14.February.2013 Thursday

History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function Gait and stance Neurologic Exam Susan R. Winkler, Pharm.D. BCPS Spring 1998

Deltoid The arm is abducted, starting from approximately 15°, against resistance. If acting normally, the deltoid can easily be seen and palpated. Shoulder abduction Axillary nerve

Supraspinatus Initiates abduction of the arm Suprascapular nerve Infraspinatus Laterally rotates the humerus Suprascapular nerve Abduction of the arm from fully adducted position against resistance. Palpated superior to Palpated superior to scapular spine. Supraspinatus & middle deltoid tested together. The person flexes the elbow and adducts the arm. The arm then laterally rotated against resistance. Infraspinatus & teres minor tested together. Palpated inferior to scapular spine.

Degenerative tendonitis of the rotator cuff The person is asked to lower the fully abducted limb slowly and smoothly. From approximately 90° abduction, the limb will suddenly drop to the side in an uncontrolled manner if the rotator cuff (especially supraspinatus part) is diseased and/or torn

Biceps brachii Elbow joint is flexed against resistance when the forearm is supinated. If acting normally, the muscle forms a prominent bulge on the anterior aspect of the arm that is easily palpated. Forearm flexor & supinator Musculocutaneous nerve

Brachialis Forearm is semipronated and flexed against resistance. If acting normally, the contracted muscle can be seen and palpated. Main flexor of the forearm Musculocutaneous nerve

Triceps brachii The arm is abducted 90° and then the flexed forearm is extended against resistance provided by the examiner. If acting normally, the triceps can be seen and palpated. Forearm extension Radial nerve

Flexor carpi ulnaris Flexor carpi radialis The person puts the posterior aspect of the forearm and hand on a flat table and is then asked to flex the wrist against resistance while the examiner palpates the muscle and its tendon. The person is asked to flex the wrist against resistance. If acting normally, its tendon can be easily seen and palpated. Flexor & adductor of the wrist Ulnar nerve Flexor & abductor of the wrist Radial nerve

Palmaris longus The wrist is flexed and the pads of the little finger and thumb are tightly pinched together. If present and acting normally, the tendon can be easily seen and palpated. Accessory flexor of the wrist, opposes shearing forces on the skin of the palm during gripping Median nerve

Pronator teres The person's forearm is flexed at the elbow and pronated from the supine position against resistance provided by the examiner. If acting normally, the muscle is prominent and can be palpated at the medial margin of the cubital fossa. Rotates radius over ulna during pronation Median nerve

Flexor digitorum superficialis One finger is flexed at the proximal interphalangeal joint against resistance and the other three fingers are held in an extended position to inactivate the flexor digitorum profundus. Flexes the metacarpophalangeal joint and proximal interphalangeal joint of each finger; also flexes the wrist joint. Median nerve

Flexor digitorum profundus The proximal interphalangeal joint is held in the extended position while the person attempts to flex the distal interphalangeal joint. The integrity of the median nerve in the proximal forearm can be tested by performing this test using the index finger, and that of the ulnar nerve can be assessed by using the little finger. Flexes the distal phalanges of the medial four fingers Lateral half median nerve Medial half ulnar nerve

Flexor pollicis longus The proximal phalanx of the thumb is held and the distal phalanx is flexed against resistance. Flexes the thumb Median nerve

Brachioradialis Relatively weak flexion of forearm; maximal when forearm is in midpronated position Radial nerve Elbow joint is flexed against resistance with the forearm in the midprone position. If the brachioradialis is acting normally, the muscle can be seen and palpated.

Extensor carpi radialis longus Extend & abduct wrist Radial nerve Wrist is extended & abducted with forearm pronated. Its tendon can be palpated proximal to the wrist.

Extensor digitorum Extends medial four digits metacarpophalangeal joints, interphalangeal joints Deep branch of radial nerve Forearm is pronated and the fingers are extended. The person attempts to keep the digits metacarpophalangeal joints as the examiner exerts pressure on the proximal phalanges by attempting to flex them. Tendons on the dorsum of the hand

Extensor carpi ulnaris Extends and adducts wrist Deep branch of radial nerve Forearm pronated & fingers are extended Extended wrist is then adducted against resistance. Muscle seen and palpated proximal part of the forearm & tendon felt proximal to ulnar head

Extensor digiti minimi Extends 5th digit joint, interphalangeal joint Deep branch of radial nerve Little finger is extended against resistance while holding digits 2-4 metacarpophalangeal joints

Abductor pollicis longus Abducts thumb and extends carpometacarpal joint Posterior interosseous nerve Thumb is abducted against resistance at the metacarpophalangeal joint. Tendon seen and palpated at the lateral side of the anatomical snuff box and on the lateral side of the adjacent extensor pollicis brevis tendon.

Extends proximal phalanx of metacarpophalangeal joint; extends carpometacarpal joint Posterior interosseous nerve Extensor pollicis brevis Thumb is extended against resistance at the metacarpophalangeal joint. lateral side of the anatomical snuff box and on the medial side of the adjacent abductor pollicis longus tendon

Extensor pollicis longus Extends distal phalanx of interphalangeal joint; extends metacarpophalangeal & carpometacarpal joints Posterior interosseous nerve Thumb is extended against resistance at the interphalangeal joint Thumb is extended against resistance at the interphalangeal joint. Tendon on the medial side of the anatomical snuff box

Abductor pollicis brevis Abducts the thumb, metacarpophalangeal joint Median nerve Flexor pollicis brevis Flexes metacarpophalangeal joint of the thumb Median nerve Abduct the thumb against resistance Flex the thumb against resistance

Lumbricals Participate in flexing metacarpophalangeal joints & extending the interphalangeal joints Medial 2 ulnar nerve Lateral 2 median nerve superiorly With the palm facing superiorly patient is asked to flex the metacarpophalangeal (MP) joints while keeping the interphalangeal joints extended. The examiner uses one finger to apply resistance along the palmar surface of the proximal phalanx of digits 2-5 individually.

Dorsal interossei Major abductors of the index, middle, and ring metacarpophalangeal joints Ulnar nerve Examiner holds adjacent extended and adducted fingers between thumb and middle finger, Providing resistance as the individual attempts to abduct the fingers (the person is asked to “spread the fingers apart”).

Palmar interossei Addduct thumb, index, ring, and little metacarpophalangeal joints Ulnar nerve A sheet of paper is placed between adjacent fingers. The individual is asked to “keep the fingers together” to prevent the paper from being pulled away by the examiner.

Trapezius The shoulder is shrugged against resistance (the person attempts to raise the shoulders as the examiner presses down on them). If the muscle is acting normally, the superior border of the muscle can be easily seen and palpated. Superior fibers elevate scapula Middle fibers retract scapula Inferior fibers depress scapula and lower the shoulder. The superior and inferior fibers work together to rotate the lateral aspect of the scapula upward, which needs to occur when raising the upper limb above the head. Spìnal accessory nerve (CN XI)

Latissimus dorsi Latissimus dorsi The arm is abducted 90° and then adducted against resistance provided by the examiner. If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold. Adductor of the humerus Extension, adduction, and medial rotation of the upper limb. Depresses the shoulder, preventing its upward movement. Thoracodorsal nerve

Rhomboids Rhomboids Individual places the hands posteriorly on the hips and pushes the elbows posteriorly against resistance provided by the examiner. Palpated along the medial borders of the scapulae; because they lie deep to the trapezius, they are unlikely to be visible during testing. Retract and rotate the scapula, depressing its glenoid cavity. Assist the serratus anterior in holding the scapula against the thoracic wall. Dorsal scapular nerve

Pectoralis major Pectoralis major Clavicular head The arm is abducted 90°; the individual then moves the arm anteriorly against resistance. If acting normally, the clavicular head can be seen and palpated. Sternocostal head The arm is abducted 60° and then adducted against resistance. If acting normally, the sternocostal head can be seen and palpated. Adduction and medial rotation of the arm Clavicular head flexes humerus Sternocostal head extends it back Lateral and medial pectoral nerves clavicular head (C5, C6), sternocostal head (C7, C8, T1) clavicular head (C5, C6), sternocostal head (C7, C8, T1)

Serratus anterior Serratus anterior The hand of the outstretched limb is pushed against a wall. If the muscle is acting normally, several digitations of the muscle can be seen and palpated. Protracts scapula and holds it against thoracic wall; rotates scapula Long thoracic nerve

Inferior lateral cutaneous nerve of arm Lateral & anterior aspects of the lower part of the arm Medial cutaneous nerve of forearm Medial surface of the forearm down to the wrist Posterior cutaneous nerve of forearm Posterior aspect of the arm and forearm M edial cutaneous nerve of arm Medial side of the distal third of the arm Lateral cutaneous nerve of forearm Lateral half of the anterior aspect forearm supraclavicular nerves (medial,intermediate,lateral) the skin as far as the middle line, the skin over the pectoralis major and deltoideus, the skin of the upper and posterior parts of the shoulder, inferior part of the deltoid muscle

Superficial branch of the radial nerve Dorsolateral aspect of the palm Dorsal aspects of the lateral 3 ½ digits distally to approximately the terminal interphalangeal joints Ulnar nerve Medial side of the palm Medial half of the dorsum of the hand 5th finger & medial half of the 4th finger Anterior surfaces of the medial 1 ½ digits Median nerve Thumb,index,middle fingers Lateral side of the ring [distal parts on the dorsum of the hand] Palmar surface of the lateral 3 ½ digits Lateral side of the palm & middle of the wrist

The dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb C7 dermatome is situated on the middle finger C8, T1, and T2 along the medial margin of the limb

Biceps brachii tendon reflex C5 & 6 flexion of the elbow joint by tapping the biceps tendon Triceps tendon reflex C6, 7, and 8 extension of the elbow joint by tapping the triceps tendon Brachioradialis tendon reflex: C5, 6, and 7 supination of the radioulnar joints by tapping the insertion of the brachioradialis tendon

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