Stanford Medicine 25:

1) Gaits:
a) Hemiplegic: This is the most common gait. The patient stands with unilateral weakness on
the affected side, arm flexed, adducted and internally rotated. Leg on same side is in
extension with plantar flexion of the foot and toes. When walking, the patient will hold his or
her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to
weakness of distal muscles (foot drop) and extensor hypertonia in lower limb. This is most
commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight
circumduction may be the only abnormalities.

b) Diplegic: Patients are involved on both sides with [extensor] spasticity in lower extremities
worse than upper extremities (tip-toe). The patient walks with an abnormally narrow base,
dragging both legs and scraping the toes. There may be scissoring of legs due to tightness
of hip adductors.

c) Parkinsonian: The patient will have rigidity, bradykinesia and universal flexion. Head, neck
will be stooped, the upper extremities are also in flexion with the fingers extended. Marche a
petits pas (festination). Patients can have difficulty initiating steps or may tend to accelerate
them. Parkinson’s disease or DIP (atypical antipsychotics, antiepileptic drugs, CCB,
gastrointestinal prokinetics).

d) Cerebellar (ataxic): Wide-based gait with clumsy and staggering movements. Resembles the
gait of acute alcohol intoxication. While standing still, their body goes into titubation. Patients
will tend to fall towards the side of the cerebellar injury.

e) Myopathic: Hip girdle muscles (abductors) are responsible for keeping the pelvis level when
walking. If you have weakness on one side, this will lead to a drop in the pelvis on the
contralateral side of the pelvis while walking (Trendelenburg sign). With bilateral weakness,
you will have dropping of the pelvis on both sides during walking leading to waddling. This
gait is seen in patient with myopathies, such as muscular dystrophy.

f) Neuropathic (steppage): Seen in patients with foot drop (weakness of foot dorsiflexion), the
cause of this gait is due to an attempt to lift the leg high enough during walking so that the
foot does not drag on the floor. If unilateral, causes include peroneal nerve palsy and L5
radiculopathy. If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth
disease and other peripheral neuropathies including those associated with uncontrolled
diabetes.

2) Fundoscopic exam:
a) Vessels emerge from the nasal side of the disc. Arteries are narrower than the veins. The
cup-to-disc ratio is normally 0.5 (this is increased in glaucoma).
b) Optic disc blurring in the setting of increased cranial pressure is referred to as papilledema
(tumors, sinus thrombosis, hydrocephalus, meningitis, malignant hypertension).

c) Roth spot (retinal hemorrhages with white or pale centers) typically caused by immune
complex mediated vasculitis often resulting from bacterial endocarditis.
 d) AV nicking (chronic hypertension stiffens and thickens arteries which will then compresses a
venule resulting in bulging on either side of the crossing) and cotton wool spots (fluffy white
patches caused by damage to nerve fibers because of axoplasmic material accumulation
from ischemia – this is found in diabetes and hypertension). Cholesterol emboli. Flame
hemorrhages (necrotic vessels bleeding into retina), copper-wire arterioles (central light
reflex occupies most of the width of the arteriole), silver-wire arterioles (reflex occupies all
the width).

3) Ankle-brachial index:
a) ABI is the systolic pressure at the ankle, divided by the systolic pressure at the arm. It is a
s/s metric for the diagnosis of peripheral arterial disease. Major cardiovascular societies
advise measuring an ABI in every smoker or diabetic over 50 years and all patients over 60-
70.
b) Blood pressure cuff and handheld doppler to measure the SBP in brachial and posterior tibial
or dorsalis pedis artery.