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Neurological Examination of the Upper Limbs Cheat Sheet (DRAFT) by

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This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction:

W
Wash Hands
I
Introduce Yourself + Patient's Identity
P
Permission
P
Patient Position + Pain
E
Explai­­nation
Patient must be placed at 45° and limbs exposed

Equipment:

 
Cotton Wool
Neurotips
Tendon Hammer
128Hz Tuning Fork

General Inspec­tion:

•Postural abnorm­alities and deform­ities
•Leaning or facial asymmetry
•Muscle wasting, fascic­ula­tions, or tremor
•Abnormal movements
•Obvious discomfort or pain
•Medical paraph­ern­alia:
Walking aids, Calipers
Ask patient to lean forward and examine back/s­capulae

Tone:

Check for pain before starting
Check tone:
Ask patient to rotate arm at shoulder

Flex and extend arms at elbow

Supination and pronation

Flex and extend hand at wrist
Extra movement => Decreased tone

Less movement => Rigidity
Increased Tone:
• Clasp knife rigidity
• Clonus
• Cog wheeling
• Lead pipe rigidity
Decreased Tone:
• lower motor neuron lesion

Power:

Test both left and right limbs, directly comparing each movement in turn.

The patient should perform each movement on their own and then attempt with the examiner resisting the movement
Pronator Drift:
Ask patient to stretch both arms out in front of them with their eyes closed and palms facing upwards.
Indication of muscle weakness, abnormal function of the cortic­ospinal tract and upper motor neurons
Shoulders:
Abduction + Adduction
Ask patient to "­Chicken Wing" and push up/down against your hands
Elbows:
Flexion + Extension
Ask patient to flex/e­xtend arm toward­s/away from you
Wrist:
Flexion + Extension
Hands out with closed fist, resist pushing up/down
Fingers:
Flexion + Extension

Adduction + Abduction
Hands out with fingers straight, resist pushing up/down

Hands out, spread fingers apart, resist pushing fingers together

Close fingers, resist pulling apart indivi­dually
Thumb:
Adduction
Patient holds out hand, resists pushing towards other fingers.

Patient forms ring with thumb and pointer finger and resists opening ring

Coordi­nation:

Finger to Nose Test:
Past pointing, Kinetic Tremor
Rapidly altern­ating wrist movements:
Supination + Pronation - Dysdia­doc­hok­inesia

Tendon Reflexes:

Limb must be totally relaxed
Biceps:
Support patient's arm on yours
C5,6
Triceps:
Allow patients arm to hang with elbow at 90°
C7
Brachi­ora­dialis:
Strike 2-3cm above the radial styloid process
C5,6
Muscle may just contract, may not be an obvious movement

Reflex may be presen­t/a­bsent, or reduce­d/brisk

Sensation:

Light Touch:
Important to touch rather then stroke

Lightly touch sternum first using cotton wool.
Ask patient to close eyes and tell you when they feel the touch.
Ask if touch feels the same on both sides
 
Posterior aspect of the shoulders
C4
 
Lateral aspect of the upper arms
C5
 
Tip of the thumb
C6
 
Tip of the middle finger
C7
 
Tip of the little finger
C8
 
Medial aspect of the lower arms
T1
 
Medial aspect of the upper arms
T2
Pain:
Repeat same process as for light touch.

Tested using a new neurotip.
Must be disposed of in the sharps bin.
Temperature:
Tested the same way as pain/light touch, rarely done.

Tested using a cold tuning fork.
Vibration Sense: (128Hz)
Strike tuning fork and hold to patient's sternum.
Ask patient to close eyes.
 
Begin on most distal bony prominance (Tip of middle finger, working proximally on each bony promin­ance)
Proprioception:
Hold middle finger at middle phalanx, ask patient to close eyes.

Demonstrate up/down for the patient, then repeat in a random direction, asking the patient to say which direction the toe is moving.

Repeat 3 times for both sides.

Continue up finger/arm until patient is correct

MRC Muscle Power Scale:

Upper Limbs Dermatome Map: