, check the sensory in root pattern. Then do the heel knee shin test. I would like to check the gait of this pt. B/L Paraplegia/ paraparesis: flaccid 1. GBS: commonest 2. Spinal shock 3. Transverse myelitis: initially 4. Severe ant horn cell disease 5. Full blown cauda equina lesion Then how to progress Spincter control: also has told by now Yapa Wijeratne
  4. 4. Sir I would like to examine the Upper limbs also. So I would know upto which level this process has ascends. Wrist tone (T1,C8): if flaccid > power biceps C5,C6 > if weak > check diapragm: single breath count Get a one breath & count for the maximum 1,2,3,… I would like to do single breath count Then check neck flexors by  Flexing the neck  Keeping the hand to resist on the forehead & flex again. Can check the other side of the neck/ trapezius & check upto accessory nerve level. If transverse myelitis you have found the sensory level. Spinal shock, transverse myelitis→pt would be in pain. Spinal shock: examine the back for spinal tenderness. Or atleast ask Spastic Tone is more. power biceps BJ/ TJ reflexes Ask the pt to open the mouth & look at the tongue: hypoglossal Look at the face: facial nerve Ask for jaw jerk. But better not to do as due to your mental stress you might hit the mouth Spastic, but UL normal tone→ look for spinal tenderness Spastic, sensory in upper abdomen, but UL flaccid  ALS- grossly wasted hands  Lesion at that level: I am suspecting a lesion at C7-8 nerve roots, so I would like to check for the sensory at that level. Hemiplegia: flaccid or spastic Both UL Spastic hemiplegia. Normal tone in UL→ pyramidal drift Tone can get compensated later by innervating myotomes. But pyramidal drift persists for some time. This can be performed, even in the lying position with closed eyes. Localize stroke. (swallowing in long case. If in short case, pulse, auscultate heart, carotids) Look at the face/ eyes: if normal, this can be at the internal capsule level. Chronic cases, CN VII palsy get corrected & treat also. Eyes: gaze palsy Hemiplegia: flaccid→polio Know stool collection etc AFP/ vaccination schedule Common peroneal inspect ULs: hypopigmented areas: palpate neck of fibula/ ulnar nerves Ataxia Yapa Wijeratne
  5. 5. head to toe CL features proximal weakenss is clearly seen in gait. If any waddle, get the pt squat & stand. Proximal weakenss Rashes (Dermatomyositis/ Myositis) UL tenderness may be there. Thyroid: pulse/ tremor If Stroke: at least tell the examiner that you want to examine the CVS for possible cause Myasthenia in unexplained weakness. If does not fit for any check for this. Ask the pt to look up for 20s for myesthenia Occular myes 50%. In other conditions also having occular involvement in ~80% Flacccid paralysis Pt is having B/L flaccid paralysis of LLs & Uls. Tone is reduced at the wrists. C5-6 power is normal. Single breath count is normal. Neck flexors & extensors have normal power. There is no spinal lesion & no sensory level. Pt is having acute flacccid paralysis involving B/L LLs & the weakness is extending upto C8-T1 level. But there is no sensory loss. So my DD are 1. Acute inflammmatory demyelinating polyneuropathy which is most likely to be GBS. 2. Chronic inflammmatory demyelinating polyneuropathy 3. Predominantly peripheral motor neuropathy So to confirm my diagnosis, NCS, LP & to support my diagnosis FBC If having diarrhea or other infective features….. Rx: 1. Ig 2. Plasmaparesis if IG not available Mx 1. Monitoring & chart a. Single breath count tds b. Motor level tds 2. If rapid, send the pt to ICU 3. Check ETT & ambu 4. Cannulate: resp arrest 5. Notify If you are to ask a single question from the pt what are you going to ask? Temporal nature of disease & onset Spastic paraparesis 1. Transverse myelitis→ MS 2. Trauma→ brown sequard Ix: Thoracic lumbar xray Yapa Wijeratne
  6. 6. MRI-dorsal/ lumbar spine/ cauda equina Stroke > CT [Brain > CT, brainstem > MRI] Foot drop Ix: Xray : neck of fibula # Uss nerve Peripheral nerve > nerve biopsy- sural Muscle biopsy-gastrocnemius soleus (in a infant-vastus medius/lateralis) Any radiculopathy Xray AP/ lateral EMG: denervation features MRI of the area NCS: NO USE. Usually normal. Yapa Wijeratne
  7. 7. Yapa Wijeratne