Reset 10 mins Pause Candidate instructionsActor instructionsMark 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 lower 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 if the candidate 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 Gait Gait First asks if the patient is safe to walk Observes gait 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 photo_camera Sensation 2 - light touch. Please state nerve root when examining Antero-medial thigh Nerve root L2 Sensation 3 photo_camera Sensation 3 - light touch. Please state nerve root when examining Medical thigh just above knee L3 Sensation 4 photo_camera Sensation 4 - light touch. Please state nerve root when examining Medical malleolus L4 Sensation 5 photo_camera Sensation 5 - light touch. Please state nerve root when examining Dorsal 1st web space L5 Sensation 6 photo_camera 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 photo_camera 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 Submit your answers to get your score.