Prepare patient

General inspection (patient sitting to begin with)

• Scars
• Skin (e.g. neurofibromata, café-au-lait)
• Abnormal movements

Shake hands

Motor system inspection

• Posture
• Muscle bulk/wasting/tenderness Abnormal movements
  • Wasting
  • Fasciculations (LMN lesion, MND, root compression, peripheral neuropathy, primary myopathy, thyrotoxicosis)
  • Tremor
• Drift (with arms extended, palms up & eyes closedwith arms extended, palms up & eyes closed)
  • downward/pronation
    • (UMN pyramidal/muscle weakness),
  • upwards/pronation
    • (cerebellar),
  • searching/random
    • (loss of proprioception)

Tone

• Wrist & elbow
  • Note hypertonia /rigidity incl lead pipe,
  • cog-wheeling (Parkinson’s) or
  • hypotonia (LMN lesion).

Palpate

• Muscle bulk
• Muscle tenderness

Power

• Shoulder

  • Abduction (C5/6): upper arms abducted to 90o (elbows fully bent) & press down proximally

  • Adduction (C6/7/8): upper arms adducted and examiner tries to abduct them.

• Elbow
  • Flexion (C5/6) & extension (C7/8) at 90o – examiner holding elbow & wrist
• Wrist
  • Cocked down & up for flexion (C6/7) & extension (C7/8) testing. Examiner uses his same wrist to test.
• Fingers
  • Extension (C7/8) – Examiner pushes down just distal to MCPJs on extended fingers
  • Flexion (C7/8) – Squeeze 2 of examiners fingers
  • Abduction (dorsal interossei, C8/T1)– examiner tries to close patient’s spread fingers by
    pressing proximally with his two index fingers
  • Adduction (palmar interossei, C8/T1) – examiner tries to pull apart closed fingers
  • Ulnar, median nerve function

Biceps C5/6

Triceps C7/8

Supinator C5/6

Finger C8

Finger–nose test—

• intention tremor,
• past-pointing

Dysdiadochokinesis

Rebound

Pain (pinprick)

Light touch (cottonwool)

Vibration (128 Hz tuning fork)

Proprioception—distal interphalangeal joint (each hand)

Thickened nerves (wrist, elbow)

Axillae

Neck

Lower limbs

Cranial nerves

Urine analysis etc