CLIN SKILLS: PNS Upper Limb Exam

Question 1

PNS upper limb general exam process

Answer 1

• introduction
• inspection
• palpation
• motor
• sensory

Question 2

PNS upper limb inspection

Answer 2

• general appearance
• pronator drift
• muscle bulk of shoulders, arms, hands
• abnormal movements
• skin: lumps, rashes, scars etc

Question 3

pronator drift test

Answer 3

• extend arms @ shoulder lvl in supination and close eyes
• +ve if hands drift downwards towards pronation > UMNL (b/c pronator muscles are stronger > supination is harder to do)

Question 4

abnormal movements to check for during PNS upper limb inspection

Answer 4

• fasciculation: random quick muscle twitches
• tremor: hold hands w/ fingers spread out
• dystonia: slow twisting movements
• chorea: slow dancing movements
• hemiballismus: limb jerks rapidly

Question 5

2 types of tremor

Answer 5

• pathological: slower at rest and reduced by voluntary movement (Parkinson’s)
• intention: absent at rest and exacerbated by movement (cerebellar)

Question 6

how to assess tremor and what do you ask if they do have it?

Answer 6

• assess w/ fingers abducted
• ask whether intermittent (cerebellar issue?) or constant (Parkinson’s) and ask abt FHx

Question 7

palpation of upper limb PNS

Answer 7

• spasm (prolonged abnormal muscle contraction - squeeze over muscle)
• fasciculations (flick biceps, triceps, forearm to see if they twitch)

Question 8

how to do motor for PNS upper limb

Answer 8

• tone
• power
• reflexes
• coordination

Question 9

how to check for tone - upper limb PNS

Answer 9

• hold Pt’s hand in handshake position, supporting their elbow
• pronate and supinate, flex and extend elbow, flex and extend wrist - rapidly and slowly

Question 10

what is muscle tone and what happens if it’s abnormal?

Answer 10

• resistance of a muscle to passive movement
• hypertonia: UMNL
• hypotonia: LMNL

Question 11

how to check for power - PNS upper limb

Answer 11

• resisted movements (grade on 0-5 scale, 5 is normal)
• shoulder: abduction, adduction, external rotation
• elbow: flexion, extension
• wrist: flexion, extension
• fingers: flexion, extension, abduction, adduction (make sure wrist isn’t flexed, otherwise false weakness)
• thumb: abduction, opposition

Question 12

PNS upper limb reflexes

Answer 12

• biceps: rest arm on table/pillow in partial pronation w/ thumbs up), tap over fingers over biceps tendon
• triceps (do scarecrow position - internal rotation, 90 deg abduction, 90 deg elbow flexion, get them to rest their arm on you) and tap directly on olecranon
  brachioradialis: arm on thigh, midway b/n pronation and supination - thumbs up
• fingers: flex 4 fingers and tap over Pt’s fingers: feel them flex into yours

Question 13

coordination - upper limb PNS

Answer 13

• finger nose test: place your index finger @ arm’s reach from Pt, get them to touch nose and then your finger, then get faster and move your finger around a bit), COMBINE WITH ballistic tracking (Pt points at your finger and you randomly move it quickly and horizontally)
• rapidly alternating movements (keep one hand supinated, pronate and supinate the other as quickly as possible)

Question 14

dysdiadochokinesia

Answer 14

• reduced ability to perform rapidly alternating movements

Question 15

dysmetria

Answer 15

• difficulty in judging distance/ROM

Question 16

dyssynergia

Answer 16

• breakdown/decomposition of movement e.g. go to reach something then hand drops away

Question 17

sensory for PNS upper limb

Answer 17

• light touch: let them feel wisp of cotton wool on sternum first, then they tell u when they feel it on each dermatome - ask if it feels the same on both sides
• temperature: let them feel cold tuning fork on sternum first, then they tell u when they feel it on each dermatome - ask if it feels the same on both sides
• vibration: let them feel vibrating and still tuning fork on sternum first, then they tell u when they feel it vibrating and stopped on distal phalanx - if they can’t feel it move proximally
• proprioception - they tell u whether u moved their distal phalanx of finger up/down - hold finger from sides (if abnormal, move proximal)
• pain
• two-point discrimination
• stereognosis

Question 18

what spinal tract/s are tested by light touch

Answer 18

• spinothalamic
• DCML

Question 19

what spinal tract/s are tested by pain and temperature

Answer 19

• spinothalamic

Question 20

2 point discrimination and normal values for fingertips

Answer 20

• ability to recognise points of contact as 2 diff points instead of 1
• 0.4-0.6 cm

Question 21

stereognosis

Answer 21

• ability to identify an object placed in your hand w/o looking