CLIN NEURO Upper Limb Exam

Question 1

Process of peripheral NEURO exam.

Answer 1

1. HH
2. Greet pt
3. Introduce yourself
4. Identify pt
5. Explanation of examination
6. Discuss exposure
7. Consent & confidentiality
8. Ask if the pt is currently in any pain/discomfort
9. Ask pt to properly exposure the area you want to examine
10. General Inspection
11. Look
12. Feel
13. Motor System Assessment
14. Sensory System Assessment
15. Radial Nerve
16. Median Nerve
17. Ulnar Nerve
18. Examine neck & spine
19. Redress.
20. Explain findings/results.
21. Ask if pt has Qs.
22. Thank pt.
23. HH.

Question 2

General Inspection

Answer 2

a. Pain
b. Aids
c. Gait
d. General appearance
e. Presence of any abnormal movements

Question 3

Look

Answer 3

a. Skin changes
b. Gait
c. Arm drifting
i. Closed eyes
ii. Extended & supinated arms
d. Muscle bulk/wasting
e. Fasciculation
f. Abnormal movements/tremor /spasm/dystonia /chorea /hemiballismus
i. Ask if intermittent/constant.

Question 4

Muscle bulk/wasting sign of:

Answer 4

Denervation, primary muscle disease or disuse.

Question 5

Fasiculation may be a sign of:

Answer 5

Benign/anterior horn cell disease.

Question 6

Dystonia

Answer 6

Slow, twisting movements.

Question 7

Chorea.

Answer 7

Dancing movements.

Question 8

Hemiballisms

Answer 8

Limb flung rapidly.

Question 9

Feel

Answer 9

a. Fasciculations
i. Tap lightly over muscles

Question 10

How to check for myotonia?

Answer 10

Handshake release
(If unable to release, may be a sign of myotonia).

Question 11

Motor System Assessment

Answer 11

a. Pronator Drift
i. Palms up and outstretched w eyes closed
b. Tone
i. Handshake
ii. Support under pt’s elbow
iii. Different speeds of flexing/extending/rotating elbow & wrist
iv. Gentle rotation movements of the elbow (side-to-side)
c. Power (do not assess at the same time unless underlined) – first ask pt to actively demonstrate movement you want to test and then apply resistive force
i. Shoulder
1. Abduction C5, C6
2. Adduction C6, C7, C8
3. External rotation C5, C6
ii. Elbow
1. Flexion C5, C6
2. Extension C7, C8
iii. Wrists
1. Flexion C6, C7
2. Extension C7, C8
iv. Fingers
1. Flexion C7, C8
2. Extension C7, C8
3. Abduction C8, T1
4. Adduction C8, T1
v. Thumb
1. Abduction
2. Opposition
d. Reflexes (need pt to relax)
i. Biceps C5, C6
1. Support pt’s forearm by either resting it on your forearm or by asking them to rest it on their thigh
2. Position the pt’s arm midway between flexion & extension
3. Place your thumb or index finger over the pt’s biceps tendon
4. Tap over your thumb/index finger
5. (Pt’s forearm should flex at the elbow).
ii. Brachioradialis C5, C6
1. Support pt’s forearm by either resting it on your forearm or by asking them to rest it on their thigh
2. Position the pt’s forearm midway between pronation and supination and the elbow flexed
3. Identify the brachioradialis tendon
4. Place your thumb or index finger over the pt’s brachioradialis tendon
5. Tap over your thumb/index finger.
6. (Pt should demonstrate flexion & supination of the forearm).
iii. Triceps C7, C8
1. Support the pt’s arm hanging so that her/his shoulder is internally rotated and at about 90o of abduction and the elbow at about 90o of flexion (midway between flexion & extension).
2. Identify the triceps tendon and its insertion on the olecranon
3. Tap over the tendon
4. (Pt’s forearm should extend at the elbow).
iv. Finger jerk C8
1. Ask the pt to open one of their hands and slightly flex 4 fingers (not the thumb).
2. Place the tips of your slightly flexed fingers over the pt’s fingers
3. Tap on your fingers
4. (Pt’s fingers should flex).
a. NB: If no reflex, ask pt to clench teeth/jaw on count of 3.
e. Coordination
i. Finger-to-nose
1. Extend pt’s arm to fullest
2. Finger stationary
3. Eyes open, then eyes closed
ii. Rapid alternating movements (clapping palm/dorsal surface of hand)
iii. Ballistic tracking
1. Same as finger-to-nose test, but with finger moving in horizontal plane.

Question 12

Power scale

Answer 12

0 no power
1 flicker
2 without gravity
3 movement overcomes gravity
4 overcomes gravity & some resistance (+/-)
5normal.

Question 13

Pronator drift may be a sign of:

Answer 13

Upper motor lesion.

Question 14

Spasticity vs rigidity.

Answer 14

Spasticity (pyramidal tract lesions) – velocity dependent, greatest at specific part of movement.
Rigidity (Parkinson’s disease) – velocity independent, resistant uniform through range of movement of the joint as affects agonist & antagonist muscles.
Remember S for spasticity for specific section of movement with observable difference in muscle tone.

Question 15

Dysdiadochokinesia may indicate

Answer 15

Cerebellar disease (unable to complete rapidly alternating movements).

Question 16

Overshooting in ballistic tracking may indicate:

Answer 16

Cerebellar disease.

Question 17

Sensory System Assessment

Answer 17

a. Pain – pinprick w neuro-tips
i. Reference point – top of chest
ii. Bilateral dermatomes
b. Temperature (w tuning fork)
i. Reference point – top of chest
ii. Bilateral dermatomes
c. Vibration – w 128 tuning fork
i. Reference point - forehead
ii. Bony prominence (e.g., DIP)
iii. Ask pt to say when it stops (corresponds to when you grip it)
1. If pt can’t feel than, keep moving more proximally.
d. Proprioception (always w pt eyes closed)
i. Isolate DIP and grasp on either side
ii. Tell pt what movement corresponds with up/down
iii. Ask pt if pointing up/down after series of random movements
e. Light touch – w wisp of cotton wool
i. Reference point - chest
ii. Bilateral dermatomes
f. Two-point discrimination – w paper clip
i. Use a clean paperclip.
ii. Reshape the paper clip so you can have the two endings ready to touch the patient’s skin simultaneously or with one end alone.
iii. Adjust the distance between the two ends as required. (e.g. 0.4 – 0.6 mm for the tips of the fingers and 3cm for palm.).
iv. Switch between using the two ends and one single end as the stimulus for touching the skin.
v. As the patient to report whether one or two points is felt.
vi. Decrease or increase the distance as required and note the shortest distance the patient is able to feel 2 points.
vii. Complete for one fingertip & palm
viii. Repeat bilaterally
g. Stereognosis
i. ID of unknown objects placed in pt’s hand

Question 18

Radial Nerve Assessment

Answer 18

a. Look for wrist drop
b. Ask pt to extend wrist & fingers
c. Ask pt to flex elbow & pronate wrist
d. Sensation in snuff box

Question 19

Median Nerve Assessment

Answer 19

a. Inspect thenar eminence
b. Pen Abductor Test
i. Reach up
ii. Adduct thumb with pen
c. Ochsner’s Clasping Test
d. Sensation of palmar lateral 31/2 digits, dorsal distal phalanx 2nd digit
i. Remember: Tinel’s & Phalen’s Test for Carpal Tunnel Syndrome screening.

Question 20

Abnormal result in Ochsner’s Clasping Test may indicate:

Answer 20

Cubital fossa lesion.

Question 21

Ulnar Nerve Assessment

Answer 21

a. Inspect for clawing of 4th & 5th digits
b. Froment’s Sign
i. Adduct to hold piece of paper with fingers as you try to remove from grip
NB: Be careful for flexing of thumb
c. Sensation on 5th digit

Question 22

Ulnar paradox

Answer 22

Clawing of 4th/5th digits - associated with ulnar nerve damage is not as exaggerated if nerve damage is more proximal.

Question 23

Reflex scale

Answer 23

0 - absent
+ - reduced
++ - normal
+++ - exaggerated
++++ - exaggerated & clonus.