Neurological exam Flashcards
How would you start an upper limb neurological examination?
Inspection:
- Scarring, symmetry
- Wasting
- Abnormal and involuntary movements
- Fasciculations
- Tremor
Look for UMN lesion posture
Pronator drift
What is the UMN posture?
Shoulders adducted, elbow and wrist flexed, pronated
How would you assess tone in an upper limb neurological examination?
“Let your arm go floppy”
- Flex/extend elbow
- Flex/extend wrist
- Pronate/supinate
What is increased tone a sign of?
UMN
How would you assess power in an upper limb neurological examination?
Ask patient to push away and pull towards; grade power out of 5
- Shoulder abduction - C5
- Shoulder adduction - C6/C7
- Elbow flexion - C5/C6
- Elbow extension - C7
- Wrist extension - C6
- Wrist flexion - C6/C7
- Finger extension - C7
- Index finger
- Little finger
- Thumb abduction - C8/T1
How would you assess reflexes in an upper limb neurological examination?
- Bicep jerk - C5/C6
- Tricep jerk - C7
- Supinator jerk - C5/C6
What is an increased reflex a sign of?
UMN
What is an absent reflex a sign of?
LMN
How would you assess sensation in an upper limb neurological examination?
Say yes when I touch the skin
- Above the shoulder tip - C4
- Deltoid area - C5
- Lateral forearm/thumb - C6
- Middle finger - C7
- Little finger/medial forearm - C8
- Medial arm - T1
Vibration sense
Joint sensation
Where would you check for vibration sense in upper neurology?
Bone prominence on thumb, then radial styloid, then olecranon, then shoulder
How would you assess coordination in an upper limb neurological examination?
- Piano playing (difficult in Parkinson’s)
- Hand slapping (cerebellar ataxia)
- Finger-nose test (cerebellar ataxia)
What causes an intention tremor?
Cerebellar lesion
What is the grading of power list?
5 - normal: full power against resistance
4 - reduced: able to move against some resistance
3 - able to move against gravity; unable to move against resistance
2 - Unable to move against gravity, but can move when gravity is eliminated
1 - visible flicker of muscle contraction, but no movement across joint
0 - no muscle contraction
What is Erb’s palsy?
C5-C7 lesion, often dude to shoulder dystocia during childbirth
Sensory loss down lateral arm and in “waiter’s tip” position
What is Klumpke’s palsy?
C8-T1 lesion, due to excessive arm traction during childbirth
Sensory loss on medial forearm and hand
Complete claw hand
Wasting of small muscles in hand
Horner’s may co-exist
How would you start a lower limb neurological examination?
Inspection
- SSWIFT
- Abnormal posturer: UMN posture or foot drop
- Soft tissue damage due to sensory loss: blisters, ulcers
What is the UMN position for the lower limb?
Hip and knee extended, foot plantarflexed and inverted
How would you assess tone in a lower limb neurological examination?
Let leg go floppy
- Leg roll
- Leg left (can reveal hypertonia if leg stays straight)
- Ankle movement + dorsiflexion
What can sudden dorsiflexion reveal?
Increased clonus: UMN lesion
How would you assess power in a lower limb neurological examination?
- Hip flexion - L1/L2
- Hip extension - L5/S1
- Knee flexion - S1/L5
- Knee extension - S3/S4
- Ankle dorsiflexion - L4
- Ankle plantarflexion - S1
- Big toe extension - L5
How would you assess reflexes in a lower limb neurological examination?
- Knee jerk - L3/L4
- Ankle jerk - S1
- Plantar flexion (Babinski) - S1
How would you assess sensation in a lower limb neurological examination?
- Anterolateral medial thigh - L2
- Medial thigh above the knee - L3
- Medial malleolus - L4
- Dorsal 1st web space - L5
- Lateral heel - S1
Vibration - big toe
Joint sensation
Where would you check for vibration sense in lower neurology?
Big toe
Medial malleolus
Tibial tuberosity
ASIS
What special tests would you do for lower limb neurology?
- Romberg’s (sensory ataxia due to proprioceptive loss)
- Straight leg raise (L5/S1 nerve impingement)
- Femoral stretch test (L4 nerve root impingement)
