1. Prof. M.ABD ELAZIZ, MD, Ph D- Clinical Pharmacology Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University Mohammad Ruhal Ain (M Pharm, R Ph, PGDPRA) Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University

2.  A full neurological examination includes assessment of the motor and sensory systems.

3. Introduce yourself to the patient and ensure that you have explained the procedure. Inform them that if they feel any discomfort then they are to let you know. Subject steps Introduction

4. - Tone - Power - Reflexes - Function - Sensation Subject steps The patient should have their lower body exposed, although in an exam situation the patient will be in shorts. Initially, observe the patient’s legs, look for any muscle wasting, fasciculation's or asymmetry.

5. TONE Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily, then pull up on the knee to check its tone.Start Check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it.clonus Any further movement of the joint may suggest clonus. clonus

6. Assess leg tone Assess knee tone TONE Cont…………………..

7. Check for ankle clonus

8. POWER Next assess the power of each of the muscle groups. Again, start at the hip asking the patient to abduct, adduct, flex and extend against your hand so you can assess how much force they can overcome. Do the same for flexion and extension at the knee and ankle as well as the toes.

9. POWER Cont……… Assess hip flexionAssess hip extension

10. Assess knee flexion Assess knee extension POWER Cont………

11. DorsiflexionPlantarflexion POWER Cont………

12. Toe dorsiflexion Toe plantarflexion POWER Cont………

13. REFLEXES Move on to test the patient’s reflexes. There are three reflexes in the lower limb: 1.The patellar reflexThe patellar reflex 2.The ankle jerkThe ankle jerk 3.The plantar reflex (elicited by stroking up the lateral aspect of the plantar surface)The plantar reflex

14. Reflexes Cont……… The patellar reflex is tested by placing the patient’s leg flexed at roughly 60º, taking the entire weight of their leg with your arm, and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg. The patellar reflex test

15. The ankle jerk is elicited by resting the patient’s leg on the bed with their hip laterally rotated. Pull the foot into dorsiflexion and hit the calcaneal tendon.calcaneal tendon The ankle jerk test Reflexes Cont………

16. Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex. An abnormal reflex would see the great toe extending.great If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex. Reflexes Cont………

17. FUNCTION -Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. - For the lower limb you should assess the patient’s walking. Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg’s test. Romberg’s test - Ask the patient to stand with their feet apart and then close their eyes. - Any swaying may be suggestive of a posterior column pathology.

18. Assess patient walkingRomberg's test Function Cont………

19. SENSATION The final test is sensation. Sensation is assessed in a number of ways. Test: light touch, pin prick, vibration, and joint position sense, or proprioception. proprioception Ask the patient to place their legs out straight on the bed. Lightly touch the patient’s sternum with a piece of cotton wool so that they know how it feels. With the patient’s eyes shut, lightly touch their leg with the cotton wool. The places to touch the patient should test each of the dermatomes – make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before.dermatomes

20. Then repeat this using a light pin prick. Sensation test with cotton woolSensation test with a pin prick Sensation Cont………

21. VIBRATION-TUNING FORK Place the fork on the patient’s sternum to show them how it should feel. Now place the tuning fork on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the tibial epicondyle and then to the greater trochanter until it feels normal.medial malleolusgreater trochanter

22. Vibration test Vibration Cont………

23. Finally assess proprioception.proprioception Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position – up or down. Ask the patient which position the joint is in.

24. Flex the interphalangeal joint upFlex the interphalangeal joint down