Basic Neurological Exam of Upper Limbs Flashcards
What are the main steps in an exam of the upper limbs?
Prepare patient Hand hygiene Inspection Tone Power Deep tendon reflexes Coordination Sensory exam Complete exam
What is the adequate exposure for this exam?
Singlet or t-shirt off
How do you prepare the patient?
Explain reason for exam In general what it'll involve Ask about pain in arms Advise them to inform you if exam uncomfortable/painful Ensure arms adequately exposed
How do you inspect the patient?
Ask patients to rest arms on pillow Inspect upper limbs Inspect cervical spine - Scars - Deformity Posture of limbs Muscle bulk - Note particular pattern if any muscle wasting Fasciculations
How do you measure tone?
Assess passive resistance against movement
Make sure patient is relaxed
Flex and extend elbow
Flex and extend wrist
Rapid supination and pronation of forearm whilst supporting elbow
How do you measure tone if resistance is detected?
Make moves unpredictable
How do you measure power?
Functional testing Compare both sides Start at shoulder Progress distally from joint to joint Clear and explicit instructions
How do you test for mild upper limb weakness?
Ask patient to close eyes
Hold arms straight out with palms facing upwards for a minute
What do you see in the test for mild upper limb weakness if there is reduced strength?
Arms start to pronate and drift down = pronator drift
What kind of patient is the mild upper limb weakness test good for?
Stroke patients
What may affect how a patient performs in a power exam?
Motivation
Pain
Changes in tone
Your own muscle strength
Which nerve roots control shoulder abduction?
C4, C5, C6
How do you test the power of shoulder abduction?
Ask patient to flex arms at elbows
Abduct shoulders to 90 degrees
Patient maintains position as you push down on elbows
Which nerve roots control elbow flexion?
C5, C6
How do you test the power of elbow flexion?
Patient flexes elbow
Apply counter resistance to forearm
Which nerve roots control elbow extension?
C7, C8
How do you test the power of elbow extension?
Patient extends elbow
Apply counter resistance to forearm
Which nerve roots control wrist extension?
C6, C7
How do you test the power of wrist extension?
Patient makes fist
Place your fist against back of patient’s hand
Patient tries to bend back wrist whilst you apply counter resistance
Which nerve roots control wrist flexion?
C6, C7, C8
How do you test the power of wrist flexion?
Patient makes fist
Flex wrist as you apply counter resistance
Which nerve roots control finger extension?
C7, C8
How do you test the power of finger extension?
Patient holds fingers out straight
Place your hands against back of patient’s fingers distal to metacarpophalangeal joints
Patient keeps fingers straight as you apply counter resistance
Which nerve roots control finger flexion?
C7, C8
How do you test the power of finger flexion?
Patient curls fingers up
Keep them flexed while you apply counter resistance
Which nerve roots control finger abduction?
C8, T1
How do you test the power of finger abduction?
Patient spreads fingers
Resist as you squeeze them together
What else does testing the power of finger abduction measure?
Ulnar nerve function
How do you test the power of finger adduction?
Patient holds folded piece of paper between fingers
You try to pull it away
What else does testing the power of finger adduction measure?
Ulnar nerve function
Which nerve roots control finger adduction?
T1
Which nerve roots control thumb abduction?
T1
How do you test the power of thumb abduction?
Abduct thumb up to touch your finger
Apply counter pressure
In which direction is thumb abduction?
Same direction as finger flexion
What else does testing the power of thumb abduction measure?
Median nerve function
Where are the deep tendon reflexes in the upper limb?
Biceps jerk
Brachioradialis jerk
Triceps jerk
Finger jerk
What must the patient be to test deep tendon reflexes?
Relaxed
What reinforcement can be used to test deep tendon reflexes in the upper limb?
Clench teeth
How do you test the biceps jerk?
Patient sits facing you Hands on lap Place your thumb/forefinger over biceps tendon at elbow Tap it with your tendon hammer Look for flexion at elbow
Which nerve roots are involved in the biceps jerk?
C5, C6
How do you test the brachioradialis jerk?
Tap over lower end of radius
Look for flexion of elbow and/or supination
Which nerve roots are involved in the brachioradialis jerk?
C5, C6
How do you test the triceps jerk?
Tap over triceps tendon
Look for brisk extension of elbow
Which nerve roots are involved in the triceps jerk?
C7, C8
How do you test for the finger jerk?
Lift patient’s fingers passively against your own
Tap your fingers
Which nerve roots are involved in the finger jerk?
C8
How do you test for coordination in the upper limb?
Finger-nose test
How do you perform the finger-nose test?
Ask patient to touch tip of their nose with their index finger >
Stretch out to nearly full extension of shoulder and elbow >
Touch your index finger repetitively
Perform for both arms
What is dydiadochokinesis?
Clumsiness of pronating and supinating one hand on the other
What sensations are tested in the upper limb?
Pain with toothpick
Light touch with cotton wool
Vibration sense with tuning fork interphalangeal joint of thumb
Proprioception of thumb
What are the dermatome testing areas of the upper limb?
C4 = shoulder C5 = "military badge" area of upper arm C6 = tip of thumb C7 = tip of middle finger C8 = tip of little finger T1 = upper inner arm
What is the last step in a neurological exam of the upper limb?
Close exam
