Lower Neurological Sensory Examination
The sensory examinations follow the same sequence - inspection, light touch, superficial pain, temperature, vibration, proprioception and Romberg's. For these exams in particular you need to remember to keep explaining to the patient what you're doing, as otherwise it can be quite an invasive and confusing examination.
As with all the examinations, begin with the same opening sequence. Being friendly and rewording questions to make them sound less rehearsed will make your bedside manner appear much more natural and confident.
- Wash hands
- Introduce yourself
- Confirm their name, age and date of birth (try and remember the first 2 for your closing summary!)
- Consent eg. I've been asked to do a sensory examination of your lower limbs today which will involve testing different aspects of sensation of your legs - is that alright with you? I'll explain everything as I go along. - Again, rephrase to what you feel most natural saying.
- Check for pain or problems in movement
- Expose the patient appropriately (remove trousers for lower sensory examination)
The inspection step is much shorter than in some other exams - it's just a quick comment on the signs below.
- Is the patient comfortable/in pain?
- Muscle wasting
The light touch step is done by dabbing the patient with a wisp of cotton wool over different dermatomes. Firstly perform a 'control' by asking the patient to close their eyes and dabbing their sternum - remembering to explain what you're going to do first! Then ask the patient to lay comfortably with their palms facing up. With an irregular rhythm, tap each of the dermatomes in turn, alternating between legs. When you feel the cotton wool can you say yes for me please? Saying the dermatomes as you test them proves to the examiner that you know exactly what you're doing, and may gain you extra marks.
The superficial pain step is very similar to the one above, but instead uses a Neurotip to assess the patient's ability to discriminate between the sharp and blunt side of the tip. Again do a control and then alternate between the legs. Swap between blunt and sharp as you like, but remember that the 'sharp' side needs to be tested on every dermatome by the end of you examination.
Don't forget to dispose of the used pin in a sharps box!
Temperature is not routinely assessed by us, but asking a question such as have you noticed any change in your perception of temperature? would show that you're acknowledging this step before you move on.
The vibration test uses a 128 Hz tuning fork (make sure you pick up the right one!) As with the previous steps, begin with a control test by placing the vibrating tuning fork on the patient's sternum while their eyes are shut, and asking them to tell you when the vibration stops (touch the end of the fork.) The lower limb vibration examination is done on the distal joint of the big toe, progressing proximally if the patient's vibration sense is abnormal. I'm going to place this tuning fork on your toe and you should feel it vibrating - can you tell me when it stops?
With the proprioception step, initially you demonstrate with the patient's eyes open rather than a control with the eyes shut. Hold their big toe on either side with two of your fingers, stabilising the toe above the distal joint with your other hand. Demonstrate moving the distal joint up and down. Then move on to do the test with the patient's eyes closed, asking them to state whether the joint has been moved up or down. A sequence of about 6 movements is about right, but make sure that it's all random, not an obvious pattern.
Can you stand up for me and close your eyes please? I'm going to assess your balance, but don't worry, I'll be here to catch you if you're unsteady. Any swaying or great loss of balance is a positive Romberg's sign and would show sensory ataxia.
As always, end your examination by thanking the patient, allowing them to cover themselves up, and washing your hands.
SUMMARY - as at the end of every examination you will be asked to summarise your findings. Begin with their name and age, and then briefly comment on each section before finishing with an overall statement such as this was a normal sensory examination.