Motor System Upper Limb

## Washes hands, appropriate dress and grooming. Introduces self and asks for consent.

* Hello my name is [Medical Student] and I'm a first year medical student at [Medical School].
* Can I please get your full name and age please?
* Mr. Doe my attending physician has asked be to examine the motor system of your upper limb, do I have your permission?

## Explains procedure to patient, positions and drapes

* Today we're going to test the reflex and muscles of your upper limb, are you comfortable with this?
* I just want to remind you that anything we find today will be confidential.
* Mr. Doe, please sit on the bed.
* The patient is properly draped.

## INSPECTION: Inspect the upper limbs commenting on deformities, length discrepancy, symmetry, muscle wasting, fasciculations, etc.

* I'm going to begin by inspecting the upper limb of the patient.
* I don't see any **deformities**.
* I don't see any **length differences** (discrepancy).
* I don't see any **asymmetry**.
* I don't see any **fasciculations**.
* I don't see any **muscle wasting**.
* I don't see any wasting of the **thenar** and **hypothenar** muscles.
* I don't see any **resting tremor** of the hands which can suggest **Parkinson's Disease**.
* Mr. Doe, please reach over and grab this object in my hands.
	+ I don't see any **intention tremor** which can suggest **Multiple** **Sclerosis**.

## TONE: Tests for muscle tone of both upper limbs and comments and findings. Describes what one would expect to find in a central vs a peripheral nervous lesion

* Mr. Doe, please relax your arms as much as possible.
* Test:
	+ Shoulder
	+ Elbow
	+ Wrist
	+ Fingers
	+ Thumb
* The patient's muscle tone felt normal.
	+ **Increased** resistance can suggest a **Central Nervous Lesion**.
	+ **Decreased** resistance can suggest a **Peripheral Nervous Lesion**.

## POWER: Tests for muscle power bilaterally and comment of findings:

* Mr. Doe, I'm now going to test your muscle power.
* You're going to hold a position and I'm going to try to overcome it.
* Please try to keep your arms raised and keep it in that position.
* Please try to keep your arms to your side and keep it in that position.
* Please keep your arms flexed.
* Please keep your arms extended.
* Please keep your wrist flexed.
* Please keep your wrist extended.
* Please spread your fingers and hold it that position.
* Please close your fingers and hold it in that position.
* Please touch your pinky with your thumb and hold it there.
* Please grab my fingers as tightly as you can.
* I would rate the muscle power 5, normal power, active movement against full resistance without fatigue.

## REFLEXES: Elicit reflexes bilaterally and comment on findings.

* Mr. Doe, I'll be tapping your arm with this hammer, please relax your arm as much as possible.
* Biceps reflex
* Triceps reflex

* Brachioradialis reflex

* I would rate these reflexes as 2+ which is average or normal.

## Check for a Hoffmann response bilaterally and comment on findings. Describe a positive response and its significance.

* I'm not going to test for Hoffmann response by flicking the patient's middle finger.
* Mr. Doe show me your hands.
* I don't see Hoffmann's sign in either hands.
* A positive Hoffmann's sign would be flexing of the fingers or adduction of the thumb.
* A positive Hoffman's sign is heightened finger flexor reflexes and can suggest an upper motor neuron lesion.
* That's all for your exam today, thank you come coming in.