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 DTR examination is using a stick figure 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 ref…
Physical Examinations III
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…
Physical Examinations II
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…
Physical Examinations I