Upper Limb Examination

To complete my examination, I would like to check the vital sign chart, check the patient’s gait, do
Romberg’s test, perform cranial nerve examination, lower limb examination, and cerebellar examination.

I did upper limb examination on (name, age, ethnicity, gender).

The patient is sitting comfortably on a chair. He is conscious, alert, and not in obvious pain or respiratory
distress. The hydration and nutritional status are fair. There are no scars, wasting of muscle, involuntary
movement, fasciculation, and tremors. Limbs appear symmetrical bilaterally. There is a cannula on the left
dorsum connected to an IV drip.

There was upper motor neuron lesion on the right side of the upper limb by evidence of
 Hypertonia at the shoulder, elbow and wrist joint
 Reduced power for shoulder abduction and adduction, elbow flexion and extension, wrist flexion
and extension, and fingers abduction and adduction, with the grade of 2/5.
 Hyperreflexia at the biceps, brachioradialis and triceps jerk.

There was also reduced sensation at the (right/left, which dermatomes)

The proprioception was intact

I was unable to assess the coordination as the muscle power is reduced

Lower Limb Examination

To complete my examination, I would like to check the vital sign chart, check the patient’s gait, do
Romberg’s test, perform cranial nerve examination, upper limb examination, and cerebellar examination.

I did lower limb examination on (name, age, ethnicity, gender).

The patient is lying comfortably on the bed at 45’. He is conscious, alert, and not in obvious pain or
respiratory distress. The hydration and nutritional status are fair. There are no scars, wasting of muscle,
involuntary movement, fasciculation, and tremors. Limbs appear symmetrical bilaterally. There is a cannula
on the left dorsum connected to an IV drip.

There was upper motor neuron lesion on the right side of the lower limb by evidence of
 Hypertonia at the hip, knee and ankle joint.
 There was also presence of clonus.
 Reduced power for hip flexion and extension, knee flexion and extension, ankle dorsiflexion and
plantar flexion, tarsal joint inversion and eversion, big toe dorsiflexion and plantar flexion, with the
grade of 2/5.
 Hyperreflexia at the knee and ankle jerk. There was also upgoing plantar response.

There was also reduced sensation at the (right/left, which dermatomes)

The proprioception was intact

I was unable to assess the coordination as the muscle power is reduced

Cranial Nerve Examination
To complete my examination, I would like to check the vital sign chart, check the patient’s gait, do
Romberg’s test, perform cranial nerve examination, lower limb examination, and cerebellar examination.

I did upper limb examination on (name, age, ethnicity, gender).

The patient is sitting comfortably on a chair. He is conscious, alert, and not in obvious pain or respiratory
distress. The hydration and nutritional status are fair. There are no scars, wasting of muscle, involuntary
movement, fasciculation, and tremors. Limbs appear symmetrical bilaterally. There is a cannula on the left
dorsum connected to an IV drip.

Olfactory (I) is intact.

Optic nerve (II)

 Visual acuity – 6/6 score.
 Visual field are full to confrontation in all quadrant.
 Pupillary reflex – Direct, consensual and relative afferent pupillary reflex.

Oculomotor, trochlear and abducens nerve (III, IV, VI)

 Ptosis
 Accommodation
 H test - Extraocular muscle movement + diplopia
 Nystagmus

Trigeminal nerve (V)

 Facial sensation for light touch at the ophthalmic, maxillary, mandibular distributions
 Clench teeth – Muscle of mastication

Facial nerve (VII)

 Facial asymmetry
 Forehead wrinkle
 Close eyes against resistance
 Puff out cheeks against resistance
 Close mouth against resistance
 Shrug neck

Vestibulocochlear nerve (VIII)

 Hearing
 Rinne and Weber’s test

Glossopharyngeal and vagus nerve (IX, X)

 Palate and uvula deviation
 Ahhh – Symmetrical rise of soft palate

Accessory nerve (XI)

 Shoulder shrug – Trapezius muscle
 Head turning – Sternocleidomastoid

Hypoglossal nerve (XII)

 Tongue wasting and fasciculation
 Tongue deviation on protrution
Upper vs Lower motor neuron signs
UMNL LMNL
Site Above anterior horn cell Anterior horn cell and below

Tone Hypertonia Hypotonia

Spastic, clasp knife Flaccid paralysis
Clonus
Power ↓ ↓

Reflex Hyperreflexia Hyporeflexia

Muscle wasting No Yes

Fasciculations No Yes

Tremor
Types
Resting tremor – Coarse in nature, occurs at rest and improved with movement
Etiologies: Parkinson’s disease
Treatment: Levodopa, anticholinergic, dopamine agonists resistance case clozapine

Postural tremor – Kinetic/action tremor appears when the arms are outstretched
Etiologies:
 Essential tremor: Coarse, more marked in one hand than another, improved with beta-blocker and
alcohol
 Exaggerated physiologic tremor: Fine tremor which is symmetrical, can be due to anxiety, beta-2
agonist usage and thyrotoxicosis
 Bat-wing tremor: Coarse tremor due to Wilson's disease
Treatment: Beta-blockers, primidone

Intention tremor appears when the hand approaches the target

Etiologies: Cerebellar syndrome (ipsilateral to the cerebellar lesion)
Treatment: Clonazepam

Fasciculations
Definition: Irregular contractions of the small areas of the muscle with no rhythmic pattern
Etiologies:
 Motor neuron disease
 Motor root compression
 Peripheral neuropathy
 Primary myopathy
 Thyrotoxicosis

Hypertonia
Spasticity Rigidity
 Pyramidal disorder – Spinal cord lesion  Extrapyramidal disorder – Parkinsonism
 It affects predominantly in one of the  It affects both agonist and antagonist muscle
antagonistic muscle groups groups
 Clasp knife phenomenon  Cogwheel or lead pipe rigidity
 Velocity dependent  Non-velocity dependent
Power
Action Muscle Nerve Segmental level
Shoulder abduction Deltoid Axillary C5, C6

Elbow flexion Biceps Musculocutaneous C5, C6

Elbow extension Triceps Radial C6, C7, C8

Wrist extension Extensor carpi radialis Radial C5-C8

and ulnaris
Thumb abduction Abductor pollicis brevis Median C8, T1

Little finger abduction Abductor digiti minimi Ulnar C8, T1

Index finger abduction Interosseus Ulnar C8, T1

Hip flexion Iliopsoas Femoral L1, L2, L3

Hip extension Gluteus maximus Inferior gluteal L5, S1, S2

Knee flexion Hamstrings Sciatic L5, S1, S2

Knee extension Quadriceps Femoral L2, L3, L4

Ankle dorsiflexion Tibialis anterior Deep peroneal L4, L5

Ankle plantar flexion Gastrocnemius Tibial S1, S2

Pattern
 Hemiplegia: One-side paralysis
 Paraplegia: Lower limbs paralysis
 Monoplegia: One limb paralysis
 Quadriplegia: Four limbs paralysis

Hemiparesis
Clinical features:
 Circumduction gait – Extension at hip and knee, adducted
 Arm – Flexion at elbow and wrist, and internal rotated at shoulder
 +/- facial involvement: UMN facial weakness, may involve palate, tongue, muscles of mastication,
 external ocular muscles
 Pyramidal drift
 Clasp-knife spasticity (in pyramidal distribution)
 Clonus
 Muscle weakness: Flexors are stronger at the UL while extensors are stronger at the LL
 Hyperreflexia
 Babinski's sign
 Hemisensory loss
 Speech disturbance: Dysphasia (receptive or expressive, depends on the site of the lesion)
 Others: Oppenheimer's sign, Hoffman's reflex, visual field defect, +/- impaired gag reflex

Spastic paraparesis
Clinical features:
 Gait: Stiff, in extension and adduction with the foot inverted and plantar flexed, scissoring gait
 Bilateral hypertonia
 Clonus
 Hyperreflexia and upgoing plantar response
 Neuropathic bladder
Etiologies
Hemiparesis UMNL
- Vascular lesions – Stroke
- SOL – Tumour, abscess
- Brainstem infarct
- Brown-Sequard syndrome
Paraparesis UMNL
- Disc prolapses
- Tumors
- Cervical spondylosis
- Infection: Abscess, syphilitic myelitis, HIV, Pott's disease
- Rheumatoid arthritis
- Haemorrhage
- Vasculopathy – Thrombosis, embolic, dissection, hypotension
- Inflammatory – Sarcoidosis, SLE, multiple sclerosis, transverse myelitis
- Subacute degeneration of cord

- Multiple sclerosis
- Motor neuron disease
- Syringomyelia
- Primary intramedullary and dural tumour
- HTLV-1
- Radiation myelopathy
- Subacute degeneration of cord

LMNL
- Gullain-Barre syndrome
- Hypokalemic periodic paralysis
- Cauda equina syndrome
Monoparesis UMNL
- Cerebral palsy
- Brown-Sequard syndrome

LMNL
- Peripheral nerve lesion
- Plexopathy
Quadriparesis UMNL
- Complete cord transection
- Amyotrophic lateral sclerosis

LMNL
- Poliomyelitis
- Gullain-Barre syndrome
- Cushing’s syndrome, acromegaly
- Dermatomyositis, polymyositis
- Duchenne/Becker muscular dystrophy
Reflex
Babinski’s sign (upgoing plantar response) Grading
- Sign of UMNL, damage to the corticospinal tract 0: Absent
1: Present but reduced
Oppenheimer’s sign 2: Normal
- Upgoing plantar response by pressing the medial side of the tibia 3: Increased, possibly normal
- Extensive lesion of the corticospinal tract 4: Greatly increased +/- clonus

Hoffman’s sign Segmental level

- Flicking of the index finer triggers thumb flexion  Biceps: C5, C6
- Sign of UMNL  Brachioradialis: C5, C6
 Triceps: C7, C8
Scapulohumeral reflex  Knee jerk: L3, L4
- Tapping of the tip of scapula causing elevation of scapula or  Ankle jerk: S1, S2
abduction of humerus  Plantar reflex: L5, S1, S2
- Lesion above C3

Abdominal reflex
- Scratching the abdominal wall towards umbilicus from 4
quadrants causes reflex contraction of rectus abdominis
- Positive – No reflex
- Segmental level: T9- T12

Primitive reflexes: Frontal lobe lesion

 Glabellar: Tapping the forehead, the eyes blink persistently
 Snout reflex: Tapping the nose induces grimacing
 Sucking reflex: Stroking the lips produces sucking movement of
the lips
 Chewing reflex: A tongue depressor placed in the mouth produces
chewing
 Grasp reflex: Stroking the palm elicits grasping that gets firmer as
you try to remove your finger
Sensory deficit
 Light touch – Anterior spinothalamic
 Pain – Lateral spinothalamic
 Vibration and proprioception – Posterior column

Romberg’s test
+ - Ataxia due to sensory (proprioception) impairment

Site Sensory loss

Sensory cortex Contralateral hemisensory loss
(parietal lobe) Gerstmann signs: Agraphaesthesis, acalculia, loss of two point discrimination, left-right
disorientation, finger agnosia
Internal capsule Contralateral hemisensory loss

Spinal cord Anterior spinal artery syndrome

- Loss of pin prick sensation
- Spared vibration and proprioception

Hemicord transection (Brown-Sequard syndrome)

- Loss of contralateral pin prink sensation
- Loss of ipsilateral vibration
- Ipsilateral weakness

Posterior column
- Loss of vibration and proprioception
- Spared pin prick sensation
- Positive Romberg’s test
Radiculopathy Numbness/paresthesia according to dermatome
Plexopathy Paresthesia of one limb
Mononeuropathy Numbness following the nerve innervation
Polyneuropathy Glove and stockings sensory loss
Loss of proprioception

Cerebellar signs
PINARDS
Past-pointing
Intentional tremor
Nystagmus
Ataxia
Rebound phenomenon
Dysdiadochokinesia
Slurred speech

Etiologies
Unilateral Bilateral
Cranial nerve involvement  Spinocerebellar ataxia
 Cerebellopontine angle lesion: Acoustic  Multiple sclerosis
neuroma  Alcohol
 Otitis media with cerebellar abscess  Antiepileptic
 Multiple sclerosis  Hypothyroidism
 PICA syndrome  Abetalipoproteinemia
 Vitamin E deficiency
No cranial nerve involvement  Paraneoplastic syndrome
 Cerebellar infarct  Friedreich’s ataxia
 Post-infections