Equipment needed for this examination
● Tendon hammer
● Something to assess soft touch e.g. cotton wool bud.
● Something to assess sharp touch e.g. Neurotip.
● Tuning fork.
Introduction
● Introduce yourself
● Wash hands
● Confirm patient details - Name and date of birth
● Describe the exam
● Gain consent
● Expose the patient appropriately.
General inspection
End of bed inspection
This should always come first in any exam, make it very clear that you’re doing this or even state that you are doing so in OSCE exams.
Throughout this assess patient’s general condition and posture, but also look around the bed for any extra clues
General inspection
Look more closely at the patient, in particular their arms.
The acronym SWIFT is often used
S - Scars
W - Wasting (of muscles)
I - Involuntary movements
F - Fasciculations
T - Tremor
Pronator drift
First ask the patient to hold out their hands at 90degrees to their body, with their eyes closed and palms upwards.
Count to 10 out loud whilst waiting to see if the patient is able to keep their arms horizontal.
If this test proves positive then the patient will unknowingly drop one or both of their arms.
The classical imagine is the arm moving inferiorly and medially rotating (palms may end facing inferiorly).
If this sign is present then it is characteristic of an Upper motor neuron lesion on that side.
Tone
Testing for tone can be done in either 1 single step or in 3 short steps.
Method 1
Take the patient’s hand in equivalent one, in your other hand take the posterior side of the distal humerus.
Once this is done then rotate each joint in a circular like motion, starting off at the wrist, then working in the elbow and then the shoulder.
If this is done correctly then you will be able to feel any variations in tone from the normal.
Repeated this on the other limb, but if possible keep the hands the same way round so that there is no differentiation in your own assessment between limbs.
→ Increased tone - hypertonia
→ Decreased tone - Hypotonia
Method 2
The other way to assess tone in the upper limb is to assess each joint independently.
Once again working distally to proximally.
Hold each side of the wrist joint and rotate in a circular motion.
Hold each side of the elbow joint and rotate in the circular motion.
Hold the patients upper arm, and place your other hand on the front of the lateral end of the clavicle, if necessary your second hand can be used to support the weight of the limb. Once again rotate this in a circular motion.
This assessment can be done from proximal to distal instead as long as you work the same way in both arms.
Hypertonia causes: Strokes, brain tumours, MS, Parkinson’s, cerebral palsy.
Hypotonia causes: Cerebral palsy, meningitis, myasthenia gravis, CMTD.
Power
Once again this part of the examination must be done distally to proximally or vice versa.
By starting off proximally at the shoulders then you will be able to get the patient to do the easiest action first.
Shoulders
Asking the patient to put their arms up with the upper arm abducted to 90 degrees and the forearm fully flexed may be difficult so often patients understand it better if you show them yourself
‘Can you put your arms up like a chicken for me?’
After establishing this position then you will need to apply pressure with 1 or 2 hands to the top and then to the bottom of the patient’s arm, asking them to resist the pressure you apply.
This should then be repeated on the opposite arm, again with the same hand(s) used previously.
Elbows
The next step is to move to the joint more distal of the shoulder, to test the power across this joint then ask the patient to fully adduct their arms whilst keeping them in a flexed position
‘Can you put your arms up like a boxer for me?’
Again for this then you will need to test both flexion and extension across the joint. To do this pull the patient’s arms away from their body, and then push them into their chest.
Do this gently to start with as the patient may be frail, but with increasing intensity, all the while asking the patient to resist you.
Wrists
Ask the patient to lay their hands, palms down on their thighs.
Once this is complete, then take the patient's wrist, holding the forearm in one and and the patient’s hand in the other.
Ask the patient to push up into your hand and then push down, move your hand accordingly.
Fingers
Get the patient to put their fingers out straight, try to apply force to the patient extending their digits.
Ask the patient to splay their hand as far apart as it will go. By applying pressure on the index and little fingers, try to get them to resist you pushing the fingers back together.
Lastly with their thumbs pointing upwards, try to push the patient’s thumbs back towards their palm, again asking them to resist your action.
Coordination
Dysdiadochokinesia
Ask the patient to place one hand on top of the other, then turn it over. This should for a patting motion with the anterior and posterior sides of one hand on the palm of the other.
Then ask the patient to speed up to go as fast as possible.
Visual representation can be given to the patient if necessary
Repeat the test using the other hand.
Finger to nose test
Ask the patient to touch the end of their nose with their index finger and then touch the end of your index finger which should be held out in front of them at a point where their arm should be fully extended.
Then ask them to repeat this motion as fast as possible.
Repeat the test using the other hand.
This can often be confusing to patients, so you may have to perform it with them.
Reflexes
There are 3 different reflexes you must test for in the upper limb; biceps, triceps and supinator.
Before doing so ensure the patient is completely relaxed, if a reflex cannot be elicited on the first try, then perform the reflex reinforcement manoeuvre.
Triceps reflex - Take the weight of the patient’s arm in one hand and with the arm at 90 degrees flexed, hit the Triceps tendon about at the space where the olecranon fossa should be.
Biceps reflex - place one finger over the top of the antecubital fossa, with the patient resting their arm on their lap. Hit your finger once it’s in this space and look proximally for a muscle twitch.
Supinator reflex - With a half medial rotation of the forearm and again the arm fully relaxed resting in the patient’s lap, place 2 fingers across this tendon around 4 inches proximal to the anatomical snuffbox. Hit your fingers when ready.
Sensory
Light touch
For this step then you will be examining each of the patient’s dermatomes with a wisp of cotton wool.
Firstly touch somewhere on their torso e.g. manubrium and check that they can feel it.
After make sure the patient closes their eyes. Ask them to say yes when they feel something.
Assess from left to right, one dermatome at a time.
This is to assess the dorsal column medial lemniscus tract.
Sharp Touch
To assess Sharp touch, carry out the same steps as for light touch, but use a neurotip or sharp object that is cleaned instead of a cotton wool bud.
This is used to assess spinothalamic function.
If there are any areas of sensory deficit throughout soft or sharp touch then map it out more closely.
Vibration
Use the 128hz tuning fork for this tis, it is usually the longer one of the two.
Ask the patient to close their eyes, assess their initial ability to feel vibration my testing it on their sternum.
After this, whilst keeping their eyes closed, then place it on their distal interphalangeal joint of their thumb and ask them if they can feel it vibrating.
Then ask them to tell you when they stop feeling it vibrating, hence then stopping the tuning fork.
This is done to assess if the patient can actually send vibration (dorsal column) or just the pressure of something touching their skin.
Proprioception
This test is done again to test the Dorsal column tract.
Hold the very tip of the tip by its sides and in the other hand hold the sides of the distal interphalangeal joint of the thumb.
With the patients eyes open, demonstrate to them what is up and what is down.
After this ask them to close their eyes and ask them if the thumb is up or down.
If the patient is unable to do this then test the joint more proximal to this.
Completing the exam
Thank the patient
Wash hands
Summarise exam
Suggest further tests or investigations: Cranial nerve exam, Lower Limb near exam, USS of any affected nerves, CT spine
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