ISCES - Neuro exam: Sensation (R)

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What are the dermatomes of the arm? R

C4, C5, C6, C7, C8, T1, T2. R

Where is the C4 dermatome? R

Over the acromioclavicular joint and across the top of the shoulder. R

Where is the C5 dermatome? R

It covers the lateral side of the arm. A good place to test this dermatome is the lateral side of the arm just above the elbow. R

Where is the C6 dermatome? R

It covers the lateral forearm and extends down the dorsal surface of the thumb and forefinger. A good place to test it is the thumb. R

Where is the C7 dermatome? R

It covers the dorsal aspect of the middle finger, and the palmar aspect of the 2nd and 3rd digits. A good place to test the C7 dermatome is the middle finger. R

Where is the C8 dermatome? R

It covers both surfaces of the 4th and 5th fingers and extends up the wrist. A good place to test sensation is on the little finger. R

Where is the T1 dermatome? R

It covers the medial side of the forearm. This is the best place to test it. R

Where is the T2 dermatome? R

The medial aspect of the upper arm. This is where to test it. R

What must be assessed as part of the sensory exam? R

Light touch, pain, proprioception and vibration sense. R

What is the method for testing light touch sensation in the upper limbs? R

Take a monofilament or a piece of cotton wool wound to a point and touch the patient's sternum to show them what it feels like, then ask them to close their eyes and say "yes" when they feel you touching them, reminding them to tell you if it feels different at any point. Then work through the dermatomes C4-T2 alternating between each arm. So therefore touch the shoulders of both arms, then the lateral upper arms, then the thumbs, then the middle fingers, then the little fingers, then the medial forearms, then the medial upper arms. R

What is the method for assessing pain sensation in the upper limbs? R

The method is exactly the same as for testing light sensation, but a neurotip is used instead. Always ask the examiner if they want you to do this test. R

How do you assess proprioception of the upper limbs? R

With patient's eyes open, ask them to watch what you are doing and move the DIP joint in the thumb down and then up, making sure to isolate the joint. With their eyes closed moved the thumb down and up randomly and ask the patient to say "up" or "down" according to what they can feel you doing. If they can't sense movement at the DIP joint, move up to the MCP joint, then up to the wrist joint, then up to the elbow and even the shoulder, until they can feel what you're doing. Be sure to always isolate the joint that you are assessing. R

How do you assess vibration sense in the upper limbs? R

Using a 128Hz tuning fork, place the vibrating tuning fork on the sternum to demonstrate to the patient what it feels like. Place vibrating tuning fork on the DIP joint of the thumb and ask patient to confirm that they can feel the vibration. You should hold the thumb near to the joint to ensure you can feel that the tuning fork is actually vibrating. Stop vibration by holding prongs of tuning fork and ask patient to confirm that they can feel it stop. If the patient can't feel the vibration move proximally on bony prominences: DIP joint of thumb, MCP joint of thumb, wrist, elbow, clavicle etc. R

What are the dermatomes of the lower limb? R

L1, L2, L3, L4, L5, S1, S2, S3, S4 & S5. R

Where can L1 be assessed? R

Right at the top of the thigh, below the inguinal ligament. R

Where can L2 be assessed? R

Front of the upper thigh. R

Where can L3 be assessed? R

Skin over the knee. R

Where can L4 be assessed? R

The medial aspect of the shin. R

Where can L5 be assessed? R

The dorsal aspect of the medial foot. R

Where can S1 be assessed? R

The sole of the foot. R

Where can S2 be assessed? R

The back of the thigh. R

What is the method for assessing light touch of the lower limbs? R

Using mono-filament or cotton wool twisted into a point, test on the patient's sternum first - don't stroke or tickle, just dab. Ask patient to close their eyes and say "yes" when they can feel you touching - and to tell you if it ever feels different. Move through the dermatomes L1-S2 in order, alternating from one leg to the other: Very top of each thigh below inguinal ligaments, front of thighs, over both knees, medial aspects of the shins, dorsal surface of big toes, soles of feet and backs of thighs. R

What is the method for assessing pain sensation in the lower limbs? R

The method is exactly the same as for testing light sensation in the lower limbs, but a neurotip is used instead of the monofilament/cotton wool. Always ask the examiner if they want you to do this test. R

What is the method for assessing proprioception in the lower limbs? R

With patient's eyes open, ask them to watch what you are doing and move the distal joint of the big toe down and then up, making sure to isolate the joint. With their eyes closed moved the toe down and up randomly and ask the patient to say "up" or "down" according to what they can feel you doing. If they can't sense movement at the distal joint, move up to the proximal joint, then up to the ankle joint, then up to the knee and even the hip, until they can feel what you're doing. Be sure to always isolate the joint you are assessing. Repeat on both toes. R

What is the method for assessing vibration sense in the lower limbs? R

Use 128Hz tuning fork. Place the vibrating tuning fork on patient's sternum to demonstrate to the patient what it feels like. Place vibrating tuning fork on distal joint of big toes and ask patient to confirm that they can feel the vibration. Hold near to joint to ensure you can feel tuning fork is actually vibrating. Stop vibration by holding prongs of tuning fork and ask patient to confirm that they can feel it stop. Move proximally on bony prominences if test proves negative until they can feel the vibration. Start on IP joint of big toe, MTP joint of big toe, medial malleolus, tibial tuberosity (knee), anterior superior iliac spine etc. R

What spinal tract carries vibration and proprioception sensation? R

The dorsal/posterior columns. R

Which tract carries fibres for light touch? R

Anterior spinothalamic (crude touch) and the dorsal columns (fine touch). R

Which tract carries pain and temperature sensation? R

Anterior spinothalamic tract. R

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