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Yr 3 examinations > upper limb neuro > Flashcards

upper limb neuro Flashcards

1
Q

start of neuro exam

A

confirm pt identity

introduce self to the patient

explain exam

ask for consent

ensure adequate exposure and position

R/L handed

ask about pain

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2
Q

stages in neuro exam and acronym

A

'’in the pouring rain she came’’

inspect

tone

power reflex

sensation

coordination

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3
Q

inspection

A

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
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4
Q

what is pronator drift

A

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

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5
Q

what is a cause of increased tone

A

UMN lesion

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6
Q

what is cause of reduced tone

A

LMN lesion

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7
Q

describe cogwheel rigidity

A

in parkinsons (pt also looks emotionless)

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

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8
Q

how do you assess tone

A

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

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9
Q

what do you use to assess/compare power

A

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

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10
Q

myotome for shoulder abduction

A

c5

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11
Q

myotome for shoulder adduction

A

c6/7

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12
Q

myotome for elbow flexion

A

c5/6

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13
Q

myotome for elbow extension

A

c7

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14
Q

myotome for wrist extension

A

c6

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15
Q

myotome for wrist flexion

A

c6/7

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16
Q

myotome for finger extension

A

c7

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17
Q

myotome for finger flexion

A

c8

18
Q

myotome for finger abduction

A

t1

19
Q

myotome for thumb abduction

A

t1

20
Q

nerve roots for the reflexes

A

biceps c5

supinator c 4 6

(5, 6 pick up sticks)

triceps c7 (7, 8 lay them straight)

21
Q

where do you hold the tendon hammer

A

at the end - make a pendulum swing

22
Q

test the reflexes

A

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

23
Q

what do you do if a reflex appears absent

A

use reinforcement manouvre

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

relaxes pt

24
Q

sensation

A

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

25
Q

UMN lesion effect on sensation

A

usually whole arm effected

26
Q

LMN lesion effect on sensation

A

only some regions affected

27
Q

how do you assess proprioception

A

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

28
Q

how do you assess vibration

A

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

29
Q

how do you assess temperature

A

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

30
Q

how do you assess cordination

A

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

31
Q

how do you assess power

A

one side at a time

support the joint being tested

32
Q

assess shoulder abduction power

A

pt abducts shoulder into horizontal plane

‘dont let me push your shoulder down’

33
Q

power elbow flexion

A

pt bring arms into saggital plane with elbows flexed,

dr hold wrist

‘put arms up like boxing, dont let me pull your wrist away’

34
Q

power elbow extension

A

in boxing position

‘try and push me away while i hold your wrist’

35
Q

power wrist extension

A

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

36
Q

finger extension power

A

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’

37
Q

finger flexion power

A

interlock grips with the patient adn try to open their fingers

'’grip my fingers and dont let me open your hand’’

38
Q

finger abduction power

A

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’’

39
Q

thumb abduction power

A

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’’

40
Q

to complete

A

thank pt and cover them

i would examine cranial nerves and lower limbs

summarise and suggets further investigations

41
Q

diagnosing in neurology

A

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

Yr 3 examinations (10 decks)

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