History
- Symptoms:
- Difficulty in fine motor tasks (e.g., dropping things, clumsiness with buttons, using utensils).
- Walking difficulty, especially gait abnormalities (e.g., shuffling, broad-based, ataxic).
- Urinary or bowel issues.
- Neck or back pain.
- Radicular symptoms (pain radiating down the limbs).
- Are these symptoms progressive?
- Any systemic symptoms like weight loss?
- Any past treatment for similar episodes?
- Headaches?
- Past Medical History (PMH):
- History of cancers, strokes, cardiovascular disease.
- Social History (SH):
- Smoking history.
- Home circumstances.
- Support network.
Examination
Look
- Ask the patient to expose fully to examine both upper and lower limbs.
- Walking Aids:
- Note if the patient uses walking aids and their type.
- Front, Side, and Back:
- Check for scars, deformities, and muscle wasting.
- Rhomberg’s Test:
- Observe balance with eyes closed.
- Stand on Heels:
- Test for proprioception and gait stability.
- Stand on Toes:
- Check for strength and balance.
- Heel-Toe Walk:
- Assess coordination and gait pattern.
- Hands for Intrinsic Wasting:
- Look for muscle atrophy in the hands.
- Feet and Legs for Wasting and Clawing:
- Inspect for muscle wasting and foot drop.
- Gait:
- Shuffling, broad-based, ataxic, unsteady, prolonged stance, reduced cadence.
Feel
- Pain:
- Check for neck or back pain.
- Sensory Examination:
- Test dermatomes and peripheral nerves.
- Offer pin prick, soft touch, 2-point discrimination, and vibration testing.
Move
- Neck & Upper Limb:
- Assess neck movements (flexion, extension, rotation).
- Lhermitte’s Sign:
- Flex neck to provoke electric shock sensation down the spine.
- Spurling’s Test:
- Compression of the cervical spine to elicit radicular symptoms.
- Shoulder Abduction Relief Sign:
- Positive if symptom relief with shoulder shrug.
- Tone:
- Motor Power – Myotomes:
- Test key muscle groups (C5, C6, C7, C8, T1).
- Reflexes – Hyper-reflexia:
- Check for exaggerated DTRs (e.g., biceps, triceps, brachioradialis).
- Signs of Myelopathy – UMN Signs:
- Scapulohumeral Reflex:
- Brisk humeral abduction on percussion of scapula spine.
- Hofman’s Test:
- Flicking the nail bed to elicit finger flexion.
- Inverted Radial Reflex Sign:
- Flexion of fingers when pressing on the radial styloid.
- Ulna Finger Escape Sign:
- Flexion of fingers with resistance during extension.
- Lower Limb Examination:
- Same steps as above for sensory, tone, power, and reflexes.
- Tests for UMN Lesions in Lower Limb:
- Babinski Sign:
- Positive if there’s an up-going plantar response.
- Clonus:
- Hyper-reflexia:
- Exaggerated reflexes in the lower limb.
Finishing
- Offer to do PR (Per Rectum) and assess perianal sensation if indicated.
- Vascular Examination:
- Check for signs of vascular compromise.
- X-Rays:
- Full spine in neutral, flexion, and extension views.
- MRI Scan:
- To confirm diagnosis and assess for cord compression and neural involvement.
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