1. Prof. M.ABD ELAZIZ, MD, Ph D- Clinical Pharmacology Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University Mohammad Ruhal Ain (M Pharm, R Ph, PGDPRA) Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University

2.  A full neurological examination includes assessment of the motor and sensory systems.

3. Introduce yourself to the patient and ensure that you have explained the procedure. Inform them that if they feel any discomfort then they are to let you know. Subject steps Introduction

4. - Tone - Power - Reflexes - Function - Sensation Subject steps The upper body of patient should be exposed for this examination, although in an exam situation the patient will be in shorts. Initially, observe the patient’s arms, look for any muscle wasting, fasciculation's or asymmetry.

5. Observe the patients arms

6. TONE -Start by examining the tone of the muscles.Start -Start proximally at the shoulder, feeling how easy the joint is to move passively. - Then move down to the elbow, wrist and hand joints, again assessing each one’s tone in turn.

7. Assess arm toneAssess wrist and hand tone TONE Cont…………………..

8. POWER Next assess the power of each of the muscle groups. Again, start at the shoulder asking the patient to abduct, and adduct against your hand so you can assess how much force they can overcome. Do the same for flexion and extension at the elbow and wrist as well as the fingers. Also checking abduction and adduction of the thumb.

9. POWER Cont……… Assess power of the shoulders

10. Elbow extension POWER Cont……… Elbow Flexon

11. Wrist flexionWrist Extension POWER Cont………

12. Finger flexion Finger Extension POWER Cont………

13. Finger abduction Abduction of the thumb POWER Cont………

14. REFLEXES Move on to test the patient’s reflexes. There are three reflexes in the upper limb: 1.The bicepsThe biceps 2.The tricepsThe triceps 3.The supinator reflexThe supinator reflex

15. Reflexes Cont……… The biceps reflex is tested by supporting the patient’s arm, with it flexed at roughly 60º, placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their arm. Biceps reflex test

16. The triceps reflex is elicited by resting the patient’s arm across their chest and hitting the triceps tendon just proximal to the elbow. Triceps reflex test Reflexes Cont………

17. Finally, with their arm rested on their abdomen, locate the supinator tendon as it crosses the radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex. Reflexes Cont……… Supinator reflex test

18. FUNCTION -Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. To assess the upper limb, you should ask the patient to touch their head with both hands and then ask them to pick up a small object such as a coin which each hand. position sense (proprioception).

19. - The final test is sensation - Sensation is tested in a number of ways. - Test: light touch, pin prick, vibration, and joint - Ask the patient to place their arms by their sides with their palms facing forwards. - Lightly touch the patient’s sternum with a piece of cotton wool so that they know how it feels. - Then, with the patient’s eyes shut, lightly touch their arm with the cotton wool. - The places to touch them should test each of the dermatomes – make sure you know these!dermatomes - Tell the patient to say “yes” every time they feel the cotton wool as it felt before. SENSATION

20. Touch sensation top of the armTouch sensation lower arm Sensation Cont……… Next repeat this using a light pin prick.

21. VIBRATION-TUNING FORK Place the fork on the patient’s sternum to show them how it should feel. Then place it on the bony prominence at the base of their thumb and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the radial stylus and then to the olecranon until it feels normal.

22. Vibration test Vibration Cont………

23. Finally assess proprioception.proprioception Hold the distal phalanx of the thumb on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position – up or down. Ask the patient which position the joint is in.

24. Thumb position up Thumb position down