Neuro - Upper Limb

Question 1

Introduction?

Answer 1

1. Wash hands
2. Your ID
3. Patients ID
4. Explanation
5. Consent
6. Ask about pain

Question 2

List the catagories of things you check throughout the examination.

Answer 2

Observation

Tone

Power

Coordination

Reflexes

Sensations

Question 3

What is in inspection?

Answer 3

General - AVPU, environment etc

SWIFT

• • Scars
• • Wasting
• • Involuntary movements
• • Fasciculations
• • Tremors

Question 4

What are the 2 types of common tremor?

Answer 4

Phsiological fine tremor

Parkinsons - pill rolling tremor

Question 5

How would you check tremor?

Answer 5

Hands out

Question 6

What else would you check after tremors?

Answer 6

Pronatory drift by asking them to close eyes and put arms out with palms upwards

Question 7

Is pronator drift an UMN lesion or a LMN lesion sign?

Answer 7

UMN

Question 8

How is tone assessed?

Answer 8

1. Ask if patient is in any pain
2. Relax arm
3. Elbow flexion/extension
4. Forearm pronation/supination
5. Wrist flexion/extension

Compare BOTH arms

Question 9

What are you looking for in tone?

Answer 9

Hypotonia

Hypertonia - spasticity or rigidity

Question 10

Spasticity vs rigidity?

Answer 10

S - velocity dependant hypertonia

R - hypertonia even with slow movements, can be throughout the motion (lead pipe) or be jerky (cog wheel)

Question 11

What is tested in power?

Answer 11

• Shoulder abduction - put your arms out like a chicken please, push down only
• Elbow flexion and extension - “arms out like a boxer, pull/push away”
• Wrist flexion and extension
• Finger flexion and extension - squeeze you finger and ask to push up using fingers
• Intinsic muscles of the hand - Splay fingers wide apart and stop you pushing them together

Do both sides and compare

Question 12

How is power grades?

Answer 12

MRC power scale - 5 is normal so after power is completed state all movements had MRC power 5

Question 13

How is coordination tested?

Answer 13

Finger nose test - their nose to you finger as fast as they can - do not move your finger

Dys-dia-do-kinesis - tap palm and pronate/supinate

TEST BOTH SIDES

Question 14

What reflexes are tested and how?

Answer 14

Biceps - C6 - place thumb/index finger over tendon and hit fingers

Triceps - C7 - hit directly

Supinator - place thumb/index finger 3/4cm above the distal end of radius and hit fingers

Question 15

Shoudl both arms be compared for reflexes?

Answer 15

Yes - for everything

Question 16

What do you do if you cannot elicit a reflex?

Answer 16

Ask patient to clench teeth just as you hit the tendon - distraction

Question 17

What are the 4 things tested in sensation section?

Answer 17

1. Light touch
2. Pinprick sensation
3. Vibration sense
4. Joint proprioception

Question 18

How is light touch done?

Answer 18

1. Show patient what the cotton wool feels like
2. Ask them to close eyes
3. Touch the…

• Thumb, middle and little fingers
• Medial and lateral forearm
• Medial and lateral upper arm

Question 19

List the dermatome areas

Answer 19

• C5 - lateral upper arm
• C6 - lateral forearm and thumb
• T1 - medial forearm
• C7 - middle finger
• C8 - pinky finger

Question 20

How to do pinprick test?

Answer 20

Same dermatomal areas as cotton wool but with a neurotip

Question 21

How to test vibration sense?

Answer 21

Show them what it feels like vibrating

Test the 128 Hz turning fork on a distal joint while eyes are closed

Do both hands

Question 22

How to test joint proprioception?

Answer 22

• Ask patient to close eyes and make up and down movements of their finger - show them first with eyes open
• Hold joint by sides so they cannot tell where you move it by feel
• Do big movement to test if they have understood you then get smaller

Question 23

How would you close this examination?

Answer 23

Thank the patient for their time

Wash hands

Let them get comfortable