Upper limb neuro exam Flashcards
What are the introductory steps for an upper limb neuro exam?
- Wash hands
- Put on PPE
- Introduce self
- Confirm patient name and DOB
- Explain examination
- Gain consent
EXTRA STEPS:
- Ask if the patient has pain anywhere.
- Specifically enquire about neck pain.
- Ask if the patient is right or left handed.
- If there are any signs of reduced cognition, carry out a GCS and speech assessment.
What comes after introduction?
Inspection.
What can be picked up from inspection of the upper limbs?
- Reduced muscle tone/muscle wasting (LMN).
- Fasciculations (UMN).
- Posture (Parkinson’s?).
- Tremor (Intention or resting?)
- Involuntary movements? (Huntington’s?)
What comes after inspection of the upper limbs?
Tone assessment.
How is the tone of the upper limbs assessed?
- Move each joint (shoulder, elbow and wrist) for the patient.
- Do this first slowly (rigidity).
- Then move them quicker (spasticity).
Both spasticity and rigidity are UMN signs.
What comes after tone assessment?
Power assessment.
How is power of movements graded?
MRC grading system:
5/5 - Normal power against resistance.
4/5 - Reduced power against resistance.
3/5 - Power against gravity w/ no resistance applied.
2/5 - Power when gravity is removed.
1/5 - Visible muscle contraction but no movements.
0/5- No visible contractions.
How is the power of the upper limbs assessed?
Pronator drift assessment - Ask the patient to hold their arms out in front of them, palms upwards. Ask them to close their eyes. Observe for 20 seconds, looking for pronation (UMN sign).
Shoulder:
Flexion - Raise arm in front of patient. Push down on patient’s arm and ask them to resist.
Extension - Extend arm behind patient. Push down on patient’s arm and ask them to resist.
Abduction - Ask patient to put their arms up like a chicken. Press down on arms and ask them to resist.
Adduction - Keep their arms up like a chicken. Push up on arms and ask them to resist.
Elbow:
Flexion - Ask patient to put their hands up like a boxer. Pull down on arm and ask them to resist.
Extension - Keep hands up like a boxer. Push back on arm and ask them to resist.
Pronation/supination - Ask the patient to put their arms out in front of them and then quickly and repeatedly pronate and supinate their forearms.
Wrist:
Flexion - Ask patient to put their hand out in front of them palm down and then to make a fist. Push up on their fist and ask them to resist.
Extension - Ask patient to keep their fist out in front of them. Push down on their fist and ask them to resist.
Fingers:
Flexion - Ask patient to put their hand out in front of them palm down, fingers straight. Press upwards on their fingers and ask them to resist.
Extension - Ask patient to keep their hand in the same position. Press downwards on their fingers and ask them to resist.
Abduction - Ask patient to splay their fingers. Press inwards on their fingers and ask the patient to resist.
Thumb:
Abduction - Ask patient to put their hands out, palms up, and extend their thumb towards the celling. Press down on their thumb and ask them to not let you press it into their palm.
Adduction - Ask patient to remain in the same position. This time, press upwards on their thumb and ask them to not let you bend it backwards.
What comes after power assessment?
Reflex assessment.
How are the reflexes assessed?
3 reflexes:
- Biceps (near the biceps tendon)
- Triceps (rear of the elbow).
- Brachoradialis (Edge of the wrist).
Hit each with the tendon hammer, with fingers overlying the tendon to avoid pain for the patient.
If reflex cannot be elicited, ask patient to clench their teeth and then try again.
What comes after reflex assessment?
Coordination assessment.
How is coordination assessed?
- Ask patient to tap each finger against the thumb on their same hand, and do this quickly and repeatedly. Also ask them to pick up a small object from the table (fine motor control).
- Hold your finger just in reach of the patient. Ask them to touch their own nose, and then your finger rapidly and repeatedly (proprioception).
- Ask the patient to close their eyes and relax. Then, still with their eyes close touch the tip of their own nose (proprioception).
- Ask the patient to rapidly touch the palm and dorsal aspect of their hand against the palm of the other hand. Do this rapidly and repeatedly. (dysdiadochokinesis).
What comes after coordination assessment?
Sensation assessment.
How is sensation in the upper limbs assessed?
- Soft touch, pin prick and temperature (if possible). Assess with the patient’s eyes closed, throughout all the different dermatomes.
- Vibration. Take a tuning fork and place it against the patients sternum. Get them to close their eyes, and show them what a vibration feels like. Then stop the vibration and show them what that feels like. Now perform the same test on the interphalangeal joint of their thumb.
- Two-point discrimination. Use the other end of the tuning fork, and get the patient to differentiate between one and two points of contact on the dorsal aspect of their hand. They should be able to differentiate for gaps bigger than at least 1cm.
- Proprioception. Patients eyes closed. Shows them what up and down feel like with their thumb. Wiggle a few times and then choose up or down - ask patient to say where their thumb is. Repeat 3-4 times.
- Cortical localisation. Patients eyes closed. Place a small item in their hand and ask them to tell what it is.
What are the different points used for dermatomal assessment of soft touch, temperature and pin-prick?
