Clinical 13: Peripheral Neurovascular exam

Question 1

What is a good way to remember what to do in a peripheral neurovascular exam?

Answer 1

I Saw Two People Riding Camels Slowly
Inspection, Special Tests, Tone, Power, Reflexes, Co-ordination, Sensation (light, pain, proprio and vibration)

Question 2

What should you look for in general inspection of a patients are the starts of a peripheral nerve examination?

Answer 2

Facial expression, alterness
Loss of muscle bulk
Fasciluations
Abnormal movements
Tremor.

Question 3

What special tests are performed in the upper limb part of the PNE?

Answer 3

Hold arms out straight, eyes shut:
Check for psueodarthiritis with palms down, protonartor drift with palms up
Rebound : push arm down, watch for overcompensation

Question 4

What special tests should be perfomed in the lower limb part of the PNA?

Answer 4

Gat - normal, heel-toe, tiptoes, heel-walking
Rombergs test - proprioceptive loss (feet together close eyes, stand still, support with hand on either side)

Question 5

What are the different types of patholigical tone in the PNE?

Answer 5

Hypotonic
Hypertonic
Claps knife spacticity - increased tone associated with UMNL
Lead pipe rigidity - hypteronia associated with Parkinsons disease
Cogwheel rigidity = a combination of led pipe rigidity and superimposed tremor.

Question 6

What is tested for tone in the lower limb PNE?

Answer 6

Pastry roll
Heel flick / leg lift
Clonus (<5 beats is abnormal)

Question 7

What scale should power be graded against?
What are the different grades?

Answer 7

0-5 on the MRC scale
0 - no contraction
1 - flicker of contraction
2 - active movement with gravity eliminated
3 - active movement against gravity
4 - active movement against gravity and resistance
5 - normal power.

Question 8

What different motions should be tested for power in the upper limb?

Answer 8

Shoulder - abduction and adduction
Elbow - flexion and extension
Wrist - flexion and extension
Fingers - abduction, adduction and extension
Thumb abduction

Question 9

What different movements for power should be tested in the lower limb exam in PNE?

Answer 9

Hip - flexion and extension
Knee - flexion and extension
Ankle - dorsiflexion and plantar flexion, inversion and eversion
Big toe dorsiflexion

Question 10

What reflexes are tested in the upper limb?
What are the associated nerve routes?

Answer 10

Biceps jerk = C5,6
Triceps jerk = C7
Supinator (brachioradialis) = C6
(Finger jerk = C8) - occurs during biceps or supinator

Question 11

What are the different reflexes tested in the lower limb neurovascular exam?
What are the associated nerve routes?

Answer 11

Adductor reflex: L3
Knee jerk : L3,L4
Ankle jerk: S1,S2
Plantar reflex : S1,S2.

Question 12

How do you test coordination in the upper limb?

Answer 12

Finger-nose test (Vary the target)
Rapid alternating movement (slappy hands)

Question 13

How do you test co-ordination in the lower limb examination?

Answer 13

Heel-shin test
Tap feet against my hands as fast as possible.

Question 14

How do you assess sensation in the upper/lower limb?

Answer 14

Test each dermatomes for:
Light touch - cotton wool
Pin-prick - neurotip
Vibration - tuning fork
Proprioception - moving distal phalanx up/down

Question 15

What notation is used to classify the different tendon reflexes?

Answer 15

+++ hyperactive
++ normal
+ sluggish
± only with reinforcement
- absent

Question 16

What are the key signs of an upper motor neuron lesion as different stages of the PNE?

Answer 16

I - pronator drift
T - spasticity (clasp knife), clonus
P - weakness
R - brisk, extensor plantar response (+ Babinski sign)

Question 17

What are the key signs of a lower motor neuron lesion on a PNE?

Answer 17

I - wasting, fasciculations
T - decreased, absent clonus
P - weakness
R - reduced, down-going plantars.

Question 18

What are the different signs of cerebellar dysfunction?

Answer 18

DANISH
Dysdiadochokinesis - impaired rapid alternating movements.
Ataxia - wide based gait, exacerbated by heel to toe
Nystagmus - rapid alternating eye movements
Intention tremor - touch my fingertip
Staccato speech - say canada goose.
Hypotonia - acute cerebellar damage.

Question 19

What are the different dermatomes in the upper arm?

Answer 19

Question 20

What are the different dermatomes in the lower limb?

Answer 20

Go down the inner leg one above knee, knee, below knee, big toe, then the heal on the outside.