Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Weakness |
Stroke (CVA) |
RF: prior CVA, AF, HTN, diabetes, CVD, smoking, obesity.
Sudden onset, unilateral upper limb weakness +/- other stroke sx e.g., facial weakness, dysphasia, ataxia/vertigo. FAST stroke screening tool: Face, Arm, Speech, Time. |
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Motor neurone disease |
Typically older, male with family history.
Slow onset weakness, often upper limbs before lower/face. UMN/LMN signs. UMN: inc tone, brisk reflexes, plantars up. LMN: reduced tone, slow reflexes, weakness, wasting, fasciculations. |
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Radial nerve palsy |
Predisposing: humeral shaft #, prolonged pressure on radial nerve against humerus (saturday night syndrome).
Wrist drop in affected hand, weakness to finger/wrist ext. Reduced sensation to lateral 1/2 dorsum of hand. |
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Median nerve palsy |
Most common presentation is carpal tunnel syndrome.
Wasting of thenar eminence. Weakness to thumb abduction. Sensation loss to lateral 1/2 palm, thumb, index, middle & lateral 1/2 ring fingers on affected hand. |
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Ulnar nerve palsy |
Predisposing: elbow trauma.
Clawed 4/5th fingers. Hypothenar wasting and wasted interosseous muscles. Weakness to finger abduction, Froment’s sign +. Sensory loss to medial 1/2 hand, 5th & medial 1/2 4th fingers. |
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Cervical radiculopathy |
As below – Weakness in a myotomal distribution e.g., C6, C7.
Motor symptoms less common than sensory. |
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| Numbness |
Cervical radiculopathy |
RF: age, male, heavy lifting, vibration, neck trauma.
Most commonly caused by degenerative change in c-spine. Neck/upper arm pain with numbness, paraesthesia +/- weakness in a dermatomal distribution e.g., C6, C7. |
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Peripheral neuropathy |
Causes: alcohol excess, B12 deficiency, cancer, CKD, diabetes, drugs, vasculitis, Charcot-Marie-Tooth disease.
Sensory (and motor) loss in peripheries i.e. hands & feet ‘glove & stocking distribution’ If suspected, examine distal —> proximal to find sensory ‘level’. |
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Carpal tunnel syndrome |
Causes: idiopathic, pregnancy, diabetes, hypothyroidism.
As for median nerve palsy. Tinel and Pahlen tests +. |
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Multiple sclerosis |
RF: young adult (<50), female sex.
Lesions disseminated in time & space so symptoms change over time. May include numbness or paraesthesia in upper limbs. |
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| Tremor |
Physiological tremor |
Associated w/ fever, anxiety, hyperthyroid state, medication.
Symmetrical, fine, postural tremor. |
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Benign essential tremor |
Associated with older age and family history.
Fine, symmetrical, postural/action, ↓ with alcohol & rest, ↑ with caffeine, stress, fatigue. |
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Intention tremor |
Associated with cerebellar lesions; seen on intention e.g., during finger-nose test.
Causes: stroke, tumour, MS, alcohol abse, medication. |
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Parkinson’s disease |
Triad of tremor, rigidity, bradykinesia.
Unilateral, resting, pill-rolling, improves on movement. |
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Checklist
|
Preparation |
Wash – Name – Explain | |
| Position patient lying on the couch at 45° | ||
| Appropriate exposure of upper limbs | ||
| General Inspection | Body habitus | |
| Obvious asymmetry to upper limbs | ||
| Clues in bed space | ||
| Inspection | Symmetry | |
| Scars | ||
| Muscle wasting | ||
| Fasciculations | ||
| Involuntary movements | ||
| Tremor | ||
| Tone | Pronator drift | |
| Circumduction of shoulder | ||
| Flexion/extension elbow | ||
| Pronation/supination of forearm | ||
| Flexion/extension wrist | ||
| Circumduction of wrist | ||
| Reinforcement | ||
| Power | Shoulder abduction | |
| Shoulder adduction | ||
| Elbow flexion | ||
| Elbow extension | ||
| Wrist flexion | ||
| Wrist extension | ||
| Finger flexion | ||
| Finger extension | ||
| Finger abduction | ||
| Thumb abduction | ||
| Reflexes | Biceps reflex | |
| Supinator reflex | ||
| Triceps reflex | ||
| Sensation | Ask patient to close their eyes | |
| Demonstrate on sternum | ||
| Fine touch | ||
| Pain | ||
| Vibration | ||
| Proprioception | ||
| Co-ordination | Finger-nose | |
| Disdiadokokinesia | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to perform a neurological examination of your upper limbs. This involves testing some of the nerves in your arms by checking movement and sensation. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclining on the couch at 45°.
Ensure the patient’s arms are fully exposed.
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus
- Obvious asymmetry when looking at and comparing the upper limbs from the end of the bed
- Clues around the bed space (e.g., Mobility aids or medication)
Inspection
Look at the patient’s arms and compare both sides, making note of any of the following:
- Symmetry – do the arms both look the same?
- Scars – from trauma or previous surgery (e.g., carpal tunnel release surgery)
- Muscle wasting – assess muscle bulk of the upper arms, thenar/hypothenar eminences, dorsal hand muscle wasting (guttering)
- Fasciculations – small, involuntary muscle twitches
- Involuntary movements – larger upper limb movement (e.g., Pseudoethetosis or choreiform movement)
- Tremor – assess laterality and if present at rest, with intention, or on movement/action (postural)
Tone
To assess tone, warn the patient that you are going to move their arms. Ask them to try to stay as relaxed as possible and let their arms go floppy whilst you take the weight of the limb and move it for them.
Take the patient’s hand as if to shake it and assess tone whilst moving the upper limb through the following:
- Shoulder circumduction
- Elbow flexion and extension
- Forearm pronation and supination
- Wrist flexion and extension
- Wrist circumduction
While moving the arm, feel for resistance to movement. Assess for increased tone (hypertonia) or reduced tone (hypotonia). If there is increased tone, is it:
- Spasticity – velocity-dependent, direction-dependent, may reduce later in movement
- Rigidity – not velocity- or direction-dependent
If there is rigidity, is there any superimposed tremor (cog-wheeling)?
If you are unsure or the examination findings are unclear you can try to reinforce and exaggerate any hypertonia by asking the patient to tap their knee with their opposite hand to the one you are holding (synkinesis).
Repeat the above with the other arm.
Power
Assess power in the upper limb by asking the patient to perform active movement against resistance. Power in all upper limb myotomes is assessed, comparing the right and left upper limbs. Isolate the joint bering tested to ensure accurate interpretation of examination findings.
Power is graded according to the MRC Scale:
0 – No movement
1 – Flicker of movement
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Normal movement
The following movements are assessed:
- Shoulder abduction: Ask the patient to fully flex their elbows and abduct the shoulders to 90°. Try to adduct the patient’s shoulders and ask them to resist. C5 myotome
- Shoulder adduction: With the patient’s arms in the same position as above, try to abduct their shoulders further and ask them to resist. C6/7 myotome
- Elbow flexion: Ask the patient to hold their arms out straight in front of them and then flex the elbows to 90°. Try to extend the patient’s elbows and ask them to resist. C5/6 myotomes
- Elbow extension: With the patient’s arms in the same position as above, try to flex their elbows and ask them to resist. C7 myotome
- Wrist flexion: Ask the patient to hod their arms straight out in front of them with their fists clenched. Try to push the patient’s first downwards and ask them to resist. C6/7 myotome
- Wrist extension: With the patient’s arms in the same position as above, try to push the patient’s fist upwards and ask them to resist. C6 myotome
- Finger flexion: Ask the patient to grip and squeeze your fingers. Try to open the patient’s hand. C8 myotome
- Finger extension: Ask the patient to hold their hands out in front of them with their palms facing down and fingers straight and adducted together. Try to push the patient’s fingers down and ask them to resist. C7 myotome
- Finger abduction: Ask the patient to spread their fingers wide. Try to adduct their fingers and ask them to resist. T1 myotome
- Thumb abduction: Ask the patient to hold their hands out with their palms facing up and point their thumbs towards the ceiling. Try to push the patient’s thumbs down and ask them to resist. T1 myotome
Reflexes
There are three reflexes to examine in the upper limb:
- Biceps reflex: Ask the patient to relax their arm in their lap. Locate the biceps tendon in the medial aspect of the antecubital fossa, press down on the tendon with your fingers, and tap your fingers with the tendon hammer. C5/6 myotomes
- Supinator reflex: With the patient’s arm in the same position as above, place your fingers over the postero-lateral aspect of the forearm, press down on the brachioradialis tendon and tap your fingers with the tendon hammer. C5/6 myotomes
- Triceps reflex: Ask the patient to adduct their shoulder and flex their elbow to 90°. Support the patient’s arm so they can relax it and locate the triceps tendon in the posterior groove just above the olecranon process. Press down on the tendon with your fingers and tap your fingers with the tendon hammer. C7 myotome
Examine each reflex in turn and assess whether the tendon reflex is normal, brisk, reduced or absent. If you are unsure or the examination findings are unclear you can reinforce and exaggerate the tendon reflexes by asking the patient to grit their teeth.
Sensation
There are several sensory modalities to be examined including:
- Fine touch
- Pain
- Vibration sense
- Proprioception
Temperature is another sensory modality but is seldom examined in an OSCE situation
To examine fine touch and pain sensation, ask the patient to close their eyes. Examine light touch first with cotton wool. Demonstrate the sensation of the cotton wool on the patient’s sternum so that they know what they are feeling for. Ask the patient to say the word ‘Yes’ when they feel the touch of the cotton wool on their arm.
Examine sensation by testing each of the dermatomes in the upper limb in turn (see diagram*), comparing both sides before moving on to the next dermatome. If the peripheral dermatomes are more affected than the proximal dermatomes, a ‘glove and stocking’ distribution of sensory loss may be suspected. A sensory level can be ascertained by starting at the fingers and checking sensation in increments proximally until sensation returns to normal.
Repeat the above process with a neuro–tip to assess pain sensation.
To examine vibration sense, with the patient’s eyes still closed, vibrate a 128Hz tuning fork, demonstrating the sensation to the patient by placing the vibrating base of the tuning fork on their sternum so that they know what they are feeling for. Then test vibration sense on the most distal joint of the thumb – the interphalangeal joint (IPJ). Ask the patient to say yes if they can feel the vibration and compare both sides. If they cannot, repeat the above on the next joint moving proximally until the sensation is felt.
To examine proprioception, ask the patient to close their eyes and hold the patient’s thumb by the proximal phalanx with one hand and the distal phalanx with the other hand (your thumb and index finger on medial/lateral side of there patient’s thumb). Flex the IPJ and tell the patient this is what “down” feels like, extend the IPJ and tell the patient this is what “up” feels like. Then move the joint and ask the patient to tell you if the joint is “up” or “down”.
Co-ordination
There are two tests of co-ordination in the upper limb:
- Finger–nose test: Hold your index finger in front of the patient’s face. Ask the patient to touch their nose with their index finger and then touch your index finger. Ask them to touch their nose again, move your index finger to a different space and ask them to touch your finger again. Repeat the above, moving your finger around the patient’s visual field. If the patient misses the target (your finger/their nose) this is called past–pointing and indicates a possible cerebellar pathology. Repeat with the other hand.
- Dysdiadochokinesia: Ask the patient to hold one of their hands out with palm facing up. Ask them to clap their other hand with palm facing down into the palm of the first hand with palm facing down. Then ask them repeat clapping, pronating and supinating the top hand to clap with the palm up and down alternately, as fast as they can. Repeat this on the other hand. If the patient is unable to do this this indicates a possible cerebellar pathology.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings you may wish to carry out neurological examination of the cranial nerves and lower limbs as well as carry out further investigations including blood tests, nerve conduction studies, CT or MR scan of the head or spine.
[*Illustrations – coming 2025]
Last updated Dec 2024
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
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