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 reflexT.jpg
 * 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.

 * Hoffman.png'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.