The Peripheral Neurological Examination encompasses the motor and sensory function of both the upper and lower limbs. The upper or lower limb examinations may be done in isolation.

Exam Summary


Upper Limb Examination

Video


1. Introduction

  • Introduce yourself and the exam
  • Ask them to remove their shirt
  • Ask if the patient is in any pain
  • Give patient a pillow
  • Hand Hygiene

2. General Inspection

  • Scars or Deformities
  • Muscle Bulk
  • Fasciculations - caused by lower motor neuron conditions
  • Inspect neck as well
3. Pronator Drift
  • Ask the patient to hold their hands outstretched, palms to the ceiling and get them to close their eyes. Observe for one minute. Drifting can be due to upper motor neuron weakness (tends to drift downwards), cerebellar lesion (drifts upwards), or posterior column loss (drift tends to be a searching movement and usually affects only fingers; called pseudoathetosis). Also note any tremor.
4. Tone
  • Ask patient to allow you to take their weight/ make their arms go floppy
  • Rapid pronation and supination
  • Elbow and wrist flexion and extension
  • Look for clonus - caused by upper motor neuron conditions

5. Power

Remember to isolate each joint.

a. Shoulder abduction (C4,C5,C6)

Ask the patient to put their arms up 'like chicken wings' (shoulders abducted). "Don't let me push your arms down"

b. Shoulder adduction (C6,C7,C8)

Now place you hand under the patient's elbow and ask them to push down against your hand.

c. Elbow flexion (C5,C6)

Ask the patient to put the hands up 'like boxing gloves' (elbows flexed). "Don't let me pull your arm."

d. Elbow extension (C7,C8)

While the elbows are still flexed place a hand against the patient's forearm. "Push against my hand"

e. Wrist Extension (C6,C7)

Ask the patient to cock their wrists like 'they are on a motorbike' (wrist extension). "Don't let me push down"

f. Wrist Flexion (C6,C7,C8)

While still in the same position. "Don't let me pull up"

g. Finger Extension (C7,C8)

"Straighten your fingers" (finger extension) "Don't let me push down."

h. Finger Flexion (C7,C8)

"Curl your fingers" (finger flexion). "Don't let me uncurl them."

i. Finger Abduction (C8,T1)

"Spread your fingers". "Don't let me move them" Push the fingers from both sides.

j. Finger Adduction (T1)

Place a piece of paper between the patient's fingers. "Don't let me pull the paper out". Remember to use the same fingers as the patient.

k. Thumb Abduction (T1)

Ask the patient to face their palms to the ceiling. Move your finger above the centre of their palm and ask the patient to touch your finger with their thumb. This will get the thumb into the abducted position. "Don't let me move your thumb."

5. Reflexes

a. Biceps Jerk (C5,C6)

b. Brachioradialis Jerk (C5,C6)

c. Triceps Jerk (C7,C8)

d. Finger Jerk (C8)

6. Coordination

a. Finger-Nose

Ask the patient to touch their nose and then your finger repeatedly as quickly and accurately as they can. Remember that you finger must be far enough away that they need to extend their arm considerably to reach it.*

b. Hand Rapid Alternating Test

Ask the patient to keep on hand still. With the other hand they must tap the palm of the stationary hand with the other hand and alternate between the palm and the dorsum. They must do this as quickly as they can and the hand must go into the air between each tap.

7. Pain – Toothpick
Dermatomes upper limbs.jpg
Dermatomes of the Upper Limb

Test each of the dermatomes of the arm (C5-T2)

8. Light Touch – Cotton Wool

9. Vibration – Tuning fork

  • Use a 128Hz Tuning fork
  • Start at Intepharyngeal joint of the thumb and ask if the patient can feel vibration and when it stops.
  • If they cannot feel vibration at the thumb move up to the next bony prominence of the hand or arm.

10. Proprioception

  • Grab the distal phalynx of the thumb from both sides and move it, showing the patient which way is up and which is down.
  • Ask the patient to close their eyes and say which way you are moving the thumb.

11. Conclude

Move to the lower limb of the examination
or
Thanks the patient and offer assistance.

Lower limb examination

Video


1. Introduction

(If necessary)
  • Introduce yourself and the exam
  • Ask them to expose their legs
  • Ask if the patient is in any pain
  • Prepare bed (flat)
  • Hand Hygiene

2. General Inspection

  • Scars or Deformities
  • Muscle Bulk
  • Fasciculations
  • Inspect lower back also

3. Gait

  • Assess fluidity of movement
  • Look at the way the foot strikes the floor
  • Look for asymmetry

4. Tone

  • Ask the patient to lie down on the bed
  • Ask patient to allow you to take their weight/ make their legs go floppy
  • Knee Flexion/ Extension and Ankle Flexion/ Extension
  • Look for clonus.

5. Power

Remember to isolate each joint

a. Hip flexion (L2,L3)

Push down on the anterior thigh with both hands and ask them to raise their leg

b. Hip extension (L4,L5,S1)

With the leg raised hold onto the heel and ask the patient to bring their leg down into the bed and resist any movement.

c. Hip abduction (L4,L5,S1)

Place your hands on the outer side of each knee and ask the patient to spread their legs/ push against your hands

d. Hip adduction (L2,L3,L4)

Place your hands on the inner side of each knee and ask the patient to bring their legs together/ push against your hands

e. Knee flexion (L5,S1)

Flex the patient's knee. Ask them to bring their foot towards them while you resist movement.

f. Knee extension (L2,L3,L4)

Flex the patient's knee. Ask them to straighten their leg while you resist movement.

g. Ankle dorsiflexion (L4,L5)

Place your hands on the top of the patient's foot and ask them to point their foot towards their face.

h. Ankle plantarflexion (S1,S2)

Place your hands on the patient's sole and ask them to push down like they are driving a car.

i. Inversion of the foot (L4, L5)

Move the foot into an inverted position. "Don't let me move your foot"

j. Eversion of the foot (L5,S1)

Move the foot into an everted position. "Don't let me move your foot"

k. Great toe extension (L4, L5, S1)

Place your finger on the great toe and ask them to move their big toe up.

6. Reflexes

a. Knee Jerk (L2,L3,L4)

b. Ankle Jerk (S1, S2)

c. Plantar reflex

Look for Babinski sign (L5,S1,S2) by running the nail of your thumb up the sole of their foot. Look only for the direction the big toe moves.

7. Coordination

  • Heel-shin test - Ask the patient to touch your finger with their toe, then bring their heel to their shin and run their heel up and down their shin as quickly and accurately as they can. Remember that poor co-ordination may also be due to muscle weakness, not just a cerebellar disorder.
  • Foot tapping - Place your hands below the patient's feet and ask them to tap your hands as quickly as they can using alternating feet.

8. Pain – Toothpick
Dermatomes lower limbs.jpg
Dermatomes of the Lower Limb

Test each of the dermatomes of the arm (L1-S2)

9. Light Touch – Cotton Wool

10. Vibration – Tuning fork

  • Use a 128Hz Tuning fork
  • Start at Interphalangeal joint of the big toe and ask if the patient can feel vibration and when it stops.
  • If they cannot feel vibration at the big toe move up to the next bony prominence of the foot or leg.

11. Proprioception

  • Show the patient what up and down is using the big toe
  • Move toe up or down while patient has eyes closed. Ask the patient which way you have moved the toe.

12. Conclude

Thank the patient and offer assistance

See Also

Muscle weakness
Sensory disturbance

Citation

Dermatomes images from http://moodle.unitec.ac.nz/mod/folder/view.php?id=235867&lang=mi_wwow