NEUROLOGICAL EXAM (UPPER AND LOWER LIMB)

Answer 1

NEUROLOGICAL EXAM (UPPER AND LOWER LIMB)
…half of it is about giving instructions
Normally in the exam, they are going to tell you to examine either the lower limb or the upper limb.
However, examination of the cranial is usually done first in practice.
Exposure
Upper Limb: If you are told to examine the upper limb the entire torso must be exposed so If they are wearing a shirt, they need to take them off. Whichever place they tell you to examine you have to expose fully including the torso.
Lower Limb: If it is the lower limb, you can take off any shorts or trousers in order to expose at least from the mid-thigh down.
Position
The patient must be in the anatomical position. Even if they are already in the anatomical position, don’t assume, just position them again.
Abnormality: The first sign from the foot of the bed will be that maybe external or internal rotation of a lower limb, which can point to a pathology on that side.

Answer 2

FOOT OF THE BED
We are inspecting for
• General habitus of the patient.
• Elderly, middle-aged, young?
• Is the patient obese, cachectic?
• Obvious wasting?
• Involuntary movement either of the limb or the entire side of the body.
Look around the bed for
• Walking aid

The neurological exam can be grouped into:
❖ Motor exam
❖ Sensory exam
❖ Spine

Answer 3

UPPER LIMB
MOTOR EXAM
The motor involves
1. Inspection
2. Palpation
3. Tone
4. Power
5. Reflexes

1. Inspection:
   Inspect for
   • Spontaneous fasciculations
   • Obvious tremors
   • Obvious wasting
   • Asymmetry of the hands.
   • Abnormal movement
   You should also inspect the posterior aspect of the limb.
2. Palpation:
   We are touching the patient for
   • Induced fasciculations in the muscle groups.
   • Muscle bulk in the muscle group. So ideally after the induced fasciculations you check for muscle bulk.
3. Tone:
   Check for tone in all the joints. You are checking if one joint is easier or more difficult to move compared to the other.
   • Shoulder
   • Elbow
   • Wrist
   With decreased tone it is far more easier to move the joint as compared to increased tone.
   Ways of checking for tone
   • WAY 1: Hold the part of the limb distal to the joint and rotate gently.
   • WAY 2: Roll the entire limb on the bed.
   • WAY 3: Lift the entire limb and drop it. How quickly it drops down will let you know if there is hypertonia or hypotonia (meaning if it takes longer for it to drop).
   In an exam, you are expected to do two of these ways. It is far easier to do the first two methods.
4. Power:
   To check for power there are two ways to check power.
5. You check power in the entire limb (i.e. the general power) and compare both limbs.
6. You check power in the compartments (i.e. in the individual muscle groups in the upper limb)
   General Power
   • Ask patient to raise both hands, use your palm to exert pressure over their anterior cubital region. If patient is able to oppose the pressure then the power is 5/5
   • If the patient lift but falls against resistance it is 4/5
   • If the patient can lift both hands, but it is not sustained against gravity then it is 3/5
   • If the patient can’t lift hands but can drag the hands along the bed then it is 2/5
   • If the patient cannot lift or drag the hands, but they can wiggle their fingers, then it is 1/5
   • If the patient cannot even wiggle the fingers, then it is 0/5
   Compartments
   • Compare both at the same time so that you can tell the difference between the
   • Shoulder, abduct and adduct (open against my hands and close against my hands)
   • Elbow, flex and extend
   • Hand: palmar grasp and fingers(for the fingers use a piece of paper to check for the power)
   Summary:
   General power is 5/5 in both limbs and power in all compartments were intact.
   However, if you find reduced power in any of the compartment you can say;
   General power is 4/5 in both limbs and power in biceps was reduced on the left side but intact in all other compartment.
7. Reflexes
   DURING THE EXAM, WE ARE LOOKING AT HOW YOU HOLD THE REFLEX HAMMER. Hold the hammer in such a way that tail of the hammer is rarely seen. The action is done at the wrist.
   Also you do the reflexes on both limbs. You do biceps on one hand you do on the other before you move on to the next reflex.
   If the patient is aware or very conscious and is assisting(i.e. by tensing the tendons) you in what you are doing, it is going to be very difficult to elicit for the reflexes. However, if you strike twice and it is not coming, move on.
   During the reflexes, you are checking how quickly or briskly, the hand moves, so you must know normal, increased(hyperreflexia) and reduced (hyporeflexia) reflexes. And it is a comparison with the other limb, so you have to do both limbs. So one side may be reduced as compared to the other side, or you may have increased reflexes on both sides.
   ➢ Biceps
   Flex the patients elbow joint to about less than 90 degrees and place arm on top of the abdomen. Place your fingers over the tendons and you are looking for muscle contraction of the biceps.
   ➢ Triceps
   Flex the elbow joint to about 90 degrees over the abdomen in order to expose the tendon. You don’t have to necessarily lift the hand. However, if you try to lift the hand some of them may try to help you and that might make eliciting reflexes difficult. Use the patellar hammer over the exposed tendon.
   ➢ Supinator
   Tell the patient to relax the palm on the side of the bed. If the patient has tensed their tendons you are never going to be able to get the reflexes. Apply a gentle strike over your finger placed at the tendons anterior to the wrist.

Answer 4

SENSORY EXAM
Preparations: Come to the exam with a swab of cotton, tooth pick and tuning folk.
It involves:
1. Light touch
2. Crude touch
3. Vibration senses
4. Proprioception

1. Light touch
   With your swab of cotton, test it at a normal place where you patient will feel it before you go and test the limbs.
   So you take the cotton and you ask the patient to close the eyes and swipe gently(lightly) in the upper part of the chest. While the patient’s eyes are closed, ask them if they feel it. If the say, “yes” ask them again that anytime they feel you have touched them they should tell you. So after that first time that you test it. In the patient, you don’t ask the patient again if they can feel the swipe. So the patient must volunteer the information to you and you are comparing both sides.
   NOTE: if you check sensations on the patient’s face you have failed.
   If you perform the light palpation and the patient does not respond, leave the dermatome and move to the next one. So you just note that there is loss of sensation in that dermatome. Then you should know which modalities is impaired in that dermatome. So you will say there is loss of sensation so (light touch/crude touch) in C5 for example.

Check the sensory in the dermatomes.
2. Crude Touch (Pain)
Temperature is rarely checked because temperature runs with pain. Once you have assessed pain, temperature is mostly likely intact because they run along the same tract.
READ ON SPINOTHALAMIC AND OTHER SPINAL TRACTS.
Ideally, you should come with a toothpick for the examination.
Check for pain in the various dermatomes of the upper hand.

3. Vibration Sense
   You must come with a tuning folk. There are two things the patient needs to tell you.
   • They must tell you when it is vibrating
   • And when it stops vibrating.
   You must check for vibration senses on the bony prominences. You are not suppose to ask the patient whether the vibration has started or it has stopped. They must volunteer that information to you.
4. Proprioception
   Use the thumb of the patient and assume the up, middle, down position. Then tell the patient to close the eyes.
   Try as much as possible not to hold any other place except the thumb, so that you don’t give the patient a bearing to know where the position of the finger is.
   You are expected to hold the sides of the patient’s thumb with your thumb and middle/index finger

Answer 5

SPINAL EXAM
Inspection
Now ask your patient to sit then you inspect the back of the spine for
• any increased curvature in the spine as compared to the normal .
YOU MUST KNOW THE NORMAL CURVATURE OF THE SPINE.
• Inspect for any masses.
Palpation
Palpate along the spine for:
• Any areas of tenderness
• Any mass
• Any curvature
In the exam, if you are told to examine upper limbs, end the examination by saying that you would also like to examine the lower limb to complete your examination and vice versa (if they told you to examine the lower limb you will say you would like to examine the upper limb to complete your examination.

Answer 6

SUMMARY – UPPER LIMB
Upper limb:
• Inspect anterior and posterior aspect of the limb. (muscle wasting)
• Palpate for induced fasciculations and muscle bulk
Motor modalities:
• Tone (shoulder, elbow, wrist; roll along the bed; lift and drop hands)
• Power (general, muscle groups)
• Reflexes
Sensory modalities:
• Fine touch
• Pain/crude touch
• Vibration sense (when it starts and when it stops)
• Proprioception
Spine
• Inspect
• Palpate

Answer 7

LOWER LIMB
…what is done in upper is also done in lower limb.
The lower limb in
Exposure and position
Expose the patient’s legs. So you can ask them to take of their shorts or trousers and leave them in their underwear. So you have to expose majority of the thigh down.
Inspection
Inspect (anterior, posterior)
• Spontaneous fasciculations
• Wasting
• Tremors
• Abnormal posture
• Abnormal movement in the limb
Palpation
Palpation (what ever you do on one side you do on the other)
• Induced fasciculations (YOU MUST KNOW THE MUSCLE GROUPS)
• Muscle bulk (for some patients you will see obvious difference in the muscle bulk)

Answer 8

MOTOR
Tone (3 methods as said in upper limb)
Power (general and muscle group) (you do one a time)
Once the patient is raising the leg at least power is 3/5. So you have to apply resistance in order to tell if the power is 4/5 or 5/5. When checking for hip extension, you have to bend down and put you hand under the thigh and tell the patient to press down against you hand.
Reflexes (Patella and ankle).
WE WANT TO SEE YOU IDENTIFY THE TENDON, PALPATE THE TENDON AND THEN STRIKE THE TENDON.
Use your left arm to lift the right leg in such a way that the popliteal fossa will rest on you arm. And make sure the tendons are relaxed before you palpate and strike. WHAT WE ARE CHEKCING IS THAT YOU ARE PLACING THE KNEE AT 90 DEGREES.
Plantar (Babinski) reflex: Normal response the toes will flex (i.e. flexor). Abnormal will be extension of the toes (extensor). If the planter does not move, you say it is equivocal. So it is either flexor, extensor or equivocal.

SENSORY
• Confirm from the chest then you come to the dermatomes of the leg for
- Light touch
- Pain
- Vibration
• Proprioception

SPINE
• Inspect
• Palpate
GAIT
Gait (because spinal level injuries can also cause paraparesis)
• Ask the patient to walk for you.
• YOU MUST KNOW ALL THE DIFFERENT POSSIBLE GAITS THE PATIENT MAY HAVE.