Upper limb neurological examination


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in neurology outpatient clinic

Patient: 50 year old patient

Task:
Your consultant has asked you to perform a full upper limb neurology examination and they will observe you
– Please provide a running commentary whilst you are examining
– After 6 minutes you will be asked a series of questions by the examiner

You are a 50 year old patient who has come to a neurology outpatient clinic. The consultant as asked if you are happy for a junior doctor to examine you and you are delighted by this. You have been asked not to give a history but to confirm your name and date of birth.

Please feel free to stop the examination is the patient causes pain or discomfort to yourself.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


Étique Examination étique
Washes hands
Exposes patient appropriately
Patient positioned at 45 degrees
Examination from left hand side


Inspection 1 General inspection
Muscle symmetry
Muscle wasting
Muscle fasciculation
Involuntary muscle movements
Tremors
Walking frame


Inspection 2 Inspection 2
Assesses for pronator drift
Patients arms outstretched, eyes closed


Tone Tone
Assesses tone by asking patient to let the arm go floppy
Pronate / supinate
Flex / extend wrist
Repeats on other side


Power 1 Power 1 - shoulders. Please state nerve root when assessing power
Abduction (C5)
Adduction (C6/7)
Both nerve roots correct when examining


Power 2 Power 2 - elbow. Please state nerve root when assessing power
Flexion (C5/6)
Extension (C7)
Both nerve roots correct when examining


Power 3 Power 3 - wrist. Please state nerve root when assessing power
Extension (C6)
Flexion (C6/7)
Both nerve roots correct when examining


Power 4 Power 4 - fingers. Please state nerve root when assessing power
Extension (C7)
Finger Abduction (T1)
Both nerve roots correct when examining


Power overall Power overall
Assess power in a “like for like” - test your muscle against the patients
Stabilises and isolates the joint


Reflex 1 Reflex 1 - Please state nerve root when assessing reflexes
Biceps jerk
C5/C6


Reflex 2 Reflex 2 - Please state nerve root when assessing reflexes
Triceps jerk
C7


Reflex 3 Reflex 3 - Please state nerve root when assessing reflexes
Supinator jerk
C5/C6


Coordination Coordination
‘Piano playing’
Dysdiadokinesis
Finger-nose test


Sensation 1 Sensation 1 - light touch
Asks patient to close eyes
Demonstrates on sternum sensation
Compares sides directly by comparing each nerve root


Sensation 2 Sensation 2 - light touch. Please state nerve root when examining
Above right shoulder tip
C4


Sensation 3 Sensation 3 - light touch. Please state nerve root when examining
Deltoid
C5


Sensation 4 Sensation 4 - light touch. Please state nerve root when examining
Tip of thumb
C6


Sensation 5 Sensation 5 - light touch. Please state nerve root when examining
Tip of middle finger
C7


Sensation 6 Sensation 6 - light touch. Please state nerve root when examining
Tip of little finger
C8


Sensation 7 Sensation 7 - light touch. Please state nerve root when examining
Medial forearm
T1


Proprioception Proprioception
Eyes closed
Use thumb DIP joint
Immobilise by holding thumb by sides only
Randomly move tip up / down
Repeat on other side


Vibration Vibration
Eyes closed
128 Hz fork
Place on sternum and confirm they can feel vibration
Test on middle finger tip (move proximal if not felt)


Closing Closing examination
Invites patient to get re-dressed
Washes hands


Patient Patient score
Candidate did not cause any pain to patient
Candidate was polite throughout examination


Question What investigations may be useful in guiding you to a diagnosis?
Nerve conduction studies
Imaging CT / MRI


Question
Review the following video. What sign is shown and what type of lesion is this?

Clonus
Upper motor neurone lesion


Question What are the clinical features of an upper motor neuron lesion?
Increased tone (spastic)
Decreased power
Brisk reflexes
Plantars up going
Co-ordination decreased


Question Describe what grade 3 power means
Able to move against gravity
Unable to move against resistance



Score