Royal Australasian College of Physicians Examinations/Resources/Clinical Exam/Short Cases/Neurology/The Lower Limb Examination

Work in progress!

This card is a suggested method for the neurological examination of the lower limb.

Example Stem: "This patient has noticed difficulty walking.  Please examine him."

Initial Inspection

 * Wash your hands
 * Introduce yourself to the patient and shake their hand
 * Ask the patient to undress to their underwear
 * With the patient standing upright in front of the examination couch, perform a general inspection
 * Look for wasting or asymmetry
 * Look for unsteadiness of their posture at rest
 * Ask them if they usually require a walking aid
 * Get them to walk a few steps away from you, assessing their gait
 * Ask them to turn and walk back towards you
 * Test their Rhomberg's sign by asking them to stand with their feet together, then close their eyes
 * Make sure they are standing away from the couch / wall so they cannot lean against it
 * Be seen to be ready to catch them if they are Rhomberg's positive
 * If their gait was normal and there was no obvious weakness, test proximal strength by asking them to squat, then rise from squatting
 * If this is normal, then ask them to repeat, looking for fatiguability suggesting myaesthenia
 * If the patient is able to do this, the abnormality is probably not in the motor system
 * While they are standing, examine their lower back for scars or tender areas
 * Ask them to lie supine on the couch
 * At rest, examine proximally for fasiculations in the thigh muscles

Assess Tone

 * Ask the patient to try and relax completely. Explain you will move their leg, but you do not want them to help at all
 * Dorsiflex and plantarflex one ankle a few times to assess their relaxation. Once happy they are relaxed, forcefully dorsiflex (not too hard!) to look for clonus