NEUROLOGICAL LOWER LIMBS EXAMINATION #MDCN #CLINICALS #MEDICAL STUDENTS #RESIDENT DOCTORS

Today we will talk about the

neurological

examination

of the

lower

extremities and I will explain to you the key things that we need to do and the first thing is for you to know: wash your hands and read the instructions I am usually giving it written on the wall, so after reading the instructions and wash your hands, the next thing you should do is greet your patient and ask for their consent to continue telling them what you will do. Good afternoon sir. Good afternoon. Dr. Adul, I would like to examine your descents. It will include me moving your legs and also checking some of your reflexes.

Okay, can I continue first? Do you have any pain anywhere that I know of? So after that, you need to seek consent. and also trying to tell the patient what you have been doing, the next thing is to go to the foot of the bed and when you get to the foot of the bed what you should do is check for abnormal postures of the

lower

extremities. Is there any abnormal pulling, so you may want to put your feet together and see if there is abnormal posture? In this case, we can see that there is a lateral rotation of the left lower extremity and this could suggest weakness in the lower extremities, so the next thing we need to do is What you should also do is check for obvious scars on inspection, perhaps scars from a pendulum release surgery, which is not present in this case.

So if there is some obvious muzzle wear at times, you may notice that just by looking at the legs and bindings as well, but if you want to be objective, although time may not allow you to do this on the exam, so which obtains a reference point using the tbi tuberosity. You measure 18 or 20 cm up, there's like 20 cm up, then you measure the circumference at this 20 cm level, so that's what you do and then when you do this, you try to measure the circumference here, so taking it out here we have like 46 cm and then we do the same thing here, checking tbs brussels landmark type, please let me pull. increase your shot a little bit then we also measure the 18cm up so there should be a definite reference point so do that and then check the circumference okay then you try to compare if there is no difference then it is approx 46 too, so same thing.

What you do for the lower extremities, you may want to measure 10cm down from the tbs speed and then check the circumference as well. Then the same here, measure 10cm down and check the circumference, however for exams, especially if the exam is for five minutes, you may want to just take a look and see if there is any obvious muscle wasting, as you can notice in cases of conditions like polio, myelitis and then also in cases of muscle atrophy, then the next thing is to check. Is there any involuntary movement that may be present? Any fasciculation?

So there are no obvious fasciculations. The impression of the c

limbs

will suggest a lower motor neurologist and this will be evidenced by muscle contraction so that he can spontaneously check if there is no check for spontaneous fasciculations. Then after that you can try tapping, so I'll tap a little bit, okay, and see if there's anything else that can move, or you can just do this and see if there's the most trigger twitches, so no I can. Appreciate n now, which suggests that there are no first equations and sometimes just see if there are obvious tremors, so the only way to remember this is to use the mnemonic p swift, so p means postural abnormalities, s means scars, loss of i for major movements f for aspirations and t for tremors, next is checking tone, so while you check tone, tone is the resistance to passive movements through a joint, so you'll check through from the hip joint, through the knee joints and through the ankle joint and you should check at the same time, you know bilaterally, when you check the right, anything that checks the right, you should also check the left, so again I said it's the resistance to passive movement through a joint, so the hip joint before you touch, I'll tell you again just to confirm if you have any joint pain.

It's not right, so I'm going to move your thighs down because I wanted to relax as much as possible, so this is to avoid. a condition called paratonia, but if the patient doesn't relax, then you could interpret this as hypertonia, so I'm going to move that, so I'm going to move your

limbs

for me, make you know as free as possible so that you can. You see the fault and I almost move with ease. I rotate it when I move the beats or when I roll the bindings, but on the other leg, yeah, which is rotated outwards, you find that when you try to do this, you know, I notice that there is some resistance. you know through you know the hot joint here then I will go to the knee joint there are two techniques you can do this and try to tell him to do it you can relax for me then do the movement then you did the movement and look for the resistance then that es, then check the other one and check if there is any resistance, so it feels a little stiff here, okay, that's it, so I can say that at this point there is some hypotonia.

Another way to check is to do this. You simply tell them to relax as much as possible. You know, just try to lift them up so you find that the legs are relaxed here and move easily, but these are on this leg where you have the most tone when you move. the eel's up legs come completely off the bed because of the hypotenuse, so you do it one, two, three and you can see the whole leg coming up in contrast to the other one where the heel was still on the ground, that tells you that there may be some hypotonia there, so you can do that, so there are two ways you can check the tone in nature and finally in the ankle joints, check that the movement stabilizes just above, then do this as well and then the next thing is To check the thick part, can you move this leg up so that it at least has a power of three more so that you can move it and hold it in the air?

So can you move the other one too so he can? I'm not moving it in a way that suggests the power has been reduced to three, so you have to check if the power is two, one, or zero. So can you move it in and out for me in the back? Okay, so you can still move it horizontally without the influence of gravity, so I'll give you a power of at least two, you couldn't do this, the next thing is to ask you to move your toes for me and if you can do that , it would be a score of one and he's still not able to do that, so I'm going to give him a score of zero and after that, now I'm going to check the individual muscle groups, so next is to check the hip flexors, which are the ones in the swiss I push my hands up please up up up so this seems weak so can I push my hands towards the bed okay this seems weak too so can you put your restraints together, Please, okay, this seems weak too, so can you take my hands off?

The next thing to do this, you want to check your knee flexors, which are your hamstrings, can you pull? Take the heel towards the botox, okay, so can you do the same thing here? heal towards botox, okay, that's weak, you can't do that. Now can you move my hands away from me, okay, I move my hands away, that also seems weak and finally look at the foot, it's like you press my hands down like you know how to press the pedal, can you do the same? here, so that's weak, you can't do that, can I push my hands up?

Okay, push my hands up, so you can't do that, then you check the inversion and version e can push my hands toward the center, you can do that. that here looks weak here so I can push my hands out so it also looks weak so you can also quickly check your l5 and s1 so I can push my finger down this is s1 what's going on here? so that's weak, okay? Don't push my finger now, you can't lift it very well, that's l5 and all that, it can't do that, so the next thing now is to check the reflexes, so one of the ways to remember the reflexes is the ankle jack , deep tendon reflexes, ankle jack is one, two, that's s1, s2, then knee jack is three four, then supinator jack is five six, biceps rupture, flexion that's five six seven eight is the um triceps that flexes.

So one of the ways we can remember that you know is one of the rhymes from elementary school days when they said one, two, dollar, three, four, knock on the door, but in this case, maybe, kick the door, then five. six lift six that's for five biceps and break realistic lift six then seven eight lay them straight so those are the root values ​​so since we're focusing on the lowest density so we start this is the technique you let it relax stretch the tendon a little bit, this is your tbs speed, this is your kneecap, so you're hitting the shank down here, so you're hitting the tendon and when you hold your reflex armor and you drop it on the particular ligament or the string, paying underneath of the standard. attention to the muscle um twitch here please let me take it down so we'll look at that now so I'm going to hit and when I hit I'm not going to quickly take off the armor on my kneecap so I'm going to let it stay like you know for a few seconds or so, okay, that's it, then look at the other one, support it and then hit, oh, okay, let's see a hyper reflex there and then for the ankle, you know? bend your knees.

You know, bent like this, stretch it a little bit, you might not need to put it on the other leg, so this is good like this and it hits and this other hit that looks increased, okay, so it looks increased, it has the ankle. so what you want to do at this point is also check your um my extensive plantar response check. You can use your orange stick or on what occasions you can use your tip or your reflex armor to check the plantar response. The ideal response is flexographic, so we come from lateral to medial and a single stroke, so the flexors pay attention to the first movement of the big toe and then the other, okay, that's another extensor response, an extensive plantar response, there you want to check your clonus to check for clonus, bend your knees a little bit, then flex and plantarflex your foot and then hold it with your hand, so let's do something like this one two and then hold it, so if there is clonus , accept some flapping movements. again one two so you can see some checks, you know, movements without clones, empty, modern, three, you know, suggested sustained clonus, um, so you might also want to check your coordination quickly so you can move the heel on the shin, please pick it up and do it again.

Okay, that's checking coordination, but if there's any cerebellar impairment, you might not be able to do it, you won't hit the target, so you're going to demonstrate it to us now. Okay, let's understand what's okay, so you'll see when you do it. We're moving this way, okay, so we miss the target, which suggests that there are no coordination problems, so ultimately, that's for the motor system, so it's important that you read the instructions carefully, since The instructions say to do the motor system. Obviously you don't need to go into the sensory system, but if the scenario says to do a

neurological

exam of the lower extremities, you need to go ahead and also check your sensory modalities, so the next one we'll check is all five. mode of thinking, so it's important that you know, remember the gamma tools that your first pocket in the Thai is l1 the second area the second pocket l2 the top rocket is healthy the media side here is l4 the side side there and the dozen is predominantly l5 so the sole of the foot and the lateral edge is s1 most of the back of the leg and the tie is s2 then you sit on the three letter word s3 and then on s3 that is the speed of your scale and you shoot your fun way to remember four letter word with s4 which is the perianal area so you check them at home starting from the feet then you go up to the right to tell him how he's going to feel so you have to be aware um so he's going to feel something like this Does it feel like a cut?

Yes or how it feels. I see something. Okay, so let me. Can you let me know when you feel him touching you? Just say yes when it's your turn. Okay, it's important not to tell the patient when you do the system.

examination

, so it is wrong for you to say something like: "you know" when you touch the patient, it is wrong for you to say "you feel him touching you now." That's wrong so you don't let the patient know so what you just need to tell him is as soon as you feel he's touching you just say yes so do it damaging by diameter so close your eyes please , just say yes when you feel like it's your turn, yes, yes, that's okay, yes, that's okay, so you can keep saying yes, that's okay, everything is okay. here,okay so you know you keep checking yeah you have to know make sure you're checking the same area and check that you know whatever you check on the right you need to check on the left.

It's wrong for you to complete your exam. right, then now go left, that's wrong. Whatever you check on the right, you must simultaneously check on the left, so the next thing is to also check the challenge position. Sense of 10 percent. Can you look at me please, so this is up? This is facing down, so please don't hold the nail bed, keep all sides together. Good grip on the position of your joint. Sense that is meditated by a bulldozer column, just like its fine touch too. The client's fine touch is also meditated. by the dosa column or the back collar, same here sir, this is up and this is down, okay, okay, so hold it gently, so close your eyes, please let me know what is up or down.

What happens now? Wait please, what happens now? Not very well, so the next thing is to do what happens with this place, so let us. I know what is above or below, okay, so what about what you will see above or below? Let me know, yeah, you're not sure. Okay, so if he doesn't get the rice from him, you might want to go ahead and do it. You know, check the ankle level and tell him this is up or down, so as soon as he's absent as soon as he's absent in the around, the force method has fallen on his joints, check the ankles, so I mean . to check if the joint question says intact in the same way, you can just say this is up, this is down and see what is able to recognize that, so it doesn't seem like it's just a problem of detecting the position of the joint, then the user has a vibration detection problem 128 That Sony fork is set to vibrate.

I'm telling you, can you feel the vibration? just the whole base of 24, okay, can I feel something? Yes, I feel the vibration, yes, let me know when it stops. Alright, do the same thing here at the base of the first letter. Anything, no, okay, then keep going up, you can go. To the media, my little ones, what happens now? Yeah, I mean, let me know when it stops okay, okay, okay, anything, no, okay, okay, so it looks like it's damaged on the side, so you can tell, put the tips into action or you can. just hit the wall, you know, hit your, you know you gotta put it on vibrate, but remember you hold the bass and all the prompts and sometimes if there's a needlepoint pen, you can also check for pricks and all the modalities.

I think after this it's important to know that if the person doesn't feel sensation all the way to the anterior superior column of the leg, any sensory loss below suggests peripheral neuropathy, but the person tells you that you know he can't feel. feel the sensations and go above asis, especially if it's affecting both lower parts, it's affecting both lower extremities and people can't feel your cut, they'll feel your pain breaking or even the vibratory sensation that you keep coming up from the base of the first goal. cell to your medial malleolus to your tibia tuberosity to your upper anterior like the spine to your sevistano and the person tells you I'm not sorry, it's most likely a spinal cord problem, so most Sometimes the end cut problems will have a sensory level visually above the anterosuperior elastic column, another thing you may also notice is that there will be weakness in both extremities and there will be some sphincter incontinence, so if I get to the exam where you will see a patient that is in unicaster or pampers it, then the person can also move the volumes of the bottle and then you have a sensory level that you believe is a spinal cord pathology, so you want to complete your examination by telling the patient to check the back of the patient, so you check the patient's back asking him if he feels okay, then you look back to check, so I'm going to lift this up so you can check for any deformity you want to check for any spinal deformity, so that's what you're trying to check.

I also want to check for tenderness in the back and ask if you feel any pain anywhere, okay then it is deformity and then tell the patient to complete their exam. He won't look at the door. Tell the patient to work so that you know if there is any problem at the door, at the same time my expression is to stand with your feet together and eyes closed to check the back of your room, which could also be positive in conditions like the ones you have problems with the dozer column, so it is important to know. that the bulldozer spine mediates those economies um fine touch vibration sensation joint position sensation and your room back, so it can be difficult to demonstrate all those signs on the exam finally my expression to work in tandem for you, that means walking in a straight line while Looking forward for cerebellar signs, that brings us to the end of the neurological examination of the lower lips.

Thank you thank you very much. Thank you very much to your patients. Thank you so much. Clean your eyes afterwards. Thanks, then you can cover. up to your patients you know it and thank you