Clinical skills: upper limb neuro exam

Question 1

What are the steps of the upper limb neurological exam?

Answer 1

Initial approach
Look
Feel
Motor system
- Tone
- Power
- Reflexes
- Coordination
Sensory system
- Spinothalamic: light touch, pain, temperature
- Corticospinal: vibration, proprioception, two point discrimination

Question 2

INITIAL APPROACH

Answer 2

• As usual, including
• Performs hand hygiene
• Positions patient correctly and examines patient with adequate exposure
• Asks the patient if they are in pain/discomfort before beginning and during the examination

Question 3

GENERAL INSPECTION

Answer 3

• Abnormal position
• Abnormal movements
• Body build
• Comfort
• Distress/pain

Question 4

LOOK

Answer 4

• Muscle bulk: hand muscles, thenar + hypothenar eminences, arms, shoulders
• Fasciculations (small muscle twitches)
• Symmetry and posture
• Skin: scars, swelling, rashes

Question 5

FEEL

Answer 5

• Muscle wasting
• Spasms and fasciculations (fasciculations by tapping over the muscles)

Question 6

MOTOR SYSTEM
What parts of the motor system do you test?

Answer 6

Tone
Power
Reflexes
Coordination

Question 7

MOTOR SYSTEM
What is the difference between tone and power?

Answer 7

Tone: a muscle’s tension at rest
Power: ability of muscle to contract to generate force, to move against resistance

Question 8

MOTOR SYSTEM
Tone: how to perform

Answer 8

Ask patient to relax wrists
For wrists and hands: passive move joints in all planes

Question 9

MOTOR SYSTEM
Power: how to perform

Answer 9

“Push against my hands”
Grade power out of 5

Thumbs: abduction, opposition
Fingers: flexion, extension, abduction, adduction
Wrists: flexion, extension
Elbows: flexion, extension
Shoulders: abduction, adduction, external rotation

Question 10

MOTOR SYSTEM
What are the reflexes?

Answer 10

Biceps
Triceps
Brachioradialis
Finger jerk

Question 11

COORDINATION
What do you need to test?

Answer 11

• Pronator drifting
• Rapidly alternating movements (pronate/supinate wrist)
• Finger-nose-finger test + ballistic tracking

Question 12

SENSORY SYSTEM
What must you do for each test?

Answer 12

• Explain test and demonstrate (on chest) with eyes open before doing it
• Do with patient’s eyes closed

Question 13

SENSORY SYSTEM
Where do you tap for each dermatome?

Answer 13

Question 14

SENSORY SYSTEMS
What 3 spinothalamic tract tests?
Where do you assess?

Answer 14

• Light touch, pain, temperature
• Over dermatomes C5/6/7/8, T1

Question 15

SENSORY SYSTEMS
What 3 corticospinal tract tests?
Where do you assess?

Answer 15

• Vibration, proprioception, 2 point discrimination
• Vibration and proprioception: distally (little finger) and if abnormal result, go more proximally
• 2 point discrmination: varying spaces and locations