You are not permitted to distribute this without prior written consent. Peripheral Nervous System Examination Upper + Lower Limbs

Size: px

Start display at page:

Download "You are not permitted to distribute this without prior written consent. Peripheral Nervous System Examination Upper + Lower Limbs"

Stewart Shon McCarthy
5 years ago
Views:

1 Yu are nt permitted t distribute this withut prir written cnsent Peripheral Nervus System Examinatin Upper + Lwer Limbs Histry The patient may present with symptms that are purely sensry/mtr r mvement (i.e.: tremr). It is imprtant t find ut the invlvement f ne mdality (i.e.: pain/temperature/prpriceptin/paraesthesiae/2-pint discriminatin/mvement/reflexes etc). Distributin, time f nset, duratin f symptms will give clues abut the diagnsis. Family histry is als imprtant, as sme cnditins are hereditary. Previus injuries, prcedures, neurlgical prblems may have resulted in the current symptm s be sure t ask abut these. Examinatin f the upper and lwer limbs General Pattern (Taller & O Cnnr pp 390) The fllwing pattern is fllwed when asked t examine the upper + lwer limbs: 1. Mtr System (GPMAFTPRC) a. General Inspectin i. Psture ii. Muscle bulk iii. Abnrmal mvements b. Fasciculatins c. Tne d. Pwer e. Reflexes f. Crdinatin 2. Sensry System (PTVPL) a. Pain & Temperature b. Vibratin & Prpriceptin c. Light Tuch General Inspectin (Upper + Lwer Limbs) Abnrmal psture (hemiplegia paralysis f ne side f bdy) Muscle Wasting (denervated muscle, muscle disease, muscle atrphy) cmpare ne side t the ther. Abnrmal mvements: tremrs Skin: neurfibrmatsis, herpes zster, cutaneus angimata, scars, injuries, urinary catheter. Shake hands with patient inability t relax the hand grip dystrphia mytnica. Hld ut bth arms utward, supinated psitin, clse eyes watch fr drift (i.e.: prnatin f wrist, flexin f fingers, dwnward/upward, searching mvement Refer t Taller pp 391 fr causes). Upper Limbs (Taller & O Cnnr pp 391) Mtr System General Inspectin (Patient at edge f bed, arms and shulder girdles expsed) Inspect fr muscle wasting Surce:

2 Yu are nt permitted t distribute this withut prir written cnsent Relax arms, rest n lap. Inspect fr fasciculatins irregular cntractins f muscles Tne (wrists & elbws bth arms) Tell patient t relax their arm. Hld their elbw with ne arm, and with the ther arm rtate their wrists (in supinated psitin) in an unpredictable randm manner Nw rtate their elbws the same way but have their arm in a prnated psitin. Pwer (Testing examiner s ability t vercme patient s vluntary muscle resistance) Take int accunt the patient s age, gender & build. Range f grading mechanism, refer t Talley pp 392. Nte any painful muscle r jint disease which may impair yur judgement (i.e.: rheumatid arthritis etc). Lk fr the fllwing: Lss f pwer, if any, 1) ne side/bth sides 2) prximal/distal/general, In each f the mvements, tell the patient t push/pull against yu as hard as they can this avids cnfusin. Test fr the fllwing: Shulder Abductin: patient abducts arms with bth elbws flexed. (C5, Elbw Wrist C6 deltid/supraspinatus) Adductin: patient adducts arms with bth elbws flexed (C6- C8 pectralis majr, latissimus drsi) Flexin: patient shuld bend elbws and nt let examiner straighten arm ut (C5, C6 biceps, brachialis) Extensin: patient shuld straighten elbw and nt let examiner bend it (C7, C8 triceps brachii) Flexin: patient bends wrist and nt let examiner straighten it ut (C6, C7 flexr carpi ulnaris, radialis) Extensin: patient straightens wrist and nt let examiner t bend it (C7, C8 extensr carpi grup) Fingers Flexin: patient squeezes tw f examiner s fingers (C7, C8 flexr digitrum prfundus and sublimis) Extensin: patient straightens fingers and nt let examiner push use side f hands (C7, C8 extensr digitrum cmmunis, extensr indicis, extensr digiti minimi) Abductin: patient spreads ut fingers, nt let examiner push them tgether (C8, T1 drsal interssei) Adductin: patients hlds paper in between their fingers, and examiner tries t pull it ut (C8, T1 plantar interssei) Reflexes Make sure the patient is relaxed, resting his/her arms n her lap with hands prnated. RELAX THE PATIENT AS MUCH AS POSSIBLE. Biceps (C5, C6): Surce:

3 Yu are nt permitted t distribute this withut prir written cnsent Once elbws are flexed and in relaxed psitin place 1 frefinger n biceps tendn and gentle let the tendn hammer fall nt that finger (hld tendn hammer near its end let gravity d mst f the wrk). If the reflex is absent: reinfrcement maneuvre. Ask patient t cunt back frm 97 r clinch teeth and try reflex again. Reflex lw/absent indicates the fllwing pssibilities: mypathy, neurpathy (mtr nerve), spndylsis (ventral rt), plimyelitis (ventral hrn cell), sensry rt r sensry nerve prblem. Triceps (C7, C8): Supprt elbw with ne hand, tap ver triceps tendn frearm shuld extend Brachiradialis (C5, C6) Have arm in prnated psitin. Place 2 fingers ver lwer end f radius just abve the wrist. Strike this spt with a tendn hammer elbw flexin shuld ccur Inverted brachiradialis respnse: frearm extensin, finger flexin. Fingers (C8) Patient hand is supinated and examiner places 2 fingers ver patient s fingers. Slight strke with tendn hammer shuld result in all fingers flexed. Crdinatin (Cerebellar functin) The cerebellum plays a vital rle in crdinating vluntary mvements. T test this, a standard series f tests is develped. Always demnstrate the mvements yurself befre asking the patient t d s. Finger nse test: Ask the patient t tuch his/her nse, turn the finger and tuch yur finger held at nearly utstretched limits. This shuld be dne slwly, and then fast. D this with patient s eyes pen & clsed. Lk fr: intentin tremr, past pinting. Rapidly alternating mvements: Patient prnates and supinates their hand n drsum f ther hand as fast as pssible. Lk fr clumsiness dysdiadchkinesis. Rebund: Patient lifts their arms twards ceiling, ask them t stp suddenly Lk fr: hyptnia (cerebellar disease delays stpping) Sensry System Pain (pin-prick) testing (Spinthalamic pathway pain + temperature) Infrm patient abut the type f pain that shuld be experienced (They may get scared at the sight f a pain). Test the pain felt at the anterir chest wall (i.e.: is it sharp/dull ) Prick the patient lightly alng each dermatme f the upper limb until any dullness is sensed. Always cmpare right with left side alng same dermatmes. Map ut any dullness by starting frm mst dull area nrmal sensatin. Dermatmes: C3, C4, C5, C6, C7, C8, T1, T2 (assciated with pp 400) Temperature testing (Spinthalamic pathway) Use a tuning frk (usually cld) fr this part f the examinatin. Tuch the patient alng the same dermatmes as fr pain and see if they can detect cld. Surce:

4 Yu are nt permitted t distribute this withut prir written cnsent Dermatmes: C3, C4, C5, C6, C7, C8, T1, T2 Vibratin Testing (Psterir Clumns) Use a 128Hz tuning frk. Patient s eyes clsed. Vibrate the frk and place n 1 f distal interphalangeal jints ask patient if they feel it yes/n. Deaden the frk and patient shuld say when this ccurs nw. Cmpare the ther side. Test ver ulnar head at wrist, elbws (lecrann), shulders. Test bny prminences. Prpriceptin (Psterir Clumns) Patient s eyes pen hld the distal interphalangeal jints by their side and shw patient: up/dwn. Patients eyes clsed: repeat the maneuvre randmly, ask patient t identify the psitins. Test at wrists and elbws in a similar manner (usually nly dne if any lesin is suspected). Light tuch testing (Psterir Clumns) Tuch the skin lightly with a wisp f cttn, alng the same dermatmes as explained abve. Patient s eyes must be clsed: say yes when tuch is felt. Cmpare left and right sides. Lwer Limbs (Talley & O Cnnr pp 408) Gait (if pssible, expse patient s legs and thighs entirely) Check fr urinary catheters present Ask the patient t d the fllwing maneuvres: Walk a few steps nrmally Walk heel/te in a line Walk n heels in a line Squat dwn and up (yu may want t be ready t supprt the patient) Mtr System Nte: Yu have dne yur general inspectin already. Yu may want t lie yur patient n the bed fr the lwer limbs prtin. Fasciculatins and Muscle Wasting Inspect fr fasciculatins. Feel the muscle bulk f the quadriceps and calves. Run hand alng shin t feel fr muscle wasting f anterir tibial muscles. Tne (knees & ankles) If patient is lying dwn, place ne hand beneath ne knee and mve the knee in a randm/unpredictable fashin. Check fr hyptnia and hypertnia. If patient sitting at edge f bed, pull leg t hrizntal and let g t see scillatins. Inspect fr hyper/hyptnia. T test tne f ankles, repeat the prcedure. Randmly mve the ankles and feel fr hyp/hypertnia. Surce:

5 Yu are nt permitted t distribute this withut prir written cnsent Pwer In each f the mvements tell patient t push/pull against yu as hard as they can. This will avid any cnfusin. Test fr the fllwing: Hip Flexin: With patient s leg straight, ask them t lift it up and nt let yu push dwn (L2, L3 psas & iliacus) Extensin: Ask patient t keep whle limb dwn and nt let yu pull it frm calf r ankle (L5-S2 gluteus maximus) Abductin: Ask the patient t abduct whle limb, nt letting yu push it back (L4-S1 gluteus medius & minimus, sartrius, tensr fasciae latae) Knee Ankle Adductin: Ask the patient t keep legs adducted and nt let yu pull them apart (L2-L4 adductrs lngus, brevis, magnus) Flexin: Ask the patient t bend the knee and nt let yu straighten it (L5, S1 hamstrings) Extensin: Ask the patient t straighten their leg and nt let yu push it back (L3, L4 quadriceps femris) Plantarflexin: Ask patient t push ft dwn and nt let yu push it back (S1, S2 gastrcnemius, sleus, plantaris) Drsiflexin: Ask patient t bring ft up and nt let yu pull it back (L4, L5 tibialis anterir, extensr digitrum/hallucis lngus, brevis) Tarsals Eversin: Ask the patient t evert the ft against resistance. Inversin: With ft in plantarflexin, ask t invert against resistance. Tes Flexin/Extensin: Ask the patient t flex and extend tes against resistance (use side f hand). Reflexes (Knee/Ankle/Plantar) Knee jerk (L3, L4): Supprt the knees at the ppliteal fssa s that they are slightly bent. Slightly hit the infrapatellar tendn. Extensin f the knee jint is nrmal. Reinfrcement maneuvre may be helpful when testing fr this. Ankle jerk (S1, S2): Have knees slightly bent, thigh slightly rtated, ft drsiflexed and tap n yur fingers, which are in turn n the sle f the ft. Plantarflexin shuld nrmally ccur. Plantarflexin (L5-S2): Explain t the patient befre attempting this prcedure. Make sure ft is in upright psitin, and RELAXED. Use a key and strke laterally, mving superirly, and medially twards the middle metatarsphalanheal jint. Flexin f the big te is nrmal (Abnrmal: Babinski s) Surce:

6 Yu are nt permitted t distribute this withut prir written cnsent Crdinatin (Cerebellar functin) Heel-shin test (eyes pen r clsed): With knee flat, ask the patient t place the heel f ne leg nt the shin f the ther, and mve up and dwn between ft/knee at mderate pace and accurately. Check fr side t side scillatins and vershting. Te-finger test: With knee bent, patients lifts their ft and tuches examiner s finger Ft-tapping test: tap heel f ft n ppsite shin as fast as pssible (check fr lss f rhythmicity). Sensry System Pain + Temperature (Spinthalamic pathway) Use a new pin, prick the fllwing dermatmes with reference t anterir chest wall. If its dull, say yes. Dermatmes t be tested: L2 (anterir thigh), L3 (frnt f knee), L4 (medial leg), L5 (lateral leg + medial drsum f ft), S1 (heel + sle), S2 (psterir thigh have patient bend their knees fr this). Fr temperature, use a cld tuning frk and ask them t say yes when they can feel the cldness. Vibratin & Prpriceptin (Psterir Clumns) Vibratin: test at the ankles, knees and ASIS (if need be). Prpriceptin: big tes, knees and hips (if need). Patient s eyes are clsed. Light tugh (Psterir Clumns) Use a cttn wisp and test fr light tuch alng the fllwing dermatmes: L3, L4, L5, S1, S2 ask the patient t say yes when they feel the light tuch. Make sure when yu perfrm the examinatin, yu always cmpare the fasciculatins, tne, pwer, reflexes, pain, temperature, vibratin, prpriceptin, light tuch. Never d ne limb all at nce and then prceed t the ther limb. Always COMPARE between the sides. Surce:

BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:

BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised: Page 1 f 6 Subject: Range f Mtin Exercises Date Develped: 4/2010 PROTOCOL FOR: All trained staff PURPOSE: Range f Mtin (ROM) exercises are very imprtant if an individual has t stay in bed r in a wheelchair.