Upper Limb Neurological Exam Flashcards

1
Q

Mnemonic for structure of this exam?

A

To postpone reflexes constitutes stupidity - Tone, power, reflexes, co-ordination, sensation.

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2
Q

How much should the patient be exposed?

A

Expose both upper limbs from shoulders to fingers.

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3
Q

Summary of general inspection?

A

Surroundings - Monitoring (ECG - autonomic problems), treatments (O2, IV infusions), paraphernalia (wheelchair, mobility aids etc.).

Patient - Asymmetry, deformity or abnormal posture (dystonia). Often due to abnormal contraction of one group of muscles.

SWIFT - Scars, Wasting of muscles, Involuntary movements, Fasciculations, Tremor

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4
Q

What is writer’s cramp?

A

Muscles of hand and forearm cramp when patient tries to write.

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5
Q

What is wry neck?

A

Torticollis - painful contraction of SCM which causes the face to point to one side. Other variants possible; retrocollis - head tilts backwards, antecollis - head tilts forwards.

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6
Q

What is resting tremor indicative of?

A

Parkinson’s disease

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7
Q

What is intention tremor indicative of?

A

Cerebellar disorder

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8
Q

Common sites of muscle wasting?

A

Proximally - deltoid, supra/infraspinatus.

Distally - 1st dorsal interosseous muscle.

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9
Q

What is fasciculation?

A

Irregular twitches under the skin overlying resting muscles caused by individual motor units firing spontaneously.

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10
Q

What causes pronator drift?

A

UMN weakness

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11
Q

What is psuedoathetosis?

A

Proprioceptive loss leading to involuntary, slow snake-like movements of distal regions (fingers and toes).

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12
Q

What is dysmetria?

A

Lack of co-ordination (due to cerebellar lesion)

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13
Q

What is myoclonus?

A

Brief jerks that can move a limb. Usually restricted to one muscle group but can be generalised.

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14
Q

What are tics?

A

Borderline psychiatric/neuro in origin. Tend to affect the face. Main manifestation in Tourette’s, but often benign in normal individuals.

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15
Q

What is TONE?

A

The resistance felt by the examiner when moving a joint passively.

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16
Q

How do you assess tone in the upper limbs?

A
  • Ask patient to lie supine on examination couch, and to relax and ‘go floppy’. Ask about painful joints or limitations of movement before proceeding.
  • Passively move each joint tested through as full a range as possible, both slowly and quickly in all anatomically possible directions.
  • Hold the patient’s hand as if shaking hands, using other hand to support elbow. Assess tone at wrist, elbow and shoulder.
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17
Q

What is hypotonia associated with?

A

LMN lesions. Usually associated with muscle wasting, weakness and hyporeflexia.

18
Q

What are the two types of hypertonia?

A

Spasticity and rigidity - UMN lesions.

19
Q

How do you grade power?

A

0 - no muscle contraction visible
1 - flicker of contraction but no movement
2 - joint movement when effect of gravity eliminated
3 - movement against gravity but not against examiners resistance
4 - movement against resistance but weaker than normal
5 - Normal power

20
Q

What do you do before assessing power?

A

Ask if the patient has any pain that may interfere with testing

21
Q

Where do you start when assessing power?

A

Start proximally

22
Q

How to assess for ‘pronator drift’?

A

Observe patient with arms outstretched and supinated and eyes closed. When one arm starts to pronate the sign is positive and it is a sign of UMN lesion.

23
Q

Difference between weakness produced by upper and lower motor neuron deficits?

A

UMN lesions produce weakness of relatively large muscle groups, whereas LMN damage can cause paresis of individual and specific muscles.

24
Q

What are the movements needed to assess power?

A
Shoulder abduction/adduction - CHICKEN
Elbow flexion/extension - BOXER
Wrist flexion/extension - MOTORBIKE
Finger flexion/extension
Finger abduction
Thumb abduction/adduction
25
Q

How should the patient be positioned for reflexes?

A

Supine on examination couch with limbs exposed. As relaxed and comfortable as possible.

26
Q

How do you record the response when assessing reflexes?

A
Increased
Normal
Diminished
Present only with reinforcement
Absent
27
Q

How do you reinforce upper limb reflexes?

A

Ask patient to clench their teeth or make a fist with the contralateral hand. Patient should relax between repeated attempts. Strike tendon immediately after command to the patient.

28
Q

What are the three reflexes and their nerve roots?

A

Biceps reflex - C5
Triceps reflex - C7
Supinator jerk - C6

29
Q

How do you ilicit Hoffmann’s reflex?

A
  • Place right index finger under distal interphalangeal joint of patient’s middle finger.
  • Use your right thumb to flick the patient’s finger downwards.
  • Look for any reflex flexion of the patient’s thumb.
30
Q

How do you ilicit a finger jerk?

A

Place middle and index fingers across the palmar surface of the proximal phalanges. Tap your own fingers with the hammer. Watch for flexion of the patient’s fingers.

31
Q

What are the three aspects of assessment of co-ordination?

A

Rebound phenomenon
Finger to nose test
Rapid alternating movements

32
Q

How to test rebound phenomenon?

A

Ask patient to stretch his arms out and maintain the position. Push patient’s wrist quickly downward and observe rebounding movement.

33
Q

How to do finger-to-nose test?

A

Ask patient to touch their nose with their finger then touch your finger tip as quickly as possible. Make the test more sensitive by changing the position of the target finger as quickly as possible. Repeat with opposite hand.

Look for dysmetria or past pointing. There may be a tremor as it approaches the target finger and the patient’s own nose (intention tremor). The movement may be slow, disjointed and clumsy (dyssynergia).

34
Q

how to assess rapid alternating movements?

A

Demonstrate the action of slapping palm repeatedly with the palm and back of opposite hand as quickly and as regularly as possible. Ask patient to repeat your action and repeat with opposite hand.

Dysdiadochokinesis = impairment of rapid alternating movement = evident as slowness, disorganisation and irregularity of movement.

35
Q

What are the 6 aspects of assessment of sensation?

A
Light touch
Superficial pain
Temperature
Vibration
Proprioception
Sterognosis and graphaesthesia
36
Q

How to assess light touch sensation/superficial pain?

A
  • With patient’s eyes closed, use a wisp of cotton wool/neurological pin and ask the patient to say ‘yes’ to each touch.
  • Time stimuli irregularly and use a dabbing rather than stroking motion.
  • Compare both sides for symmetry
37
Q

How to assess for temperature sensation?

A

Touch patient with cold metallic object (i.e. a tuning fork) and ask if it feels cold.

38
Q

How to assess for vibration sensation?

A
  • Place a vibrating tuning fork over the sternum and ask the patient if they feel it vibrating.
  • Place the vibrating tuning fork on the distal IP join of the forefinger. If sensation is impaired, move proximally.
39
Q

How to assess for proprioception?

A
  • With patient’s eyes open, demonstrate the procedure. Hold the distal phalanx of the middle finger and explain that you are going to move it up and down, demonstrating as you do so.
  • Ask the patient to close their eyes and identify the direction of small movements in a random order.
  • Test both sides. If impaired, test more proximal joint in same limb.
40
Q

How to assess for stereognosis/graphaethesia?

A
  • Ask patient to close their eyes. Place familiar object in their hands and ask them to identify it (i.e. key or coin).
  • Use blunt end of pencil or orange stick and trace letters or digits on the patient’s palm. Ask the patient to identify the figure.
41
Q

End pieces?

A

Examine the lower limbs and cranial nerves.