Peripheral nerve examination

WIPER and General examination

In an examination the mnemonic WIPER may serve as a reminder to wash your hands, introduce yourself, gain permission, expose the patient and reposition them as appropriate for the examination about to be performed. Simultaenously you should carry out a general examination noting the patients appearance, condition, and any clues from the environment. This forms the beginning of your mental account of the patient and can be remembered as ACC. See General Examination and Observations for more detail. The standard format that follows is always inspection, palpation, percussion, auscultation, and contemplation (Osler, Canadian turn of 19C physician, father of modern medicine). Additionally it is helpful to carry out the examination routine in a set sequence for example general, hands, neck, face, then specific, in this case, the chest wall. Finish by carrying out, or listing, relevent further clinical examinations and investigations, and presenting your findings. N.B. It’s a good idea to aim to be able to define, explain, and suggest a differential for any finding that you report.

Peripheral Nerve Examination

General inspection

  • Are there any disability aids at the bedside?

Peripheral Nerve Examination

  • Examination divided into Motor and Sensory modalities and Upper and Lower limbs.

  • Motor

    • Inspection (fasiculation, muscle wasting, asymmetry and spot diagnoses)

    • Tone

    • Power (active/passive movement, isolate muscle groups, MRC grading)

    • Reflexes

    • Coordination

  • Sensory

    • Touch

    • Pain

    • Temp

    • Vibration

    • Proprioception

Upper Limbs

  • Are there signs of fasiculation, muscle wasting, or asymetry? Is there a Parkinsons facies? Is there a Horner’s? (pancoasts tumor), Are there Rheumatoid hands/nodules, Psoriatic hands/plaques?

  • ’put arms out palms up and close your eyes’ (myelopathy hand sign and sensory wandering)

  • Tone, move arm and rotate wrist

  • Power,

    • ’put arms like this and stop me pushing down’

    • ’don’t let me pull you away’, ’push me away’

    • ’try and straighten your wrist’, ’try and bend your wrist’

    • ’squeeze my fingers’

    • ’stop me pushing your fingers in’

    • ’stop me pulling the paper away’

    • ’try and point your thumb up to the ceiling’

    • ’join your thumb and little finger. Try and stop me pulling them apart’

  • Reflexes, biceps (C5/6), supinator (C5/6), triceps (C6/7)

  • Coordination, past-pointing, dysdiadokinesia (cerebellar)

  • Sensory examination according to dermatome

Lower Limbs

  • Are there signs of fasiculation, muscle wasting, or asymetry? Are the tibia bowed? Is there pes cavus? Is there a size difference? (polio, congential hemiplegia)

  • Tone lift knee, roll leg and test for clonus at the ankle

  • Power,

    • ’keep your leg straight and lift it. Try and stop me pushing you down. Try and stop me pushing you up.’

    • ’bend your leg. Try and straighten it. Try and bend your leg’

    • ’pull me towards you with your toes. Push me away’

  • Reflexes, knee (L3/4), ankle (S1/2), plantar

  • Coordination, ’run your heel down you shin, lift up and repeat’

  • Sensory examination according to dermatome

Completion

Either do these things and/or say ”To complete my examination I would....``

Further examinations

Sensory examination (if not done), gait, cerebellar examination (DANISH, remember heel-to-toe walking and Romberg’s for ataxia - only positive if more unsteady with eyes closed than open), peripheral vascular examination

Further investigations

  • directed to underlying diagnosis
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