Upper Limb Neurological Exam Notes

Introduction

• Host greeting: "What's up Ninjaneurs?"
• Topic: Upper limb neurological exam.
• Comprehensive notes available on Patreon.
• Call to action: Like, comment, and subscribe.
• Celebration of reaching 1 million subscribers.

Patient Assessment

• Patient Introduction: Patient Q is introduced.
• Initial Observations:
  • Assess symmetry between right and left arm.
  • Look for muscle bulk and atrophy indicators.
  • Check for abnormal posturing or movements (contractures, tremors, dyskinesia).

Muscle Appearance

• Key Observations:
  • No asymmetry in muscle bulk observed.
  • No abnormal posturing or movements noted.
  • No fasciculations or tremors present.

Muscle Tone Assessment

• Importance of assessing tone using the Modified Ashworth Scale.
• Types of Tone:
  • Hypotonia: Floppy muscles, indicative of lower motor neuron lesion.
  • Hypertonia: Increased resistance, possibly indicative of upper motor neuron lesion.
  • Subtypes include:
    • Spasticity: Velocity-dependent resistance.
    • Rigidity: Velocity-independent resistance (lead pipe, cogwheel).
• Tone Assessment Method:
  • Relaxed arm, flex and extend at elbow, wrist movements, and shoulder movements.
  • Normal tone was noted.

Power/Strength Assessment

• Power Scale (0-5):
  • 5: Full strength against resistance.
  • 4: Mild to moderate strength against resistance.
  • 3: Can move against gravity.
  • 2: Movement possible with no gravity.
  • 1: Flicker of movement.
  • 0: No movement.
• Strength Testing:
  • Start from proximal (shoulder joint) to distal (fingers).
  • Include abduction, adduction, flexion, extension testing for various muscle groups.
  • Normal strength (5/5) in all tests.

Reflexes Assessment

• Reflex hammer used for testing:
  • Triceps Reflex: Extension response.
  • Biceps Reflex: Flexion response.
  • Brachioradialis Reflex: Flexion response.
• Grading Reflexes (0-4):
  • 4: Hyperreflexic with clonus.
  • 3: Hyperreflexic without clonus.
  • 2: Normal reflex.
  • 1: Hyporeflexic.
  • 0: Areflexic.
• Patient's reflexes graded as 2 (normal).

Sensation Assessment

• Elementary Sensations:
  • Light touch, pain, vibration, proprioception.
  • Temperature was not assessed but noted as important.
• Light Touch Testing:
  • Cotton swab used to test dermatomes (C5-T2).
  • Patient's response confirmed intact sensation.
• Pain Testing:
  • Thumbtack used for superficial pain testing.
  • Responses also confirmed intact sensation.
• Vibration Testing:
  • Tuning fork applied to distal and proximal joints.
  • Intact bilaterally confirmed.
• Proprioception Testing:
  • Tested using the DIP of fingers.
  • Patient able to identify movements correctly.
• Discriminative Sensations:
  • Stereognosis: Identification of objects by feel.
  • Graphesthesia: Identification of written letters/numbers on the hand.
  • Extinction/Neglect: Ability to identify sensations on both sides.

Coordination Assessment

• Finger-to-Nose Test:
  • Assessing for dysmetria and intention tremors.
• Rapid Alternating Movements:
  • Checking for dysdiadochokinesis.
• Cerebellar Drift:
  • Identifying drift in the arms.
• Rebound Phenomenon:
  • Examining the reaction during resistance to movement.

Conclusion

• Recap of the assessment steps:
  1. Appearance
  2. Tone
  3. Power/Strength
  4. Reflexes
  5. Sensory Modalities
  6. Coordination
• Thank you to patient Q for participation.
• Encouragement to check out Q's Twitch channel.