Upper Limb Examination

Introduction

1. Wash hands

Wash your hands using the Ayliffe technique

2. Introduce yourself

Introduce yourself and give your name and grade

3. Check patient details

Clarify patient’s identity by confirming name and asking for their DOB

4. Describe examination

Explain what examination you are performing and what it involves

5. Gain verbal consent

6. Offer a chaperone

Ask if they would like a chaperone

Peripheral Examination

1. Position patient at 45 degrees

Initially lie the patient at 45 degrees and expose them from their waist up

2. End of bed inspection

Inspect the patient from the end of the best and look for the following:

Patient

Muscle bulk        

• Decreased (Lower motor lesion, late on upper motor lesions)
• Increased (muscular dystrophy)

Tremor

• Slow coarse tremor unilateral (Parkinson’s Disease)
• Bilateral action tremor (Essential Tremor)
• Intention tremor (Cerebellar damage)

Abnormal movements

• Fasciculation - irregular twitches under skin (Lower motor neurone disease in wasted muscle)
• Myoclonic jerks - sudden contractions (Epilepsy, brain damage, dementia)
• Chorea - writhing movements (Huntington's chorea)

Adjuncts

• eg. any supplemental O2 (%), IV lines, infusions, catheter

Paraphernalia

• Walking aids, wheelchair

Neuro examination

1. Inspect for tone

Ask the patient to shake your hand and check for the signs below. Inspect both the right and left and compare. Move arm slowly then quickly to check for rigidity and spasticity.

Muscle bulk

• Feel their grip and muscle bulk of hands

Tone

• Hypotonia/flaccidity - reduced tone associated with muscle wasting, weakness and reduced reflexes (Lower motor neurone disease)
• Hypertonia/rigidity - [picked up on slow movements] increased tone associated with increased reflexes (Upper motor neurone disease)
• Cogwheel rigidity - jerky movements (Parkinson’s disease)
• Spasticity - [picked up on quicker movements] a catch found on quick movements (upper motor neurone lesion)

2. Inspect for power

Inspect the power in the upper limb by asking the patient to apply force against the direction you are pushing or pulling. Compare the right and left sides at the same time. Check the joints below for the following:

Finger

• Abduction, adduction, flexion and extension

Thumb

• Extension and opposition

Wrist

• Flexion and extension

Elbow

• Flexion and extension

Shoulder

• Abduction, adduction, flexion and extension

3. Test the patient's reflexes

Use a tendon hammer to elicit the patient's reflexes. Test the following three reflexes and compare the right to left side:

• Supinator reflex (C5, C6) - ask the patient to rest their arm across their abdomen, strike them midway up their forearm over the supinator tendon.
• Biceps reflex (C5, C6) - ask the patient to straighten their arm. Strike over the biceps tendon in the antecubital fossa.
• Triceps reflex (C6, C7) - hold the arm at 90 degrees and rest it upon yours. Strike the triceps tendon superior to the lateral epicondyle

• Increased response (upper motor neurone lesion)
• Decreased response (lower motor neurone lesion)

4. Inspect for sensation

Inspect the upper limbs for sensation to light touch, pain, vibration and proprioception. Examine each dermatome and compare right to left.

Light touch (Large fast-conducting axons)

• Examine both sides. Compare each side  to see if there is a loss of gross sensation in area. Does this fit a dermatome or cutaneous nerve pattern?

Pain (Spinothalamic tract)

• If you are provided with a neurotip, now check if they can appreciate the difference between light touch and pain. Ask them to keep their eyes open as you demonstrate the difference on either their hand or sternum. Then ask them to close their eyes and ask them whether you are pressing with the sharp / dull end of the neurotip.

Vibration (Medial lemniscus)

• Again if provided with a 128Hz tuning fork test for vibration sensation. Initially demonstrate on either their stenum or hand. Place the tuning fork on bony protuberances distally working your way proximally.

Proprioception (Dorsal columns)

• Test for proprioception by demonstrating to the patient when their joint is up or down. Ask them to close their eyes and tell you whether you have placed a joint pointing up or down. Start with the most distal joint and work your way proximally.

SPECIAL TESTS

Stereognosis (Dorsal column, Parietal lobe)

• Ask the patient to close their eyes then place a small common object in the patient's hand e.g. 20p coin. Ask them to deduce what it is by just feeling it.

Graphaesthesia (Dorsal column, Parietal lobe) if patient unable to grasp

• Use a blunt object and draw a number or letter on the patient's palm with their eyes closed. Ask them to confirm it.

5. Test the coordination of the upper limbs

Test the coordination of the upper limbs by asking the patient to do the following.

Finger-nose test (intention tremor)

• Ask the patient to use their index finger to touch their nose then your finger. Move your finger around to test for intention tremor. Compare right to left.

Dysdiadokinesis

• Ask the patient to clap their left hand with their right. Then ask them to alternate from back to front (palm and dorsum) as quick as they can. Compare their right hand to their left.

End of examination

1. Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

2. State other exams for completion Turn to the examiner and state what else you would do to complete the exam.

3. State what tests you would perform

Explain to the examiner what tests and investigations you would perform

• Dip/MC&S - infection

• FBC - Infection
• U&E - Hyperkalaemia,  Hyponatraemia
• LFT - Metastases
• B12 / folate - peripheral neuropathy