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Neurologic Examination:
 Science Education: Essentials of Physical Examinations II

Male Rectal Exam

JoVE Science Education

Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

While its usefulness in cancer screening is debated, the male rectal examination remains an important part of the physical exam. The exam is indicated in selected patients with lower urinary tract symptoms, urinary and/or fecal incontinence or retention, back pain, anorectal symptoms, abdominal complaints, trauma patients, unexplained anemia, weight loss, or bone pain. There are no absolute contraindications to the rectal exam; however, relative contraindications include patient unwillingness to undergo the exam, severe rectal pain, recent anorectal surgery or trauma, and neutropenia. When performing the rectal exam, the examiner should conceptualize the relevant anatomy. The external anal sphincter is the most distal part of the anal canal, which extends three to four centimeters before transitioning into the rectum. The prostate gland lies anterior to the rectum, just beyond the anal canal. The posterior surface of the prostate, including its apex, base, lateral lobes, and median sulcus, can be palpated through the rectal wall (Figure 1). The normal consistency of the prostate is similar to the thenar eminence when the hand is in a tight fist. The thumb knuckle is representativ

 Science Education: Essentials of Physical Examinations I

Proper Adjustment of Patient Attire during the Physical Exam

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, and Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

In order to optimize the predictive value of the physical examination, the provider must perform maneuvers correctly. The proper use of drapes is an important component of correctly performing physical examination maneuvers. Skin lesions are missed when "inspection" occurs through clothing, crackles are erroneously reported when the lungs are examined through a t-shirt, and subtle findings on the heart exam go undetected when auscultation is performed over clothing. Accordingly, the best practice standards call for examining with one's hands or equipment in direct contact with the patient's skin (i.e., do not examine through a gown, drape, or clothing). In addition to its clinical value, the correct draping technique is important for improving the patient's comfort level during the encounter. Like all other aspects of the physical exam, it takes deliberate thought and practice to find the right balance between draping, which is done to preserve patient modesty, and exposure, which is necessary to optimize access to the parts that need examination. Individual provider styles in the use of gowns and drapes vary consider

 Science Education: Essentials of Physical Examinations III

Motor Exam II

JoVE Science Education

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA

There are two main types of reflexes that are tested on a neurological examination: stretch or deep tendon reflexes, and superficial reflexes. A deep tendon reflex (DTR) results from the stimulation of a stretch-sensitive afferent from a neuromuscular spindle, which, via a single synapse, stimulates a motor nerve leading to a muscle contraction. DTRs are increased in chronic upper motor neuron lesions (lesions of the pyramidal tract) and decreased in lower motor neuron lesions and nerve and muscle disorders. There is a wide variation of responses and reflexes graded from 0 to 4+ (Table 1). DTRs are commonly tested to help localize neurologic disorders. A common method of recording findings during the DTRs examination is using of a stick ure diagram. The DTR test can help distinguish upper and lower motor neuron problems and can assist in localizing nerve root compression as well. Although the DTR of nearly any skeletal muscle could be tested, the reflexes that are routinely tested are: brachioradialis, biceps, triceps, patellar, and Achilles (Table 2). Superficial reflexes are segmental reflex responses that result from stim

 Science Education: Essentials of Physical Examinations I

General Approach to the Physical Exam

JoVE Science Education

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

The examination of the body is fundamental to the practice of medicine. Since the Roman Empire, physicians have described the connection between alterations in function of specific parts of the body and specific disease states and have sought to further scientific understanding to improve bedside diagnosis. However, in this modern age of increasing technology within medical diagnostics, it is important to consider the role that physical examination plays today. It is misguided to believe that physical examination holds all the answers, and much has been written about the questionable utility of certain maneuvers previously held in high regard. It is equally misguided to suggest that physical examination plays little role in the modern patient encounter. Physical examination remains a valuable diagnostic tool; there are many diagnoses that can only be made by physical examination. A diagnosis made by labs or imaging is rarely done in the absence of findings detectable at the bedside. As the provider conducts a history and physical, they are actively generating and testing hypotheses to explain the patient's condition. The information one gathers may not replace the need

 JoVE Medicine

State of the Art Cranial Ultrasound Imaging in Neonates

1Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, 2Department of Radiology, Erasmus MC-Sophia Children's Hospital, 3Department of Pediatrics, Division of Neonatology, UZ Brussel, 4Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, 5Department of Pediatrics, Division of Neonatology, Isala Hospital, 6Department of Pediatrics, Koningin Paola Children's Hospital


JoVE 52238

 Science Education: Essentials of Physical Examinations III

Cranial Nerves Exam II (VII-XII)

JoVE Science Education

Source: Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women's/Massachusetts General Hospital, Boston, Massachusetts, USA

The cranial nerve (CN) examination follows the mental status evaluation in a neurological exam. However, the examination of the cranial nerves begins with observations made upon greeting the patient. For example, weakness of the facial muscles that are innervated by the cranial nerve VII can be readily apparent during the first encounter with the patient. Cranial nerve VII, the Facial nerve, also has sensory branches, which innervate the taste buds on the anterior two-thirds of the tongue and the medial aspect of the external auditory canal. Therefore, finding ipsilateral taste dysfunction in the patient with facial weakness confirms the involvement of CN VII. In addition, knowledge of the neuroanatomy helps the clinician to localize level of the lesion: unilateral weakness of the lower facial muscles suggests a supranuclear lesion on the opposite side, while lesions involving the nuclear or infranuclear portion of the facial nerve, manifest with an ipsilateral paralysis of all the facial muscles on the involved side. Cranial nerve VIII, the Acoustic nerve, has two divisions: the hearing (cochlear) division, and the vestibular division, which innervates

 Science Education: Essentials of Physical Examinations II

Eye Exam

JoVE Science Education

Source: Richard Glickman-Simon, MD, Assistant Professor, Department of Public Health and Community Medicine, Tufts University School of Medicine, MA

Proper evaluation of the eyes in a general practice setting involves vision testing, orbit inspection, and ophthalmoscopic examination. Before beginning the exam, it is crucial to be familiar with the anatomy and physiology of the eye. The upper eyelid should be slightly over the iris, but it shouldn't cover the pupil when open; the lower lid lies below the iris. The sclera normally appears white or slightly buff in color. The appearance of conjunctiva, a transparent membrane covering the anterior sclera and the inner eyelids, is a sensitive indicator of ocular disorders, such as infections and inflammation. The tear-producing lacrimal gland lies above and lateral to the eyeball. Tears spread down and across the eye to drain medially into two lacrimal puncta before passing into the lacrimal sac and nasolacrimal duct to the nose. The iris divides the anterior from the posterior chamber. Muscles of the iris control the size of the pupil, and muscles of the ciliary body behind it control the focal length of the lens. The ciliary body also produces aqueous humor, which largely determines intraocular pressure (Figure 1). Cranial nerve

 JoVE Medicine

Utilizing Repetitive Transcranial Magnetic Stimulation to Improve Language Function in Stroke Patients with Chronic Non-fluent Aphasia

1Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 2Center for Cognitive Neuroscience, University of Pennsylvania, 3Veterans Affairs Boston Healthcare System, 4Harold Goodglass Aphasia Research Center, Boston University School of Medicine, 5Department of Neurology, Boston University School of Medicine


JoVE 50228

 Science Education: Essentials of Physical Examinations III

Lower Back Exam

JoVE Science Education

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

The back is the most common source of pain in the body. Examination of the back can be a challenge due to its numerous structures including the bones, discs, ligaments, nerves, and muscles - all of which can generate pain. Sometimes, the location of the pain can be suggestive of etiology. The essential components of the lower back exam include inspection and palpation for signs of deformity and inflammation, evaluation of the range of motion of the back, testing the strength of the muscles innervated by the nerves exiting in the lumbar-sacral spine, neurological evaluation, and special tests, including the Stork test and Patrick's test.

 Science Education: Essentials of Physical Examinations III

Neck Exam

JoVE Science Education

Source: Robert E. Sallis, MD. Kaiser Permanente, Fontana, California, USA

Examination of the neck can be a challenge because of the many bones, joints, and ligaments that make up the underlying cervical spine. The cervical spine is composed of seven vertebrae stacked in gentle C-shaped curve. The anterior part of each vertebra is made up of the thick bony body, which is linked to the body above and below by intervertebral discs. These discs help provide stability and shock absorption to the cervical spine. The posterior elements of the vertebra, which include the laminae, transverse, and spinous processes and the facet joints, form a protective canal for the cervical spinal cord and its nerve roots. The cervical spine supports the head and protects the neural elements as they come from the brain and from the spinal cord. Therefore, injuries or disorders affecting the neck can also affect the underlying spinal cord and have potentially catastrophic consequences. The significant motion that occurs in the neck places the cervical spine at increased risk for injury and degenerative changes. The cervical spine is also a common source of radicular pain in the shoulder. For this reason, the neck should be evaluated as a routine part of every shoulder exam.

 JoVE Medicine

3D-Neuronavigation In Vivo Through a Patient's Brain During a Spontaneous Migraine Headache

1Headache & Orofacial Pain Effort (H.O.P.E.), Biological & Materials Sciences Department, University of Michigan School of Dentistry, 2Michigan Center for Oral Health Research (MCOHR), University of Michigan School of Dentistry, 3Translational Neuroimaging Laboratory, Molecular & Behavioral Neuroscience Institute, University of Michigan, 4PET Physics Section, Division of Nuclear Medicine, Radiology Department, University of Michigan, 53DLab, University of Michigan, 6Department of Obstetrics and Gynecology, University of Michigan


JoVE 50682

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 JoVE Medicine

A Multimodal Imaging- and Stimulation-based Method of Evaluating Connectivity-related Brain Excitability in Patients with Epilepsy

1Department of Neurology, Harvard Medical School, 2Department of Neurology, Beth Israel Deaconess Medical Center, 3Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, 4Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, 5Department of Neurology, Massachusetts General Hospital


JoVE 53727

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 JoVE Behavior

Vision Training Methods for Sports Concussion Mitigation and Management

1Neurology and Rehabilitative Medicine, University of Cincinnati, 2Division of Sports Medicine, Department of Orthopaedic Surgery, University of Cincinnati, 3Department of Athletics, University of Cincinnati, 4Department of Neurosurgery, University of Cincinnati, 5College of Education, Criminal Justice, and Human Services, University of Cincinnati, 6Division of Sports Medicine, Cincinnati Children's Hospital Medical Center


JoVE 52648

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 Science Education: Essentials of Lab Animal Research

Diagnostic Necropsy and Tissue Harvest

JoVE Science Education

Source: Kay Stewart, RVT, RLATG, CMAR; Valerie A. Schroeder, RVT, RLATG. University of Notre Dame, IN

Many animal experiments rely on final data collection time points that are gathered from the harvesting and testing of organs and tissues. The use of appropriate methods for the collection of organs and tissues can impact the quality of the samples and the analysis of the data that is gleaned for the testing of the tissues. The method of euthanasia of the animal can also impact the quality of the samples. This manuscript will outline proper necropsy techniques for rats.

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 JoVE Medicine

Flexible Colonoscopy in Mice to Evaluate the Severity of Colitis and Colorectal Tumors Using a Validated Endoscopic Scoring System

1Division of Gastroenterology, Case Western Reserve University School of Medicine, Cleveland, 2Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, 3Digestive Health Research Center, Case Western Reserve University School of Medicine, Cleveland


JoVE 50843

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 Science Education: Essentials of Physical Examinations II

Abdominal Exam I: Inspection and Auscultation

JoVE Science Education

Source: Alexander Goldfarb, MD, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center, MA

Gastrointestinal disease accounts for millions of office visits and hospital admissions annually. Physical examination of the abdomen is a crucial tool in diagnosing diseases of the gastrointestinal tract; in addition, it can help identify pathological processes in cardiovascular, urinary, and other systems. As physical examination in general, the examination of the abdominal region is important for establishing physician-patient contact, for reaching the preliminary diagnosis and selecting subsequent laboratory and imaging tests, and determining the urgency of care. As with the other parts of a physical examination, visual inspection and auscultation of the abdomen are done in a systematic fashion so that no potential findings are missed. Special attention should be paid to potential problems already identified by the patient's history. Here we assume that the patient has already been identified, and has had history taken, symptoms discussed, and areas of potential concern identified. In this video we will not review the patient's history; instead, we will go directly to the physical examination. Before we get to the examination, let's briefly review s

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 Science Education: Essentials of Physical Examinations II

Pelvic Exam III: Bimanual and Rectovaginal Exam

JoVE Science Education

Source:

Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT

Tiffany Cook, GTA, Praxis Clinical, New Haven, CT

Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

A bimanual exam is a thorough check of a patient's cervix, uterus, and ovaries. It can tell an experienced provider a great deal, as it may lead to the discovery of abnormalities, such as cysts, fibroids, or malignancies. However, it's useful even in the absence of such findings, as it allows the practitioner to establish an understanding of the patient's anatomy for future reference. Performing the bimanual exam before the speculum exam can help relax patients, mentally and physically, before what is often perceived as the "most invasive" part of the exam. A practitioner already familiar with the patient's anatomy can insert a speculum more smoothly and comfortably. However, lubrication used during the bimanual exam may interfere with processing certain samples obtained during the speculum exam. Providers must be familiar with local laboratory processing requirements before committing to a specific order of examination. This demonstration begins

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 Science Education: Essentials of Physical Examinations II

Comprehensive Breast Exam

JoVE Science Education

Source:
Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT
Tiffany Cook, GTA, Praxis Clinical, New Haven, CT
Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT

Breast exams are a key part of an annual gynecological exam and are important for all patients, no matter their sex or gender expression. One out of every 8 women will be diagnosed with breast cancer; male breast cancer, though less common, has a lifetime incidence of 1 in 1000. Breast exams can feel invasive to patients, so it is important to do everything possible to make the patients feel comfortable and empowered, rather than vulnerable. Examiners should be aware of what they are communicating, both verbally and non-verbally, and give their patients control wherever possible (for instance, always allowing them to remove their own gowns). Examiners may choose to utilize chaperones for the patients' (as well as their own) comfort. Some institutions require the use of chaperones. While it is always important to avoid overly clinical language, certain colloquial words can cross the line from caring to overly intimate in this exam. It is helpful to avoid the words "touch" and "feel" in this exam, as this lan

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 JoVE Behavior

The 4 Mountains Test: A Short Test of Spatial Memory with High Sensitivity for the Diagnosis of Pre-dementia Alzheimer's Disease

1Department of Clinical Neurosciences, University of Cambridge, 2Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, 3U.O. Direzione Scientifica, Fondazione IRCCS Istituto Neurologico Carlo Besta, 4Institute of Cognitive Neuroscience, University College London, 5Department of Psychology, University of York


JoVE 54454

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 JoVE Medicine

Fetal Echocardiography and Pulsed-wave Doppler Ultrasound in a Rabbit Model of Intrauterine Growth Restriction

1Division Woman and Child, Department Women, University Hospitals Leuven, 2The Ritchie Centre, Monash Institute of Medical Research, Department of Obstetrics and Gynaecology, Monash University, Victoria, Australia, 3Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, 4Fetal and Perinatal Medicine Research Group, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), 5Maternal-Fetal Medicine Department, ICGON, Hospital Clínic, Universitat de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)


JoVE 50392

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