Neurological Examination of the Limbs - Explanation

okay so thanks for that Jake now I want to watch you walk up and down please at the end of the couch to and fro and whilst he's doing that I'm looking to see if he's got a stiff-legged gate looking for spasticity I'm looking to see what his posture is like to see whether he's got arm swing to see whether he's stooped or not I'm looking and listening to see whether he's got a foot slapping gate having done that I'm now watch him in the other plane I'm going to see if he's got a broad-based a taxier and just stop there please and a more exacting test of coordination of gate is to get him to walk five steps like this Heel To Toe can you do that for me please Jake okay that's fine thanks very much and now we're going to do romberg's test so I want you to stand with your feet together okay eyes open to start with are you okay like that yeah fine yeah okay and now eyes closed and I'm standing here to catch him just in case this is a positive romberg's test and he sways excessively which he isn't doing okay so that's the end of that part of the examination so I'd like you to strip off to your underclothes please and climb on the couch okay the neurological examination of the limbs is done separately first the arms and then the legs and whilst you're examining the arms remember to examine the scapula which anatomically are part of the arms and also note that his arms and legs need to be bare so I'm now going to stand by the couch and inspect his arms and legs can you just uh uncurl your hands and rest your hands down like that thank you with an impatient I note items around the bed such as walking aids or calipers I also no his resting posture any asymmetry any added movements or any obvious wasting with or without for ciculation next I'm going to inspect his arms more closely and now can you sit forwards please Jake so I can look at your scapula okay that's fine will you rest back again please as with all parts of this examination I compare the two sides I'm looking at muscle bulk in case there's any wasting or facul any asymmetry an abnormality perhaps of resting posture or any abnormal involuntary movements next I want you to put your hands out like that please with your eyes closed I'm looking to see if there's any pronator drift on one side which would suggest a subtle paramal deficit on that side I can't see any evidence of that okay thanks you can put your hands hands down next I'm going to examine tone in his arms so I want you to let your arms go loose and floppy please Jake I'm going to begin with the elbow flexion and extension then superation and pronation of the wrist flexion and extension of the wrist and then I'm comparing the two sides left elbow superation pronation again and flexion extension of the wrist okay thank you and looking for an increase or decrease in tone in parameter deficits clasp knife rigidity and or clonus may be found in extra parameter deficits I'll find Cog Wheeling or lead pipe rigidity and in a lower mot neurone Legion I would expect the tone to be decreased next I'm going to assess power again comparing left with right beginning proximally working distally it's important to secure the joint so that you any test power around one joint at any time where possible compare your power with the patient when testing elbow flexion for example oppose his biceps with yours I'm looking to see if there is any weakness and if there is what is the pattern of that weakness next Jake I'm going to test the strength in your arms I want you to put your elbows up like this and push up against me then push down on my hands I want you to pull your elbow towards you push me away pull towards you push me away tight fist don't let me push it down tight fist straight fingers don't let me push them down straight fingers I want you to push your fingers apart stop me pushing them together push your fingers apart stop me pushing them together and now I want you to push your thumb against my thumb push your thumb against my thumb makebe one of those and stop me pulling your finger and thumb apart okay thank you coordination in the arms is tested using the finger nose test and with rapid alternating superation and pronation movements in the finger noose test I'm particularly looking for past pointing I.E action tremor or kinetic Tremor next I'm going to test coordination Jake I want you to touch my finger and then touch your nose first with your right hand back and forth to and fro it's important to make sure that he's stretching his arm out and also important to make sure that he's super nating and pronating appropriately whilst he's doing this test and now the left hand please same again okay that's fine thank you and now I want you to do this patting the back of your hand front back front back like that quick as you can and then the other way around so any Corruption of this movement would be dis diodo kyia but he hasn't got it next I'm going to do the reflexes note how I hold the tendon Hammer at the end so I can use it like a passive pendulum rather than giving him a firm blow with the hammer so I need his arms to be relaxed I'm going to do the supernus first comparing the two sides now I'm going to do the biceps jerk and the triceps I'm going to finish off with the finger check on either side if you have difficulty eliciting any of the reflexes use reinforcement get your patient to clench their teeth and try again immediately I routinely test four modalities pin prick light touch proception and vibration sense for pin PRI and light touch I validate the sensation of the patient's sternum and then checked for sensation either in each dermatome individually or distally depending on the pattern I'm expecting I routinely leave out deep pain and temperature sensation which are only necessary in specific cases so to test pin prick perception take a neuro tip and try it out on your subject giving him two or three Pricks in a particular position to make sure that he can feel that it's sharp before moving on to the dermatomal examination so Jake I want you to tell me if this is sharp or blunt sharp okay so we're now going to examine his dermatomes beginning with C4 sharp or blunt sharp and there Sharp C5 Shar C5 sh C6 sh C6 sh C7 sharp C7 Shar C8 sharp C8 Shar T1 Shar T1 sharp T2 sharp T2 sharp and seeing as that was okay I will now just make sure that distal sensation is also okay beginning with a median nerve innovated finger sharp or blunt sharp and an all the nerve finger sharp all the nerve sharp medium nerve sharp oh that's fine thank you examination of light touch follows the same pattern as the examination of pen prick it's done with a cotton wool ball and take care to make sure it's a touch and not a stroke so Jake Can You Feel the light touch there yeah okay thanks so I'll now examine his dermatomes again C4 yep C5 yep yep C6 yep yep C7 yep C7 yep C8 yep C8 yep T1 yep T1 yep and T2 yeah and then disty the median nerve innovated finger yep Anna finger yep enna Y and median yep okay thank you next I'm going to test Pro perception or joint position sense so Jake I'm going to get a hold of your third finger I want to get those out of the way I'm going to move the end of your finger up or down and you're going to close your eyes and tell me whether you can feel it moving up or down okay notice how I'm splinting his finger so it's just the distal fail length that I'm moving okay you ready y now up now up now down now down now down now down and that's okay on on that side so I'm going to do the other side now down now down now down now up now up now down now down now up and that's fine the patient should be able to perceive the smallest movement you can make so if he can feel his distal phth lengths going up and down then you can stop there if he can't you go to a more proximal joint so you might need to flex and extend his whole finger or his wrist or even his elbow before you get to a joint where he can perceive the movement and don't forget to compare the left side with the right side finally I'm going to examine vibration sense I'm going to use a 128 Hertz tuning fork and I'm going to validate the feeling of vibration on the sternum first so Jake tell me if you can feel that vibrating yep okay and then on his fingertip yep okay then on the other side side yep okay now close your eyes tell me when it stops now and if he couldn't have felt it on his fingertips I would have then tested vibration sense more proximately on bony prominences until I got to a point at which he could feel the vibration next Jake I'd like to examine your legs and I'd be looking at muscle bulk I'm looking for any wasting or for ciculation I'm looking for any abnormality of posture any asymmetry and any abnormal involuntary movements next I'm going to examine tone so Jake let your legs go loose and floppy first I'm going to test the tone at the hip comparing one side with the other then at the knee then the ankle okay thanks that's fine clonus is a sign of increased tone it is a rapid sustained jerking and may be found on for stretching of the quadriceps or Dy flexion of the ankle now I'm going to test for clonus and Jake this is going to involved four stretching of your quadriceps and your calf muscles okay might hurt a bit okay so quads first and then the calve muscle bend your knee Let It Go as Loose as you can so that's a very rapid movement the fastest movement I can make and that's fine thank you next I'm going to examine power as before I'm going to be comparing the two sides and where I can I'm going to be splinting the joint so that I'm testing the power around one joint at a time so Jake I want you to lift your right leg up in the air hold it straight and stop me pushing it down so that's hip flexion same on the other side hip extension push down into my hand stop me lifting your leg thank you push down bend your knee pull your heel towards your bottom so knee flexion push out straight knee extension same on the other side pull towards you push me away pull your foot up towards you stop me pushing it down Pull up and now push down push down okay that's fine thank you next I'm going to test coordination in the legs using the heel Shin test so Jake I want you to lift your right leg up in the air please and hold it steady put your heel on your knee on the other side and hold it steady and then run your heel down your shin okay that's fine thanks now the other way around lift your left heel in the air hold it steady put your heel on your knee hold it steady and run your heel down your shin okay fine next I'm going to do the reflexes in his legs I'm going to hold the tendon Hammer at the end so I can make a pendulum action when I'm eliciting the reflexes I want you to bend your knees up please Jake bend them up to the same extent and I'm going to hit his quadriceps tendon on either side and there's the knee jerk flop your knee down towards me to do this is to do his ankle jerk let your leg go loose there's an ankle jerk on one side same on the other side and now I'm going to do his planter responses I'm going to use the blunt end of the neuro tip but this is going to hurt a bit Jake I'm going to scratch the sole of your foot and I'm going to look for the first movement of the great toe so I begin the scratch distally and bring it proximately there's the movement of his great toe I don't need to go any further with that one and on this side again his toes are flexing so that's normal with the planter reflex the toes should plant flex and AD duct if they extend and abduct this indicates an upper mot neon leion a positive babinsky reflex I routinely test four modalities pin prick light touch Pro perception and vibration sense for pin PRI and light touch I validate the sensation of the patient's sternum and then checked for sensation either in each dermatome individually or dist depending on the pattern I'm expecting and now I'm going to test pin prick in the legs I'm going to use a neurot tip and I'm going to validate the sensation against his sternum so Jake Can You Feel The sharpness of the neurot tip yep okay now I'm going to test his legs in a dermatomal pattern beginning with L1 sharp or blunt sharp sharp or blant sharp okay L2 sharp sharp L3 Shar Shar L4 Shar Shar L5 Shar Shar and S1 Shar Shar and if necessary I would test also for pin prick impairment distally in case I thought he'd got a peripheral neurop ay beginning with his toe tips and coming more proximally sharp or blunt there sharp sharp or blunt sharp sharp or blunt sharp sharp or blunt sharp and I don't need to test more proximately because he can feel it sharp disty and now I'm going to test light touch in the legs I'm going to use cotton wool and I'm going to validate the sensation on his sternum so Jake can you feel the touch yep okay now I'm going to test the sensation in his legs following a dermatomal pattern beginning with L1 can you feel the touch y y now L2 yep yep L3 yep yep L4 yep yep L5 yep yep and S1 yep yep and if necessary alternatively I could test sensation distally working proximately if I thought he had had a peripheral neuropathy so I'll be on his big toe can you feel that y little toe y big toe y little toe yeah and seeing as he can feel it distally I don't need to work any more proximately with a light touch because that's normal I'm now going to test Pro perception or joint position sense in the toes so Jake I'm going to get a hold of your big toe here and I'm going to move it up or down I want you to close your eyes and now tell me which way I'm moving it now down now down now down now down now up now down now up I'm going to test the other side now up now up now up now down now down now down now down now up okay and that's fine thank you if the patient can feel the smallest movement I can make of the big toe I don't need to test any further but if you can't manage small movements to the great toe then I make big movements if he can't feel those then I would go up to the ankle and dorsy flex or PL to flex the ankle and then if necessary if he couldn't even feel movements at the ankle I would do something similar at the knee with flexion and extension and now I'm going to test vibration sense I'm going to use a 128 Hertz tuning fork and I'm going to validate the sensation on his sternum so Jake can you feel that vibrating y okay and now I'm going to test the sensation distantly on his big toes yeah feel that vibrating Can you feel it there yep I want you to close your eyes now and tell me when it stops no and that's fine and that's normal if he couldn't feel the vibration distally then I would work more proximally on the bony prominences until I found a point at which he could perceive the vibration this completes the full neurological examination of the arms and legs but don't forget to examine the cranial nerves and higher mental function and if you suspect somebody's got a spinal cord lesion it may be necessary not only to examine sensation in the arms and legs but also on the abdomen and chest looking for a sensory level and sometimes s it's necessary to perform a rectal examination to examine anal tone and also to test perianal sensation with pin prick

Channel: University of Leicester

Views: 3,153,983

Keywords: Romberg's Test, Arms, Inspection, Tone, Power, Coordination, Reflexes, Sensation, Pin Prick, Light Touch, Proprioception, Vibration

Id: 8TWzS2sSYwU

Length: 20min 46sec (1246 seconds)

Published: Tue May 08 2012