How to use these guides
The articles in this series, which can be torn out for use in practice, are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to aid consideration of differential diagnoses in situations where life-threatening conditions have been ruled out.
The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation are advised to support understanding supplemental to these articles. Key questions are included for reader consideration and to direct further study.
Most examinations are taught in a rigid format. However, in clinical practice, practitioners need to be flexible and adapt their approach depending on the presenting condition and circumstances. While there is no single set way to carry out each of these examinations, a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.
Contemporary texts provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied; however, differences will be highlighted. Readers will be signposted to these key texts for each clinical examination.
The series will cover the following systems:
This month's article will explain the examination of the neurological system, more specifically the assessment of the upper limbs. Examination of upper and lower limbs will be described separately, with the lower limbs discussed in next month's issue. As explained in the series overview, it is important to introduce yourself to the patient, explain what you intend to do for each part of the assessment, and gain consent from the patient prior to assessment (Pilberry and Lethridge, 2015). This examination would form part of a detailed secondary survey, following a primary survey and completion of the patient history. The depth you go into may be dependent on whether abnormalities are detected (Japp and Robertson, 2018). Always ensure adherence to infection control principles prior to commencing, and throughout the examination (Kirk, 2020). Finally, always thank your patient on completion of your assessment.
Equipment required
The following equipment is needed:
The ideal position of the patient is for them to be sat up with their limbs exposed; however, where adaptation is required, it is important that this is documented. It is essential to respect patient dignity and the surrounding environment, covering up where necessary, then exposing the limb when required. Examination of left and right limbs should be directly compared at each stage.
Overview
Neurological examination of the limbs may include the following (Japp and Robertson, 2018):
General observations
Prior to completing an upper limb neurological examination, note any general observations on initial patient contact, inclusive of their general surroundings which could indicate signs of neurological impairment (Thomas and Monaghan, 2014; Advanced Medical Life Support, 2017; Walker, 2018), for example:
Inspection
Observe and look closely at the upper limbs for:
Reflection:
What could the presence of these potentially indicate? Consider differential diagnoses
Tone
This involves assessment of the patient's resting tone (Thomas and Monaghan, 2014). Ask the patient to relax. This may be difficult as once a person is informed to relax, they become more conscious of this and may indeed become more tense (Thomas and Monaghan, 2014; Walker, 2018). Consider giving them a verbal task, or engage in light conversation.
Hold one of their hands, supporting the elbow, then move each of the joints (shoulder, elbow and wrists) in a range of movements, including flexion, extension, rotation, pronation/supination, etc (Talley and O'Connor, 2018). Compare with opposite arm, assessing for differences in tone.
An increase in resistance to the movements indicates increased muscle tone, whereas a decrease in resistance indicates a decreased muscle tone (Schwartz, 2018).
Reflection:
Consider the causes of increased or decreased muscle tone
Power
Assess the power in both arms, comparing each side in turn. Demonstrate each movement outlined below first, and then ask the patient to do so themselves. After they have done so, ask them to repeat again with you resisting their movement (Thomas and Monaghan, 2014). It is important to consider the patient's age, sex and build in order ascertain their normal power, using your judgement on your own resistance strength (Talley and O'Connor, 2018; Walker, 2018).
Shoulders
Assess the shoulders by asking the patient to flex their elbows and abduct their arms approximately 45o. Then ask them to abduct and then adduct their arm from their shoulder.
Elbows
With the patient's arms flexed at 90°, hold their elbow and ask them to flex and extend their elbow against resistance.
Wrists
With the patient making a fist, hold their forearm; then ask them to flex and extend their wrist.
Fingers
Ask the patient to perform the following movements:
Pronator drift
With the patient's eyes closed, ask them to extend both arms, palms upwards—for at least 20 seconds (Lindridge, 2016). A downward pronation movement indicates weakness.
Coordination
Finger-nose test
With the patient touching their nose, ask them to touch your finger held out in front of them, ensuring full extension of their arm. Start slowly and then ask them to repeat this as quickly as possible (Douglas et al, 2013; Talley and O'Connor, 2018). There is nothing gained from moving your own finger around (Walker, 2018).
Repeat for both hands.
Reflection:
What findings might you expect to see with poor coordination? What could this potentially indicate?
Rapidly alternating movements
Ask the patient to place one hand in the other, palm up. Then ask them to flip it over, then back again as quickly as possible, hitting the same spot (Walker, 2018). Once complete, repeat with the other hand (Lindridge, 2016).
Reflection:
What could a slow and clumsy action indicate?
Reflexes
It is important that the limb is relaxed when assessing reflexes. This skill can also take some time to master; therefore, practice is required (Walker, 2018). Bounce the tendon hammer off the tendon, not the muscle (Douglas et al, 2013). Sufficient force is required to ensure muscle contraction (Walker, 2018). Compare opposite sides, noting the presence or absence of the reflex, or whether they are brisk or reduced. Reinforcement (i.e. asking patient to grit their teeth or interlock fingers and pull apart) can be used to enhance a reflex if it appears absent (Bickley, 2014). With practice, you will learn the correct amount of force needed to strike the hammer (Talley and O'Connor, 2018).
Reflection:
How are reflex responses recorded/graded? What is the significance of this in paramedic practice?
Biceps
With the patient's arm relaxed across the abdomen, hold the elbow with your thumb or first two fingers against the tendon. Then strike your thumb or fingers with the tendon hammer (Schwartz, 2014).
Triceps
Flex the patient's elbow, then support their arm. Strike the tendon directly just above the olecranon process (Talley and O'Connor, 2018). Alternatively, hang the patient's arm over your arm, striking the triceps tendon (Schwartz, 2014).
Supinator
Relax the arm in a semi-flexion/semi-pronation angle, resting on the patient's knee (Schwartz, 2014). Place your finger or thumb over the tendon which lies on the lateral aspect of the radial bone (Walker, 2018), then strike with the tendon hammer.
Sensation
A dermatome is an area of skin that provides sensory information to the central nervous system (Tortora and Derrickson, 2017). This part of the examination assesses dermatomes in the upper limbs using both light touch and pain (pin-prick) sensation (Japp and Robertson, 2018).
Light touch
This can be tested using cotton wool or soft gauze. Try not to stroke the skin as this stimulates different nerve pathways (Thomas and Monaghan, 2014).
Pain
This is tested preferably using a ‘neuro-tip’.
For both light touch and pain, touch the patient on the sternum so they know how the sensation should feel. This is the control test. Then with their eyes closed, touch the following areas/dermatomes, comparing both sides, asking them to tell you when they feel the touch. Walker (2018) however indicates that the pin-prick (pain) test can take place with the patient's eyes open. Locations include: Shoulder tip (Dermatome: C4); lateral aspect of upper arm (C5); lateral side of the thumb (C6); middle fingertip (C7); medial side of the little finger (C8); medial aspect of the lower arm (T1); medial aspect of upper arm (T2).
Ask the patient to tell you when they feel the touch and whether this feels the same or different to the alternate side.
Vibration
Using a 128 Hz tuning fork, strike it then place it upwards on the sternum, so the patient can feel the sensation. This is the control test.
With the patient's eyes closed, strike the tuning fork and place it on the most distal bony prominence (distal interphalangeal (DIP) joint). Stop the vibration with your other hand, asking the patient to confirm when they feel the vibration stop. If the patient correctly identifies this, end the test here. Otherwise, move to the next proximal joint and repeat the test until they can feel it (Bickley, 2014).
Proprioception
With the patient's eyes closed, hold their little finger at either side, distal to the DIP joint (Talley and O'Connor, 2018). Then move the joint up and down, informing them of the direction (Lindridge, 2016). After doing so, move the digit at random, asking the patient to tell you what position the digit is in. With normal proprioception, the patient can tell you their finger position. This would be the end of the test.
If they are unable to tell you, move proximal to the next joint and test again—similar to the process for vibration sense (proximal interphalangeal joint (PIP), metacarpophalangeal joint (MCP), wrist, elbow, and shoulder) (Bickley, 2014).
For each of the assessments in the upper limb neurological assessment, consider the causes of acute and chronic impairments and the clinical significance of these. This assessment is supplementary to other neurological assessments undertaken within the secondary survey, such as the Glasgow Coma Scale and also further in-depth elements of neurological examination not covered in this article. You may consider assessment of the lower limbs and a cranial nerve examination if required. Next month's article will continue with a discussion on the assessment of the lower limbs.