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Examinations > Upper limb neuro examination > Flashcards

Upper limb neuro examination Flashcards

1
Q

What is the first part of any introduction to an examination?

A

Wash hands
Intro self
Pt details

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2
Q

Explain an ULN exam to a patient

A

I’ve been asked to examine your upper limbs today, it’s going to involve moving your arms about a bit, testing your reflexes, sensation and coordination, would that be alright?

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3
Q

What else would you include in your intro?

A

Expose ok?
Chaperone?
Pain or discomfort?
Ask handiness of the pt

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4
Q

What equipment if needed in a ULN

A

Tendon hammer.
Neuro tip.
Cotton wool.
Tuning fork (128Hz).

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5
Q

What do you inspect in a ULN exam?

A

Bedside
General appearance
SWIFT with arms outstretched pronated

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6
Q

When inspecting the bedside what are you looking for?

A

Wheelchair.
Walking stick.
Urinary catheter.

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7
Q

When inspecting generally what are you looking for?

A

Any limb deformity or posturing.

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8
Q

What do the following potentially indicate?
a) Hypomimia (lack of expression)
b) Ptosis + frontal balding
c) Ptosis + ophthalmoplegia

A

a) Parkinson’s
b) Myotonic dystrophy
c) Myasthenia gravis

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9
Q

What does SWIFT stand for?

A

Scars.
Wasting of muscles.
Involuntary movements (dystonia, chorea, myoclonus).
Fasciculations.
Tremor (Parkinson’s disease, essential tremor).

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10
Q

How do you assess for pronator drift?

What does it indicate?

A

Ask the patient to close their eyes + place arms outstretched supinated.
Observe the hands + arms for signs of pronation.

Upper motor neurone pathology.

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11
Q

What are the 5 main aspects of the ULN exam?

A

Tone
Power
Reflexes
Coordination
Sensation

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12
Q

How do you assess tone in a ULN exam?

A

Ask the patient to let their arm go floppy, hold the patient’s hand + elbow whilst moving major joints passively.
Is there normal, even or uneven resistance

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13
Q

What movement do you want to do when assessing tone?

A

Flex/extend/abduct/adduct the shoulder joint.
Flex + extend the elbow joint.
Pronate + supinate forearm
Move wrist through its full range of motion.

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14
Q

When pronating and supinating the forearm what should you feel for?

A

Any spasticity = spastic catch

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15
Q

What does hypotonia feel like?

A

Floppy + heavy

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16
Q

What 2 ways can hypertonia present?

A

Spasticity

Rigidity

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17
Q

Describe the difference between spasticity and rigidity?

What d they indicate?

A

Spasticity is velocity dependent so the faster you move, the more resistance, spastic catch

Rigidity is same irrespective of the speed of movement, lead pipe rigidity

Spasticity - indicates UMN lesion

Rigidity - indicates extrapyramidal lesion, Parkinsonism

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18
Q

What is the best way to asses power in a ULN exam?

A

Assess power one side at a time + compare like for like (finger test finger).
Stabilise + isolate the joint when testing.
MRC muscle power assessment scale for scoring

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19
Q

Where do you want to assess power in a ULN exam?

A

Shoulders

Elbows

Wrist

Fringers

20
Q

What shoulder movements do you want to assess?

What instructions do you give to the patient?

A

ABduction (C5) – “Don’t let me push your shoulders down”.
C5 = hands to the sky.

ADduction (C6/7) – “Don’t let me pull your arms from your sides”.

21
Q

What elbow movements do you want to assess?

What instructions do you give to the patient?

A

Flexion (C5/6) – “Don’t let me pull your arm away from you”.
C5/6 = pick up sticks.

Extension (C7) – “Don’t let me push your arm towards you”.

22
Q

What wrist movements do you want to assess?

What instructions do you give to the patient?

A

Extension (C6) – “Cock your wrists back and don’t let me push them down”.

Flexion (C6/7) – “Point your wrists down and don’t let me pull them up”.

23
Q

What finger movements do you want to assess?

What instructions do you give to the patient?

A

Finger extension (C7) – “Put your fingers out straight and don’t let me push them down”.
C7 = paper.

Finger flexion (C8) – “Put your fingers out straight and don’t let me push them up”.
C8 = rock.

Finger ABduction (T1) – “Splay your fingers + don’t let me push them together”.
- First dorsal interosseous, FDI (index finger).
- ABductor digiti minimi, ADM (little finger).
T1 = scissors.

Thumb ABduction (C8/T1) – “Point your thumbs to the ceiling + don’t let me push them down”.

Thumb ADduction (C8) – “Try to point your thumbs to the ceiling + don’t let me push them down”.

24
Q

What reflexes do you want to check in a ULN exam?

A

Biceps reflex (C5/6)

Triceps reflex (C7)

Supinator reflex (C6)

Hoffman’s reflex

25
Q

What reinforcement manoeuvre can do you to accentuate a reflex?

A

Clench teeth

26
Q

How to do test the biceps reflex?

A

Place finger over the biceps tendon in the antecubital fossa.

27
Q

How do you test the triceps reflex?

A

Place forearm at 90°C flexion + tap the triceps tendon.

28
Q

How do you test the supinator reflex?

A

Located 4” proximal to base of the thumb.

29
Q

How do you test the Hoffman’s reflex?

What is a positive test?

A

Loosely hold the middle finger + flick fingernail downwards, allowing the middle finger to flick upward reflexively.

Thumb flexion + adduction on the same hand occurs.

30
Q

How do you assess the sensation in the ULN exam?

A

Assess dermatomes C5–T1.

Provide a comparison point (sternum/forehead) and then
ask patient to close eyes.

Ask patient to say yes when they are touched.

Compare left to right + ask if it feels the same on both sides.

31
Q

What does light touch sensation test?

What do you use?

A

Assesses dorsal/posterior columns + spinothalamic tracts.

Use cotton wool.

32
Q

What does vibration sensation test?

A

Assesses dorsal/posterior columns.

33
Q

How do you assess vibration sense?

A

Place on interphalangeal joint of thumb + ask if they can feel it buzzing + if they feel it stop.

If vibration sensation is impaired, continue to assess the bony prominence of more proximal joints –
- Carpometacarpal joint of thumb.
- Radiocarpal joint.
- Elbow joint.
- Shoulder joint.

34
Q

How do you asses proprioception in the ULN exam?

A

Assesses dorsal/posterior columns.

Hold the distal phalanx of their thumbs by its sides.

Demonstrate the movement of the thumbs upwards + downwards to the patient whilst they watch.

Ask patient to close their eyes + state if you are moving thumbs up/down.

If patient is unable to correctly identify the direction then move to a more proximal joint –
- Finger.
- Wrist.
- Elbow.
- Shoulder.

35
Q

How do you test for stereognosis?

A

Identify a coin/key placed in the patient’s hands with eyes closed.

36
Q

How do you test for graphesthesia?

A

Identify a number being drawn on their palms.

37
Q

How do you test for 2-point discrimination?

A

Ask patient if they feel one or two points on their fingers.
If patient is unable to correctly identify distally, try more proximal.

38
Q

What tests do you use to test coordination in the ULN?

A

Finger to nose test

Dysdiadochokinesia

Touch thumb to each fingertip on same hand rapidly.

39
Q

How do you perform the finger to nose test?

A

Finger to own nose with eyes closed.

Ask patient to touch their nose with the tip of their index finger then touch your fingertip + do as fast as possible, make sure patient fully outstretches arm.

40
Q

What does inability to do / impairment of finger to nose test indicate?

A

Inability (past pointing/dysmetria) may suggest cerebellar pathology.

Can be impaired in sensory ataxia (caused by loss of proprioception).

Can be caused by weakness in arm.

41
Q

How do you test for dysdiadochokinesia?

A

Demonstrate patting the palm of your hand with the back/palm of other hand as rapidly as possible + ask patient to copy.

42
Q

What does inability / impairment when testing for dysdiadochokinesia indicate?

A

Inability (very slow/irregular) may suggest cerebellar ataxia.

Can be impaired in sensory ataxia or with Parkinsonism.

43
Q

Upon completing the exam what do you do first?

A

Thank patient
Wash hands

44
Q

To complete my exam…

A

I’d like to do a lower limb neurological examination and a full cranial nerve examination

45
Q

Summarise a ULN exam

A

Today I performed a ULN exam on ____ a __ y/o ___.

On general inspection ___ appeared comfy at rest

There were no abnormalities in posture, deformities, muscle wasting or fasciculations detected

Pronator drift was -ve

Tone was normal throughout

Power was 5/5 in all muscle groups bilaterally

Reflexes were normal + present

Coordination was intact

Sensation was normal in all modalities tested

In summary, this was consistent w/ a normal ULN exam

Examinations (18 decks)

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