Basic Neurological Exam of Upper Limbs

Question 1

What are the main steps in an exam of the upper limbs?

Answer 1

Prepare patient
Hand hygiene
Inspection
Tone
Power
Deep tendon reflexes
Coordination
Sensory exam
Complete exam

Question 2

What is the adequate exposure for this exam?

Answer 2

Singlet or t-shirt off

Question 3

How do you prepare the patient?

Answer 3

Explain reason for exam
In general what it'll involve
Ask about pain in arms
Advise them to inform you if exam uncomfortable/painful
Ensure arms adequately exposed

Question 4

How do you inspect the patient?

Answer 4

Ask patients to rest arms on pillow
Inspect upper limbs
Inspect cervical spine
- Scars
- Deformity
Posture of limbs
Muscle bulk
- Note particular pattern if any muscle wasting
Fasciculations

Question 5

How do you measure tone?

Answer 5

Assess passive resistance against movement
Make sure patient is relaxed
Flex and extend elbow
Flex and extend wrist
Rapid supination and pronation of forearm whilst supporting elbow

Question 6

How do you measure tone if resistance is detected?

Answer 6

Make moves unpredictable

Question 7

How do you measure power?

Answer 7

Functional testing
Compare both sides
Start at shoulder
Progress distally from joint to joint
Clear and explicit instructions

Question 8

How do you test for mild upper limb weakness?

Answer 8

Ask patient to close eyes

Hold arms straight out with palms facing upwards for a minute

Question 9

What do you see in the test for mild upper limb weakness if there is reduced strength?

Answer 9

Arms start to pronate and drift down = pronator drift

Question 10

What kind of patient is the mild upper limb weakness test good for?

Answer 10

Stroke patients

Question 11

What may affect how a patient performs in a power exam?

Answer 11

Motivation
Pain
Changes in tone
Your own muscle strength

Question 12

Which nerve roots control shoulder abduction?

Answer 12

C4, C5, C6

Question 13

How do you test the power of shoulder abduction?

Answer 13

Ask patient to flex arms at elbows
Abduct shoulders to 90 degrees
Patient maintains position as you push down on elbows

Question 14

Which nerve roots control elbow flexion?

Answer 14

C5, C6

Question 15

How do you test the power of elbow flexion?

Answer 15

Patient flexes elbow

Apply counter resistance to forearm

Question 16

Which nerve roots control elbow extension?

Answer 16

C7, C8

Question 17

How do you test the power of elbow extension?

Answer 17

Patient extends elbow

Apply counter resistance to forearm

Question 18

Which nerve roots control wrist extension?

Answer 18

C6, C7

Question 19

How do you test the power of wrist extension?

Answer 19

Patient makes fist
Place your fist against back of patient’s hand
Patient tries to bend back wrist whilst you apply counter resistance

Question 20

Which nerve roots control wrist flexion?

Answer 20

C6, C7, C8

Question 21

How do you test the power of wrist flexion?

Answer 21

Patient makes fist

Flex wrist as you apply counter resistance

Question 22

Which nerve roots control finger extension?

Answer 22

C7, C8

Question 23

How do you test the power of finger extension?

Answer 23

Patient holds fingers out straight
Place your hands against back of patient’s fingers distal to metacarpophalangeal joints
Patient keeps fingers straight as you apply counter resistance

Question 24

Which nerve roots control finger flexion?

Answer 24

C7, C8

Question 25

How do you test the power of finger flexion?

Answer 25

Patient curls fingers up | Keep them flexed while you apply counter resistance

Question 26

Which nerve roots control finger abduction?

Answer 26

C8, T1

Question 27

How do you test the power of finger abduction?

Answer 27

Patient spreads fingers | Resist as you squeeze them together

Question 28

What else does testing the power of finger abduction measure?

Answer 28

Ulnar nerve function

Question 29

How do you test the power of finger adduction?

Answer 29

Patient holds folded piece of paper between fingers | You try to pull it away

Question 30

What else does testing the power of finger adduction measure?

Answer 30

Ulnar nerve function

Question 31

Which nerve roots control finger adduction?

Answer 31

T1

Question 32

Which nerve roots control thumb abduction?

Answer 32

T1

Question 33

How do you test the power of thumb abduction?

Answer 33

Abduct thumb up to touch your finger | Apply counter pressure

Question 34

In which direction is thumb abduction?

Answer 34

Same direction as finger flexion

Question 35

What else does testing the power of thumb abduction measure?

Answer 35

Median nerve function

Question 36

Where are the deep tendon reflexes in the upper limb?

Answer 36

Biceps jerk Brachioradialis jerk Triceps jerk Finger jerk

Question 37

What must the patient be to test deep tendon reflexes?

Answer 37

Relaxed

Question 38

What reinforcement can be used to test deep tendon reflexes in the upper limb?

Answer 38

Clench teeth

Question 39

How do you test the biceps jerk?

Answer 39

``` Patient sits facing you Hands on lap Place your thumb/forefinger over biceps tendon at elbow Tap it with your tendon hammer Look for flexion at elbow ```

Question 40

Which nerve roots are involved in the biceps jerk?

Answer 40

C5, C6

Question 41

How do you test the brachioradialis jerk?

Answer 41

Tap over lower end of radius | Look for flexion of elbow and/or supination

Question 42

Which nerve roots are involved in the brachioradialis jerk?

Answer 42

C5, C6

Question 43

How do you test the triceps jerk?

Answer 43

Tap over triceps tendon | Look for brisk extension of elbow

Question 44

Which nerve roots are involved in the triceps jerk?

Answer 44

C7, C8

Question 45

How do you test for the finger jerk?

Answer 45

Lift patient's fingers passively against your own | Tap your fingers

Question 46

Which nerve roots are involved in the finger jerk?

Answer 46

C8

Question 47

How do you test for coordination in the upper limb?

Answer 47

Finger-nose test

Question 48

How do you perform the finger-nose test?

Answer 48

Ask patient to touch tip of their nose with their index finger > Stretch out to nearly full extension of shoulder and elbow > Touch your index finger repetitively Perform for both arms

Question 49

What is dydiadochokinesis?

Answer 49

Clumsiness of pronating and supinating one hand on the other

Question 50

What sensations are tested in the upper limb?

Answer 50

Pain with toothpick Light touch with cotton wool Vibration sense with tuning fork interphalangeal joint of thumb Proprioception of thumb

Question 51

What are the dermatome testing areas of the upper limb?

Answer 51

``` C4 = shoulder C5 = "military badge" area of upper arm C6 = tip of thumb C7 = tip of middle finger C8 = tip of little finger T1 = upper inner arm ```

Question 52

What is the last step in a neurological exam of the upper limb?

Answer 52

Close exam