The upper limb neurological examination is part of the neurological exam that focuses on the motor and sensory neurons that innervate the upper limbs. It is useful in identifying pathology that affects the upper limbs. The key components of this examination are; tone, power, reflexes, sensation and function. The ability to test these in a systematic and slick manner is one of the key requirements as a medical student. Although often neurological examinations are dubbed as the harder ones in OSCEs, if you begin by understanding what each nerve does and what signs/symptoms to look for then it becomes a case of pattern recognition. Pathology found in upper limb neurological examinations can vary from upper or lower motor neurone lesion, muscular dystrophy or Parkinson's disease.
Wash your hands using the Ayliffe technique
Introduce yourself and give your name and grade
“Hi, my name is John Smith and I am a 4th year medical student”
Clarify patients identity by confirming name and asking for their DOB
Explain what examination you are performing and what it involves
“I have been asked to perform an upper limb neuro exam on you today. This involves having a look at your hands and arms, checking their strength and testing your co‐ordination.”
“Would this be ok with you?”
Ask if they would like a chaperone
“The exam involves you having to remove your upper garment. Would you like a chaperone for the exam?”
Initially lie the patient at 45 degrees and expose them from their waist up
Inspect the patient from the end of the bed and look for the following:
Adjuncts ‐ eg. any supplemental O2 (%), IV lines, infusions, catheter
Paraphernalia ‐ Walking aids, wheelchair
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.
NB ‐ Ask the patient to relax and go floppy when checking tone and reflexes.
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:
Use a tendon hammer to illicit the patients reflexes. Test the following three reflexes and compare the right to left side:
NB ‐ To reinforce the reflex, ask the patient to clench their jaw prior to striking the tendon.
Inspect the upper limbs for sensation to light touch, pain, vibration and proprioception. Examine each dermatome and compare right to left.
NB ‐ You can only examine with the tools that you have been given. Therefore, if you are not provided with a neurotip or 128Hz tuning fork, you will not be able to test pain and vibration. The minimum you will be expected to do is gross sensation “Can you feel me touch you here?”.
Test the coordination of the upper limbs by asking the patient to do the following.
Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.
“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”
Turn to the examiner and state what else you would do to complete the exam.
“To complete the examination I would check the patients pain and vibration sensation (if a neurotip or tuning fork was not provided). I would also complete fundoscopy of the patients eyes.”
Explain to the examiner what tests and investigations you would perform