upper limb neuro

Question 1

start of neuro exam

Answer 1

confirm pt identity

introduce self to the patient

explain exam

ask for consent

ensure adequate exposure and position

R/L handed

ask about pain

Question 2

stages in neuro exam and acronym

Answer 2

'’in the pouring rain she came’’

inspect

tone

power reflex

sensation

coordination

Question 3

inspection

Answer 3

check for pronator drift

inspect bedside - medicines and walking aids, orthoses, does pt look well/not, posture

habitus

other signs of neurological conditions eg hypomimia, facial muscle wasting

look closer - see if there are changes in the skin:

• SWIFT - scars, wastage (muscles of arms and hands - thenar/hypothenar, dorsal hand guttering), involuntary movements, fasiculations, tremor
• neurofibromas
• cafe au lait spots

Question 4

what is pronator drift

Answer 4

ask pt to hold arms out fully extended with palms facing upwards and close their eyes

shows weakness in arm so hand pronates down and distal flexion

problem in corticospinal tract - contralateral to arm (pyramidal weakness)

if arm goes up = cerebellar lesion - can be accenuated by rebound - pushings patients wrists down briskly and then quickly letting go

Question 5

what is a cause of increased tone

Answer 5

UMN lesion

Question 6

what is cause of reduced tone

Answer 6

LMN lesion

Question 7

describe cogwheel rigidity

Answer 7

in parkinsons (pt also looks emotionless)

it is a parkinson’s tremor on top of an increased tone

Question 8

how do you assess tone

Answer 8

elbow - hold pts hand as if you’re shaking hands - support elbow with other hand and repeatedly flex and extend their elbow to full range

forearm - in same position with elbow at 90 degrees - repeatedly pronate and supinate hand in alternating directions

wrist - hold forearm just proximal to wrist and flex then extend then rotate their hand on their wrist

Question 9

what do you use to assess/compare power

Answer 9

medical research council scale (MRC)

0 = nothing

1 = flicker of muscle contraction only

2 = movement of muscle at joint, only when gravity is eliminated

3 = movement of joint against gravity buit not against resistance

4 = some resistance (just a bit weak)

5 = full power

Question 10

myotome for shoulder abduction

Answer 10

c5

Question 11

myotome for shoulder adduction

Answer 11

c6/7

Question 12

myotome for elbow flexion

Answer 12

c5/6

Question 13

myotome for elbow extension

Answer 13

c7

Question 14

myotome for wrist extension

Answer 14

c6

Question 15

myotome for wrist flexion

Answer 15

c6/7

Question 16

myotome for finger extension

Answer 16

c7

Question 17

myotome for finger flexion

Answer 17

c8

Question 18

myotome for finger abduction

Answer 18

t1

Question 19

myotome for thumb abduction

Answer 19

t1

Question 20

nerve roots for the reflexes

Answer 20

biceps c5

supinator c 4 6

(5, 6 pick up sticks)

triceps c7 (7, 8 lay them straight)

Question 21

where do you hold the tendon hammer

Answer 21

at the end - make a pendulum swing

Question 22

test the reflexes

Answer 22

biceps - ask pt to relax their arms across their lap, place index finger across their biceps tendon and then strike your finger

supinator - with the patients arm still relaxed across their lap, place your index finger and middle finger over the brachioradialis tendon and strike yoru fingers

triceps - hold their ipsilateral wrist with one hand while they let their arm go floppy - strike triceps tendon

Question 23

what do you do if a reflex appears absent

Answer 23

use reinforcement manouvre

ask pt to clench teeth and close eyes while you hit tendon

relaxes pt

Question 24

sensation

Answer 24

demonstrate in the sternum

make sure pts eyes closed - use cotton wool (dorsal column) - compare R and L

pain (spinothalamic) - use neurotip (tests spinothalamic)

get pt to close eyes and say if they feel sharp/blunt

test proprioception, vibration and temperature - start distally and only work up if cant feel it

go by dermatomes and peripheral nerves if you’re suspecting nerve/nerve root pathology

start from testing prox-distal or vice versa if expecting to find glove and stocking snesnory loss or a sensory level

Question 25

UMN lesion effect on sensation

Answer 25

usually whole arm effected

Question 26

LMN lesion effect on sensation

Answer 26

only some regions affected

Question 27

how do you assess proprioception

Answer 27

assess dorsal column joint position sense up and down movement of fingers hold proximal phalamx of the thumb with your index finger above and below hold side fo fingers with other hand rather than top so cant feel pressure change it is teh ability to sense the body position do 3 times if they get it wrong move to the metacarpophalangeal joint, then wrist etc until they can correctly state the position

Question 28

how do you assess vibration

Answer 28

use 128Hz tuning fork - check they feel vibrations dorsal columns place round base on sternum to demonstrate what it feels like then hold on the interphalangeal joint of the thumb ask if they can feel it vibrate then get them to tell you whne it stops vibrating if they cant feel vibration move to the metacarpophalangeal joint, radial styloid, etc

Question 29

how do you assess temperature

Answer 29

spinothalamic tract use 128hz tuning fork (horizontal) to see if the patient can feel it as cold on their sternum if they can hold the prongs on the dorsum of the hand and see if they can feel them as cold - move proximally until they can

Question 30

how do you assess cordination

Answer 30

finger-nose test - see if got past pointing and intention tremor = dysmetria (cerebellar lesion) make sure arm is extended fully in finger nose test test for dysdiadokinesia - clap on back of hand - looking for cerebellar lesion

Question 31

how do you assess power

Answer 31

one side at a time support the joint being tested

Question 32

assess shoulder abduction power

Answer 32

pt abducts shoulder into horizontal plane 'dont let me push your shoulder down'

Question 33

power elbow flexion

Answer 33

pt bring arms into saggital plane with elbows flexed, dr hold wrist 'put arms up like boxing, dont let me pull your wrist away'

Question 34

power elbow extension

Answer 34

in boxing position 'try and push me away while i hold your wrist'

Question 35

power wrist extension

Answer 35

pt hold arms out straight while making fist stabalise ipsilateral wrist with one hand and use the posterior side of your fist to push one down

Question 36

finger extension power

Answer 36

patient holds their arm out straight with fingers extended stabalise their ipsilateral wrist with 1 hand and use the posterior side of your other hand's extended fingers to try and push their's down ''hold your fingers out straight, now im going to try and push your fingers down, dont let me'

Question 37

finger flexion power

Answer 37

interlock grips with the patient adn try to open their fingers ''grip my fingers and dont let me open your hand''

Question 38

finger abduction power

Answer 38

ask pt to spread their fingers - try to push their little and index fingers forward, using your spread fingers - with the same digits as the one your touching ''spread ypour fingers, dont let me push them inwards''

Question 39

thumb abduction power

Answer 39

ask the pt to hold their palms facing up and point their thumbs into the air try to push their thumbs down to the palms ''dont let me push your thumbs down''

Question 40

to complete

Answer 40

thank pt and cover them i would examine cranial nerves and lower limbs summarise and suggets further investigations

Question 41

diagnosing in neurology

Answer 41

throughout the exam think is the pathology: unilateral/bilateral UMN/LMN weakness - proximal, distal or pyramidal sensory loss - glove and stocking, sensory level, dermatomal or peripheral nerve