Peripheral Neurological Exam Flashcards
What is the overall sequence for the PNE?
1) Inspection of muscle bulk, movement
2) inspection of muscle tone
3) Inspection of muscle strength
4) inspection of reflexes
5) sensory exam
6) Cerebellar exam
How do you inspect for normal bulk and movement
1) Drape properly
2) Look for
- TIcs
- Tremors (Postural/ resting/ intention/ physiological)
- Fasciculations–> random contractions of the muscle
- Assess muscle bulk (Atrophy/ hypertrophy)
- Pronator drift test
What is the pronator drift test?
Patient sits or stands with arms stretched out infront of them with palms suppinated
2 possible pathological events
1) if one hand pronates = upper motor neuron lesion
2) if one arm drifts upward= cerebellar disease
How do you assess for muscle tone?
1)Grip test Have the patient grip your index and middle fingers as hard as possible, hold for a few seconds and then let go
–> if they can’t let go myotonia has been elicited
myotonia= inability to relax muscles after a voluntary contraction
2) Passively move joints looking for
- spasticity–> rate dependant resistance of motion ( move joint fast and get resistance)
- rigidity–> increased tone is not rate dependant (lead pipe)
- hypotonia–> decreased resistance and muscles are soft and limp
3) assess for clonus
- support and paritally flex knee
- briskly dorsiflex flood then maintain foot flexed
- if rhythmic oscillating movements detected= myoclonus
How do you assess muscle strength?
1)Squat then stand up
( can modify for older patients by having them sit and chair and get up)
2)Perform muscle movements against resistance ( graded 0-5 on Medical Council Research Scale)
What are the major deep tendon reflexes?
Biceps (C5-6)
Triceps (C7-8)
Brachioradialis (C6 mainly)
Patellar (L3-4)
Ankle (S1)
How do you grade reflexes?
0= absent
1+ =hypoactive
2+= normal
3+=hyperactive
4+= hyperactive with clonus
How do you go about testing reflexes in total in the peripheral neurological exam?
check bilaterally
1) deep tendon reflexes + grade
- if not found then reinforcement tecnique used
- if hyperactive check for clonus
2) Test for primitive reflexes= BABINSKI
3) Test superficial reflexes
a) abdominal–> stroke all 4 quadrents toward the umbilicus and look for abdominal muscle activity
b) chremasteric (L1-2)
c) anal (s 2,3,4)
How do you test sensory function on the peripheral nerve exam?
test sensory function in the dermatome distrobution–> pick a point and go circularly outward from it–> find where they can’t feel –> tests all the dermatomes
1)light touch
2)pinprick
3)temperature
4)vibration
- 128Hz tuning fork on sternum to make sure they can feel
- test vibration over joints bilaterally
5)proprioception
- starting distally on an extremity
- grasp the sides of a joint ( ie DIP)
- flex joint up or down and ask patient to tell you if the joint is up or down
6) special tests
a) two point discrimination->patient closes eyes and you note the smallest distance they can discriminate
normal values
2-4 mm on lips and fingers
8-15 mm on palms of hands
30-40mm on shins or back
b)graphesthesia–> write a number on the palm of a person with their eyes closed and ask them what it was
How do you test cerebellar function in the peripheral nerve exam?
1)Romberg->
a) feet together standing eyes open–> observe balance–> once stable
b) feet together standing eyes closed–> observe balance for 1 minute–> should be able to do with minimal swaying
positive romberg is if they are about to fall–> make sure you are in a position to catch them
2)finger to nose test
alternating patient touches nose and then touches your** index finger with **their index finger WITH THEIR ARM FULLY EXTENDED
3)rapid alternating movements test (upper and lower extremety)
- rapid supination and pronation of their hand on the dorsum of their hand
- patient taps heel on their shin as fast as they can
4)gait and balance
observe balance through all of the following
- observe patients normal gait
- comment on balance, steadiness, smoothness, turns
+
heel to toe gait–> rules out mid line cerebellar lesions
walk on toes–> helps exlude S1 lesion
walk on heels–> helps exclude L4 or L5 lesion
UMN vs LMN lesion
