Peripheral Nerve Examination

Question 1

What is the first thing to do before beginning the examination?

Answer 1

• wash hands and don PPE
• introduce yourself to the patient
• confirm patient details

Question 2

How do you gain consent for the examination?

Answer 2

I am going to perform an examination of your peripheral nervous system today, this will involve me assessing the tone in your joints, the power of your muscles, your sensation and doing some movements. Would that be okay?

Question 3

What MUST you do before beginning the examination?

Answer 3

Ask if the patient is in pain or discomfort

Repeat this throughout the exam at regular intervals.

Question 4

What should your general inspection of the environment involve?

Answer 4

Is there any walking aids, callipers, casts, supports etc in the immediate environment?

Question 5

What should you look for on general inspection of the limb in question?

Answer 5

• postural abnormalities and deformities
• muscle wasting
• fasciculations/tremor
• abnormal movements

Question 6

What aspects of the limb do you test?

Answer 6

• tone
• power
• coordination
• reflexes
• sensation

Question 7

How do you assess tone? Upper? Lower?

Answer 7

• check patient does not have pain before starting
• ask the patient to remain as relaxed as possible— ‘loose and floppy’
  Upper
• flex and extend hand at the wrist (isolate the joint by holding forearm firmly)
• flex and extend arm at elbows (isolate the joint by holding the upper arm firmly)
  Lower
• roll leg away from yourself
• flex the knee slightly and then let go
• hold calf and flex ankle and perform circumduction

Question 8

How do you explain what you are doing to assess tone to a patient?

Answer 8

I am now going to assess the tone of your joints and muscles. I am going to complete the movements for you, just try to stay as relaxed and loose as possible. If you experience pain at any time please tell me to stop.

Question 9

How do you assess pronator drift?

Answer 9

Ask patient to raise both arms infront of them palmar surface upwards, and hold them in position. Then ask the patient to close their eyes.
In a positive sign, the hand will pronate itself.

Question 10

In which movements do you assess power in the shoulders? How is this assessed?

Answer 10

ABduction- Hands on top, push up against me.
ADduction- hands underneath, push down against me.

Question 11

How do you assess power of the elbows?

Answer 11

Flexion- arms in front of you, pull me towards you.
Extension- arms in front of you, push against me.

Test power against your own— forearm on forearm

Question 12

How do you assess power in the wrists?

Answer 12

Make a fist. Cock your wrist back. Resist me pushing down- extension
Push down against me— flexion

Question 13

How do you assess power in the fingers?

Answer 13

Flexion- fingers out, push down against me (straight fingers)
Extension-fingers out, push up against me (straight fingers)
ADduction- fingers spread apart, try to close your fingers
ABduction- fingers together, try to spread apart
Make on ‘okay’ sign and stop me pulling your finger and thumb apart

Question 14

How do you assess power of the thumb?

Answer 14

Hold the patients hand and use opposite thumb to assess.
Resist me pushing from each side.

Question 15

How do you assess coordination? (Upper)

Answer 15

• finger to nose test= I’d like you to touch your finger to your nose and then touch my finger as I move it around. (Check stretching arm and supinating/pronating appropriately)
• dysdiadochokinesis= ask patient to quickly touch their palmar and dorsal surface on their opposite hand, then swap.

Question 16

Which tendon reflexes are tested in the upper limb? Which myotome is affected?

Answer 16

Triceps- C7 (direct)
Biceps- C5/6 (not direct)
Brachioradialis- C5/6 (not direct)

Place finger in appropriate position on tendon and hit tendon hammer to the thumb. NOT directly at patient.

Question 17

What are the different modalities assessed within sensation? How are these tested?

Answer 17

• light touch (cotton wool)
• pain (neurotip)
• proprioception (movement with isolation)
• vibration (tuning fork)

Question 18

In which areas is the patient tested?

Answer 18

Shoulder (C4)
Lateral aspect upper arm (C5)
Lateral aspect of forearm and hand (C6)
Tip of middle finger (C7)
Medial aspect of hand (C8)
Medial aspect of forearm (T1)
Medial aspect of upper arm (T2)

Question 19

How do you assess proprioception?

Answer 19

Start with the most distal joint, isolate the joint. Validate by demonstrating what is up and what is down. Ask patient to close their eyes, move the joint and ask the patient to tell you if they feel the movement and in which direction the distal phalanx is moving.
Move proximally until the patient can identify the movement.

Question 20

How do you assess vibration?

Answer 20

Use tuning fork on bony prominences.
Start Distally and move proximally until they are able to feel the vibration.
Validate on sternum before beginning.
Start on middle toe- ask if they feel it vibrating. Ask them to close their eyes and tell you when it stops vibrating—- touch the prongs.

Question 21

When testing light touch, pain and vibration what is it important to do?

Answer 21

Validate the sensation as a control ie on the sternum, using same instrument and pressure as will be applied during the examination of the limb.