Upper Limb Flashcards
Introduction
WIPER QQ -wash hands + PPE -introduction -patient ID DOB -explanation I've been asked to examine your arms which involves an assessment of your muscles, sensation and reflexes -repositioning - sitting -question - do you have any questions for me? are you happy for me to begin my examination? do you have any stiffness of pain in your arms or shoulders?
Inspection from end of bed
I am going to talk through what I’m looking for throughout to my senior
- I am looking around the bed for any medical paraphanelia
- I am looking for any deformities, wasting, asymmetry, rashes, scars and swelling
Bedside
-walking aids, orthotics, prescriptions
Patient
-deformity, wasting, asymmetry, rashes, fasciculations, scars
-truncal balance - swaying trunk (cerebellar?)
Pronator drift
I am now assessing for pronator drift
Hold arms up, palms up, eyes closed
Ask them to keep their arms still for 30s (mention this in OSCEs but test briefly)
If there are issues, arms will automatically pronate and fall = UMN issue
Tone
- how would you assess this
- what are you looking for?
I am now assessing the patient’s tone
Support elbow, shake hands -supination, pronation -flexion, extension of fingers, wrists, elbows -abduction, adduction of shoulders Slowly then quickly
Assess for
- clasp knife - velocity dependent (faster = stiffer) (UMN)
- cogwheel - jerky resistance (BG)
- leadpipe - sustained resistance (BG)
Pronator drift - hold arms out, palms up, eyes closed, 30s -pronation and falling arms => UMN Push down on arms => rebound -excess rebound => UMN -no rebound => cerebellar
Power
- how would you assess this
- what are you looking for
- what nerve roots are you assessing with each movement
I am assessing the power
- shoulder ABD, ADD
- elbow FLEX, EXT
- wrist FLEX, EXT
- finger FLEX, EXT ABD
- thumb ABD
Stabilise joint, compare both sides
C5 C6-8
Shoulder ABD, ADD - chicken arms
C5-6 C7-8
Elbows FE - boxer arms
C7-8
Wrist FE - cock wrists
T1
- 1st, 4th finger ABD - splayed
- Thumb ABD - pointed to the sky
How would you record power
-MRC scale
5 - normal 4 - active mv against gravity and resistance 3 - active mv against gravity 2 - active mv with gravity eliminated 1 - flicker/trace of contraction 0 - no contraction
Reflexes
-location and nerve roots being tested
I am assessing the biceps, triceps and pronator reflex
C7-8 - tricep
- patients hand on opposite shoulder
- place fingers on tendon above olecranon => feel contraction
C5-6 - bicep
-place your fingers on biceps tendon, tap your fingers => feel contraction
C5-6 - pronator
-tendon medial to radial pulse on dorsal side of forearm => tap fingers to feel contraction
Coordination
- how would you test this
- what are you testing for?
I am assessing coordination
Finger to own nose repeatedly with dom hand as fast as possible
Finger to my finger - repeat and move finger
-change finger with patient when testing the other side
-hold finger at a distance that forces the patient to extend their arm
Past pointing (cerebellar)
Dysdiachokinesia (cerebellar issue) - pancake hands as fast as possible
-do this with the patient so you can compare to yourself
Sensation
- light touch - dorsal
- pain - spinothalamic
- temperature - spinothalamic
- dermatome locations
I am now assessing light touch, pain
Close eyes
Cotton wool on chest - confirm central sensation
Dermatomal testing on alternate sides
Repeat with neurotip
-also test distal fingers, move proximally if diabetic neuropathy suspected
Repeat with tuning fork
C5 - lateral arm C6 - lateral forearm C7 - middle finger C8 - medial forearm T1 - medial arm
Vibration - dorsal column testing
I am now assessing vibration sense
Ask patient to close eyes
Place end of large tuning fork on thumb ICP
-ask if they feel the vibration
-ask if they feel the vibration stop when you stop the forks vibrating
If impaired
ICP => MCP => wrist => elbow => shoulder
Proprioception - dorsal column testing
I am now assessing proprioception
Hold thumb by the sides
Explain that you’ll move thumb ICP up and down and let them get used to that movement
With eyes closed ask if they can identify if their thumb is up or down
If impaired, progressively test proximal joints up limb
Further examinations
Bedside
- Hx
- cerebellar function
- cranial nerves
- lower limbs
Bloods
- FBC, LFT, U&E - FOR BASELINE
- B12, folate - may contribute to peripheral neuropathy
- glucose - diabetic nephropathy
Imaging
-Head CT
