Upper limb neuro examination Flashcards by Bethany Smith

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

Wash hands
Intro self
Pt details

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Explain an ULN exam to a patient

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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What else would you include in your intro?

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

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What equipment if needed in a ULN

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

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What do you inspect in a ULN exam?

Bedside
General appearance
SWIFT with arms outstretched pronated

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When inspecting the bedside what are you looking for?

Wheelchair.
Walking stick.
Urinary catheter.

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When inspecting generally what are you looking for?

Any limb deformity or posturing.

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

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

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What does SWIFT stand for?

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

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How do you assess for pronator drift?

What does it indicate?

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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What are the 5 main aspects of the ULN exam?

Tone
Power
Reflexes
Coordination
Sensation

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How do you assess tone in a ULN exam?

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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What movement do you want to do when assessing tone?

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

Any spasticity = spastic catch

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What does hypotonia feel like?

Floppy + heavy

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What 2 ways can hypertonia present?

Spasticity

Rigidity

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Describe the difference between spasticity and rigidity?

What d they indicate?

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

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

Shoulders

Elbows

Wrist

Fringers

What shoulder movements do you want to assess?

What instructions do you give to the patient?

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”.

What elbow movements do you want to assess?

What instructions do you give to the patient?

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”.

What wrist movements do you want to assess?

What instructions do you give to the patient?

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”.

What finger movements do you want to assess?

What instructions do you give to the patient?

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”.

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

Biceps reflex (C5/6)

Triceps reflex (C7)

Supinator reflex (C6)

Hoffman’s reflex

What reinforcement manoeuvre can do you to accentuate a reflex?

Clench teeth

How to do test the biceps reflex?

Place finger over the biceps tendon in the antecubital fossa.

How do you test the triceps reflex?

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

How do you test the supinator reflex?

Located 4” proximal to base of the thumb.

How do you test the Hoffman's reflex? What is a positive test?

Loosely hold the middle finger + flick fingernail downwards, allowing the middle finger to flick upward reflexively. Thumb flexion + adduction on the same hand occurs.

How do you assess the sensation in the ULN exam?

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.

What does light touch sensation test? What do you use?

Assesses dorsal/posterior columns + spinothalamic tracts. Use cotton wool.

What does vibration sensation test?

Assesses dorsal/posterior columns.

How do you assess vibration sense?

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.

How do you asses proprioception in the ULN exam?

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.

How do you test for stereognosis?

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

How do you test for graphesthesia?

Identify a number being drawn on their palms.

How do you test for 2-point discrimination?

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

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

Finger to nose test Dysdiadochokinesia Touch thumb to each fingertip on same hand rapidly.

How do you perform the finger to nose test?

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.

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

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.

How do you test for dysdiadochokinesia?

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

What does inability / impairment when testing for dysdiadochokinesia indicate?

Inability (very slow/irregular) may suggest cerebellar ataxia. Can be impaired in sensory ataxia or with Parkinsonism.

Upon completing the exam what do you do first?

Thank patient Wash hands

To complete my exam...

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

Summarise a ULN exam

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