Neurological Examination UL and LL Flashcards
What are the major categories of neurological diseases?
Infectious Traumatic Genetic Vascular Degenerative Toxic Metabolic Neoplastic Inflammatory/Immune
What are the four divisions of a neurological examination?
Cranial nerve
Upper limb
Lower limb
Additional exams and tests
What is the cranial nerve examination for?
A test of the brain and it’s neuronal pathways to locate where along the nervous system the problem and lesion is occurring
What is the difference between UMN and LMN conditions?
Both reduced power however
UMN - increased tone, reflexes, normal muscle bulk and plantar up
LMN - reduced tone, reduced or absent reflexes, wasting and atrophy and platar down
What are the general sections of a limb exam?
Inspection Tone Power Reflexes Co-ordination Sensation (light touch, vibration, proprioception, pain, temperature)
What are you visually inspecting for UL?
SWIFT - scars, wasting, involuntary fasiculations and tremors.
Make sure to take a proper look, compare both sides. Look both inside and outside of the arm.
How do we examine UL tone?
Ask patient to go floppy and ask if in any pain.
Test elbow flexion and extension
Test tone in wrist with flexion and extension
Test on pronation and supination
Test one side and then the other immediately to compare the sides.
How do we examine power for UL?
Shoulder abduction - put arms up (like the chicken song) and don’t let me push them down
Shoulder adduction - same but push up
Elbow flexion and extension - push me towards and away from you
Wrist and finger extension - cock wrist up and keep it there (apply force)
Small muscles of the hand
- Interossei
dorsal - spread fingers apart
palmer - hold this paper between your fingers and ill try and pull it out
What is key about the power examination for UL?
Compare like for like e.g. use your interossei to pull the paper from between their fingers so you can compare your muscles against their’s
How do we grade power?
MRS power scale out of 5
What reflexes do we test for UL?
Biceps (C5, C6)
Supinator (C5, C6, C7)
Triceps (C6, C7, C8)
(Finger flexors bonus)
Compare both sides!
What is the next step if a reflex is absent?
Reinforcement! So to clench their teeth or do the jandrassik movement. If still absent it could be technique or honestly absent!
What is hoffman’s sign?
The babinski sign of the UL, flick the third phalynx of middle finger and their thumb will move.
How do we examine co-ordination?
- Rebound - ask to put both arms out and tap them, most people will drop their arms and rebound back, with poor coordination it will bounce for a while first
- Finger to nose test (pass pointing and intention tremor)
- Dysdiadokokinesia - rapidly altering movements, so flipping hand back and forward in the palm of the other (left side of brain is effected in left-sided problem)
What are the main giveaways for cerebellar dysfunction (poor co-ordination)?
Dysdiadokokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia
THIS
Examine a normal patient and present it back!
On slide!
What do we inspect on LL exam?
SWIFT again but bony deformities (pes cavus is common), may check gait.
How do we assess LL tone?
Ask for any pain in their legs
- Roll leg from side to side
- Place hand under knee joint and briskly lift up leg (hard in UMN)
- With knee flexed check ankles by doing flexion and dorsiflexion, and then examine for clonus (UMN)
How do we test power for LL?
Hip flexion - raise leg straight and don’t let me push it down
Hip extension - push down against my hand
Knee flexion and extension - don’t let me straighten knee
Ankle plantar and dorsi flexion (isolate ankle)
Eversion and inversion
How do we test reflexes for LL?
Knee jerk (L2-L4) do it at right angles so you're taking the patient's weight Ankle jerk (S1, L5) tap Achilles tendon and look for gastroc action Plantar reflex (S1) toes curl down wards if you scrape up the patients foot. If they go up it's pathological. Normal in babies.
What is the plantar response?
Blunt instrument across lateral border of foot, normal that big toe curls down, if up then babinski sign/plantar response.
UMN and LMN are where in the nervous system?
UMN - brain, spinal cord
LMN - cell body, nerve, neuromuscular junction and muscles
What might you see around a patient’s bedside?
A wheelchair
Bottle for urine or catheter
Walking aids
Muscle wasting
What is pronator drift?
Whilst trying to supinate the arm, subtle upper limb weakness pronates it. The lesion is an upper motor neurone one, so flexes are stronger than extensors in upper arms. This is reversed in legs.
What is the difference between spasticity and rigidity?
Spasticity is where there’s increased tone when you move the limb with greater velocity.
Rigidity is where tone is increased throughout movement, not dependent on velocity.
There are four areas of sensation we test, what are they and what tracts control them?
Light touch - dorsal column Pin prick (alternate between sharp and blunt tip) - spinothalamic Vibration (using a tuning fork on distal bony prominence, do vibration and then stop and ask patient when it's stopped, move upwards on prominences if they can't identify) - dorsal column Proprioception - dorsal column
What can cause a peripheral neuropathy?
Alcohol abuse
Diabetic neuropathy
Usually a glove and stocking distribution
How do we test proprioception?
Move the patients thumb up and down. Ask them to tell you if it’s up or down. Move along arm if it’s wrong e.g. do wrist then elbow until they get it right.
How do you assess upper limb coordination?
Testing cerebellar function.
Dysdiadochokinesia.
- Put left hand out, palm up, and then sandwich right on top. Then, flip the right so back of hand is touching. Get them to flip quickly from one to the other.
- Get patient to touch their nose and your finger, whilst you move your finger. They may over shoot, poor depth perception (pass pointing). Do with both hands.
What is an intention tremor?
A tremor that gets worse when trying to touch for something.
What might we assess during gait assessment?
Speed Symmetry Stance Stability Arm swinging Steps Turning (may be harder or be shuffling)
What is a parkinsonian gait?
Shuffling gait
Pill rolling tremor in hands
What are the common gait abnormalities?
Ataxic gait (sensory or ataxic) Parkinsonian gait High stepping gait Waddling gait Hemiparetic gait (one leg is stiff) Spastic paraparesis
What is romberg’s test for ataxia type?
Ask patient to stand with their legs together. Put your hands either side so they don’t fall. Ask them to close their eyes. If patient wobbles - sensory ataxia.
If patient unsteadiness doesn’t change, it is cerebellar.
