Neurological examination

Its neurological assessment with printable AV aids.

1. NEUROLOGICAL ASSESSMENT Presented by- Mr. Deepak Patel M.Sc. Nursing

2. 1) INTRODUCTION In general, a neurological examination is focused on finding out whether there are lesions in the central and peripheral nervous systems or there is another diffuse process that is troubling the patient. It can be used both as a screening tool, and as an investigative tool.

3. 2) DEFINITION “A neurological examination is the assessment of sensory neurons and motor responses, especially reflexes, to determine whether the nervous system is impaired.”

4. 3 ) ANATOMY AND PHYSIOLOGY OF NERVOUS SYSTEM

5. Two Content Layout with Table First bullet point here Second bullet point here Third bullet point here Class Group 1 Group 2 Class 1 82 95 Class 2 76 88 Class 3 84 90

6. The Brain

7. Nervous System

8. Neuron

9. Neuron

10. Nerves

11. 4) GOALS OF NEUROLOGICAL EXAMINATION “Check-out printable leaflet in later slide”

12. 5 ) INDICATIONS FOR NEUROLOGICAL EXAMINATION “Check-out printable leaflet in later slide”

13. 6) EQUIPMENTS NEEDED FOR NEUROLOGICAL EXAMINATION Check-out pamphlet in later slide….

14. EQUIPMENTS RATIONALE 1. SHEET To cover patient 2. GLOVES To prevent cross infection 3. REFLEX HAMMER To elicit the reflex 4. TONGUE DEPRESSOR To examine the pharynx 5. TUNNING FORK (128+512Hz) To assess auditory nerve 6. SNELLEN CHART To assess visual acuity 7. PEN LIGHT OR OTOSCOPE To through light in cavities: Ear, nose 8. COTTON SWABS To wipe secretions 9. BP APPARATUS & STETHOSCOPE To assess vital signs & auscultation 10. KIDNEY TRAY To collect the waste 11. TEST TUBE To keep hot and cold water 12. WATCH To measure time duration 13. COMMON PIN/NEEDLE To elicit the reflex 14. FRUIT- ORANGE/LEMON To test sense of smell 15. PEN/COIN To elicit the reflex

15. 7 ) HISTORY TAKING Age, sex, occupation Presenting complaints History of present and past illness Neurological system review questions Family and social history Personal history: drug abuse Genetic history Gynaecological and obstetrical history

16. 8) NEUROLOGICAL ASSESSMENT PROCEDURES MENTAL STATUS EXAMINATION CRANIAL NERVE EXAMINATION MOTOR FUNCTION ASSESSMENT SENSORY FUNCTION ASSESSMENT ASSESSMENT OF CEREBELLAR FUNCTION ASSESSMENT OF REFLEXES

17. I ) MENTAL STATUS EXAMINATION A. LEVEL OF CONSCIOUSNESS- Note if patient is awake and alert. If not describe what level of stimulus is needed to arouse and keep patient awake. E.g.- “open eyes to noxious stimuli; falls back asleep if not continuously stimulated.”

18. I ) MENTAL STATUS EXAMINATION B. ATTENTIVENESS- Patient is attentive if able to attend to you and the examination without getting easily distracted. Have patient spell word backwards or count the months of year backward.

19. I ) MENTAL STATUS EXAMINATION C . ORIENTATION- Ask patient’s full name, location and full date. Patient is “oriented X3” if all 3 are entirely correct. If not oriented X3, write out patient’s responses. Do not say “oriented X2 OR 1”

20. I ) MENTAL STATUS EXAMINATION D. SPEECH AND LANGUAGE- Listen to patient’s verbal output: Fluency: Comprehension: Repetition: Naming: Reading: Writing:

21. I ) MENTAL STATUS EXAMINATION E . MEMORY- Registration: Immediate recall Recent memory Remote memory

22. I ) MENTAL STATUS EXAMINATION F . HIGHER INTELLECTUAL FUNCTION- General knowledge: Abstraction: Judgement: Insight: Reasoning:

23. II) CRANIAL NERVES EXAMINATION A . CN-I OLFACTORY NERVE- Have patient close eyes. Occlude one nostril and test other using non irritating substances (e.g.. Fruit orange/lemon) avoid those that stimulate trigeminal nerve endings or taste buds (e.g. Peppermint, menthol, ammonia, alcohol swabs). Compare 2 sides.

24. Testing Olfactory Nerve

25. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 1. Visual Acuity: Hold Snellen’s chart at comfortable reading distance (14 inches). Cover 1 eye and have patient read chart. For each eye, record smallest line patient can read. Glasses should be on (looking for optic nerve lesion, not refractive error.)

26. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 2. Visual Fields: Stand directly in front of patient and have patient look you in both eyes. Hold your hands midway between you and the patient for enough laterally that you can barely see them out of the corner of your eyes.

27. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 2. Visual Fields: Wiggle a finger on one hand. Ask patient to indicate on which side the finger is moving. Repeat in upper and lower temporal quadrants. If abnormality is suspected or is found on screening test above, test all 4 quadrants of each eye individually.

28. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 2. Visual Fields: Have patient close one eye; you should close your own eye that is opposite the patient’s closed eye, since you will be serving as the control. Move a finger or penlight into the periphery of each visual quadrant (upper and lower temporal and nasal), asking patient to indicate when movement is detected. It should be seen by you and patient at the same time.

29. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 3. Fundoscopy: Have patient focus on distant wall. Be sure your head is not obstructing patient’s view of that target. View optic disc using ophthalmoscope. Note disc colour and presence of venous pulsations, papilledema (disc hyperaemia, blurred margins, absent venous pulsation) or haemorrhages.

30. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 4 . Pupillary Function (CN-II & CN-III): Test pupillary reaction to light – Dim room light as necessary. Ask patient to look into distance to avoid effect of accommodation. Shine bright light obliquely into each pupil.

31. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 4 . Pupillary Function (CN-II & CN-III): Test pupillary reaction to light – Look for both direct (same eye) and consensual (other eye) constriction. Record pupil size in mm (normal is about 2-5mm) and any asymmetry or irregularity.

32. II) CRANIAL NERVES EXAMINATION B. CN- I I OPTIC NERVE 4 . Pupillary Function (CN-II & CN-III): b) If light reflex is abnormal test pupillary reaction to accommodation Hold finger 10cm away from patient’s nose. Have patient alternate looking into distance and at finger. Observe pupillary response.

33. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves Visual inspection- Look at ocular alignment at rest (primary gaze), Does the reflection of light hit at same location in each eye? Is one eye deviated in, out, up and down? Observe for ptosis (lid droopiness).

34. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves b. 6 cardinal directions of gaze- Stand 3-6 feet in front of patient. Ask patient to follow you finger with the eyes without moving the head, place your hand on top of head to keep it still if necessary. Move your finger in the six cardinal direction and observe whether movements are full in each eye.

35. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves b. 6 cardinal directions of gaze-

36. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves c . Convergence- Ask patient to follow your finger with the eyes without moving the head. Hold lids up necessary. Move your finger toward bridge of patient’s nose and observe eye movements.

37. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves d. Smooth pursuits- Steadily move you finger horizontally and then vertically as in testing individual extra ocular muscles, but this time, look at smoothness of following movements.

38. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves e . Saccades- (Discrete, rapid movement from one object to another) Hold up your hands in front of patient (with each hand held a few inches lateral to the eye) Have patient alternate looking from one hand to another. Observe accuracy with eyes reach target. (check for consistency, oscillations)

39. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves f. Nystagmus- Observe for involuntary horizontal, vertical or rotary oscillation of the eyeballs at primary gaze (looking straight ahead) and on sustained horizontal and vertical gaze. If present, note direction of movement and whether movement persists or fatigues. A few beats of Nystagmus at extremes of gaze is normal finding.

40. II) CRANIAL NERVES EXAMINATION C. CN-III, IV, VI Oculomotor, Trochlear, Abducens Nerves g . Pupillary light response- (See CN-II)

41. II) CRANIAL NERVES EXAMINATION D . CN-V TRIGEMINAL NERVE Facial sensation- Use sharp end of a broken cotton swab or a pin to test pain sensation on forehead, check and jaw of each side of face. Ask patient to tell you whether it feels about the same on both sides.

42. II) CRANIAL NERVES EXAMINATION D . CN-V TRIGEMINAL NERVE Facial sensation-

43. II) CRANIAL NERVES EXAMINATION D . CN-V TRIGEMINAL NERVE b. Corneal Reflex (CN-V & CN-VII)- Lightly touch peripheral aspect of cornea from the side with fine wisp of cotton. Look for normal blink reaction of both eyes. Repeat on other side. If response is less than brisk, touch cornea more centrally.

44. II) CRANIAL NERVES EXAMINATION D . CN-V TRIGEMINAL NERVE c. Temporalis and Masseter strength- Ask patient to open mouth and clench teeth. Palpate temporalis and masseter muscles.

45. II) CRANIAL NERVES EXAMINATION E . CN-VII FACIAL NERVE Observe for any facial asymmetry at rest in forehead wrinkles, palpebral fissure width, nasolabial folds or corner of mouth. Ask patient to do the following and note any lag, weakness or asymmetry -Smile -Puff out cheeks -close both lips and resist to open them -close both eyes and resist to open them -raise eyebrows Corneal reflex (see CN-V)

46. II) CRANIAL NERVES EXAMINATION F . CN-VIII ACOUSTIC NERVE Screen hearing Face patient and hold out your arms with your fingers near each ear. Rub your fingers together on one side. Ask patient to tell you when and on which side the rubbing is. Increase intensity as needed, Note any asymmetry.

47. II) CRANIAL NERVES EXAMINATION F . CN-VIII ACOUSTIC NERVE Rinne Test- Use a 256Hz tuning fork, tap on knee or forearm, then hold the base of beating tuning fork on the mastoid process behind the ear. When the patient stops hearing it then place it beside the external auditory meatus in line with the ear canal. In normal hearing air conduction is greater than bone conduction(AC>BC) so the patient will still hear the tuning fork. In conductive deafness there is impairment of conduction and bone conduction is better (BC>AC). In sensorineural deafness the normal pattern is retained AC>BC but both components are reduced compared to the normal ear.

48. II) CRANIAL NERVES EXAMINATION F . CN-VIII ACOUSTIC NERVE 2. Weber’s Test- The base of a vibrating tuning fork is placed on the middle of the forehead or on the top of the head (vertex) and the patient is asked in which ear the sound is loudest in, normally the sound is heard equally in both ears or in the middle. If the sound is heard best in the affected ear then there is unilateral conductive hearing loss on that side as only the vibration transmitted directly through bone to the middle ear ossicles can be heard. In contrast if it is heard best in the good ear then there is sensorineural hearing loss in the affected ear.

49. II) CRANIAL NERVES EXAMINATION G . CN-IX & X ( GLASSOPHARYNGEAL & VAGUS NERVE) Listen to patient’s voice. Note any hoarseness, nasal or breathy quality. Ask patient to say “Ah” and watch movement of soft palate and pharynx. Note any asymmetry of palate elevation. 3. Ask patient to swallow and to cough. 4. In the unconscious or uncooperative patient , test gag reflex. Stimulate back of throat with a cotton swab on each side. Look for gagging after each stimulus.

50. II) CRANIAL NERVES EXAMINATION H . CN-XI SPINAL ACCESSORY NERVE Trapezius- From behind patient, look for atrophy or asymmetry of trapezii. Ask patient to shrug shoulders against resistance and note strength. Ask patient to push head back against resistance and note strength.

51. II) CRANIAL NERVES EXAMINATION H . CN-XI SPINAL ACCESSORY NERVE b. Sternocleidomastoid- Place hand on lower face and ask patient to turn head towards that side against resistance. Observe contraction of opposite sternocleidomastoid.

52. II) CRANIAL NERVES EXAMINATION I . CN-XII HYPOGLOSSAL NERVE Note tongue position at rest in the mouth and on protrusion. Does tongue deviate in either position? Ask patient to stick out tongue and move it from side to side. Note strength and rapidity of movements. Have patient push tongue into each cheek while you push from the outside. Note strength.

53. III) MOTOR FUNCTION ASSESSMENT A . VISUAL INSPECTION Note muscle bulk. Look for generalized of focal muscle wasting or hypertrophy. Look for extraneous movements, e.g. tremors (at rest, with action) fasciculation (muscle twitching). Note speed of movement, e.g. slow to initiate (bradykinesia)

54. III) MOTOR FUNCTION ASSESSMENT B . TONE (muscle tension at rest) Ask patient to relax. Flex and extend patient’s wrists, elbows, ankles and knees. Look for resistance that is decreased (hypotonia) or increased (through out range of motion=rigidity; spring like=spasticity)

55. III) MOTOR FUNCTION ASSESSMENT B . TONE (muscle tension at rest) Ask patient to relax. Flex and extend patient’s wrists, elbows, ankles and knees. Look for resistance that is decreased (hypotonia) or increased (through out range of motion=rigidity; spring like=spasticity)

56. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Isolate muscle you are testing so patient can not use strong muscle that have similar function to compensate for weak one tested. Fix proximal joint when testing distally. E.g.- if testing pronation, fix the humerus so patient can not use shoulder to compensate for weak pronation.

57. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Give yourself the advantage e.g.- when testing deltoid, press on outstretched hand rather than elbow. Have patient walk on heels and toes and do deep knee bend or get out of chair without using arms. Test at least the following muscles on both sides:

58. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Deltoid: abduction (elevation) of upper arm (C5-C6; Axillary nerve) Biceps: flexion of forearm at elbow (C6-C8; Radial nerve) Triceps: extension of forearm at elbow (C6-C8) Extensor carpiradialis: dorsiflexion of hand at wrist (C5-C6; Radial nerve)

59. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Abductor pollicis brevis: palmer abduction of thumb at right angle to palm (C8-T1; Median nerve) Interossei: finger abduction (dorsal) and adduction (palmer) (C8-T1; Ulnar nerve) Iliopsoas: hip flexion (L1-L3; Femoral nerve) Quadriceps: Knee extension (L2-L4; Femoral nerve)

60. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Hamstrings: knee flexion (L5-S2; Sciatic nerve) Tibialis anterior: foot dorsiflexion (L4-L5; deep perineal nerve) Gastrocnemius/Soleus: foot plantar flexion (S1-S2; T ibial nerve)

61. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Assign score of 0-5 for each muscle based on medical research council scale. Note if strength fatigues after sustained muscle contraction.

62. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Assign score of 0-5 for each muscle based on medical research council scale. Note if strength fatigues after sustained muscle contraction.

63. III) MOTOR FUNCTION ASSESSMENT C . STRENGTH AND ENDURANCE Assign score of 0-5 for each muscle based on medical research council scale. Note if strength fatigues after sustained muscle contraction.

64. IV) SENSORY SYSTEM A . GENERAL POINTS Explain each test before you do it. Explain otherwise specified, the patient’s eye should be closed during testing. Test all 4 extremities. Compare side to side and ask if the two sides are about the same. Avoid leading question like “is this sharp?”

65. IV) SENSORY SYSTEM A . GENERAL POINTS Compare distal and proximal areas of the extremities. When you detect an area of sensory loss, map out its boundaries in detail.

66. IV) SENSORY SYSTEM B . VIBRATION Use a 128Hz (low pitched) tuning fork. Lightly strike tines against your hand and place stem of the fork over most distal joint of patient’s great toe. Ask whether patient feels anything and what the sensation is. If vibration is felt, ask when it goes away. Count number of seconds.

67. IV) SENSORY SYSTEM B . VIBRATION Repeat on other side, being sure to strike the fork with about equal force and compare during vibration is felt. If vibration sense is impaired, move proximally one joint at a time until it is felt. Test the fingers in a similar fashion.

68. IV) SENSORY SYSTEM C . JOINT POSITION SENSE Grasp patient’s great toe on side of distal phalanx and hold it away from other toes to avoid friction. Demonstrate to patient what “up” and “down” feel like and tell patient you will move the toe in one of these two directions only. Move toe a few degrees and ask patient to identify direction in which toe was moved.

69. IV) SENSORY SYSTEM C . JOINT POSITION SENSE If position sense is impaired, increase stimulus intensity (move toe a greater distance); if skill impaired, test at more proximal joint (ankle..>..knee..>hip) Test fingers in a similar fashion.

70. IV) SENSORY SYSTEM D . PAIN Use a safety pin or sharp end of a broken cotton swab. Test for a distal gradient of sensory loss in leg by applying stimulus at toes and marching your way up to knee. Ask patient if the sensation is about the same or if it changes as you move up the leg.

71. IV) SENSORY SYSTEM D . PAIN Test for sensory loss in most commonly affected nerve and nerve root distributions. Test the following:- Palmer aspect of index finger (median nerve) Palmer aspect of 5 th finger (ulnar nerve) Web space between great toe and 2 nd toe on dorsal surface of foot (L5) Lateral surface of foot (S1)

72. IV) SENSORY SYSTEM D . PAIN b. Apply stimulus to one and then another of those location in the upper or lower extremity, asking patient if the two areas are about the same. 4. In the patient complaining of sensory symptoms, nerve stimulus from abnormal area to normal area, asking patient to report when stimulus begins to feel stronger.

73. IV) SENSORY SYSTEM E . TEMPERATURE Testing of temperature is usually reserved for the patient in whom testing of pain sensation is abnormal. Press a cold tuning fork against the skin to make sure there is temperature loss in same distribution as pain loss. Use test tubes with hot and cold water and apply the test tube to patient skin and ask whether it is hot or cold.

74. IV) SENSORY SYSTEM F . LIGHT TOUCH Touch the skin lightly with your fingers. Ask patient to respond whenever a touch is felt (e.g. Left arm) Test face arms and legs in random order.

75. IV) SENSORY SYSTEM G . DOUBLE SIMULTANEOUS STIMULATION (test for extinction/tactile neglect) Can be performed only when light touch is intact. Touch both sides of patient’s face or body simultaneously. Ask patient to indicate whether touch is felt on the left, right or both.

76. IV) SENSORY SYSTEM H . GRAPHESTHESIA (Integrative sensation) Can be performed only when light touch in intact. Using a pen cap, paper clip, or your finger, draw a number in patient’s palm or, for more sensitivity on index finger. Ask patient to identify the number.

77. IV) SENSORY SYSTEM I . ROMBERG Have patient stand with feet together and eye open. Have patient close eyes. Hold your arms out to steady/catch patient if necessary. Watch for development of swaying or falling when eyes are closed (Positive Romberg); indicates either impaired proprioception or vestibular dysfunction.

78. V ) ASSESSMENT OF CEREBELLAR FUNCTION 1 . GAIT Have the patient walk heel to toe in a straight line forwards and backwards. Assess for abnormalities such as stiff posture, staggering, wide base of support, lack of arm swing, unequal steps, dragging or slapping of foot, and presence of ataxia (lack of coordination).

79. V ) ASSESSMENT OF CEREBELLAR FUNCTION 2. ROMBERG’S TEST With eyes closed, have the patient stand with feet together and arms extended to the front, palms up. Your patient should be able to maintain their balance. Stay next to the patient when they are performing this test in particular, so if they begin to fall, you can catch them.

80. V ) ASSESSMENT OF CEREBELLAR FUNCTION 3 . ALTENATING PALM SLAP TEST Have your patient rapidly slap one hand on the palm of the other, alternation palm up and then palm down-test both sides. Abnormal findings might be lack of coordination or slow, clumsy movements.

81. V ) ASSESSMENT OF CEREBELLAR FUNCTION 4. THE FINGER TO FINGER TEST To perform, have the patient touch your index finger with their index finger, as you move your index finger in the space around them patient should be able to do this without missing the mark.

82. V ) ASSESSMENT OF CEREBELLAR FUNCTION 5 . THE FINGER TO NOSE TEST To perform, have your patient touch their nose with their index finger of each hand with eyes shut. Patient should be able to do this without missing the mark.

83. V ) ASSESSMENT OF CEREBELLAR FUNCTION 6. THE HEEL TO SHIN TEST While standing, have your patient touch the feet of one foot to the knee of the opposite leg. While maintaining this contact, have the patient run the heel down the shin to the ankle. Test each leg. If your patient misses the mark, lower extremity coordination may be impaired.

84. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 1. Conjunctival reflex- Doctor will touch wisp of the cotton wool to the white portion of the i.e. Bulbar conjunctiva. Response is closer of both eyes.

85. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 2 . Corneal reflex- Doctor will touch the wisp of cotton wool to black portion of eye i.e. cornea closer of both eyes is normal response.

86. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 3 . Palatal and Pharyngeal reflex- Doctor will touch soft palate or post pharyngeal wall with tongue depressor. Doctor will expect a response in the form of coughing.

87. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 4. Abdominal reflex- Ask the patient to lie down his back and flex the knees and relax abdominal muscles. Now blunt end of hammer is moved, radiating away from umbilicus in all directions. While testing this reflex abdominal muscle will show a movement, in the form of the response.

88. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 5 . Plantar reflex Root value of the plantar reflex is L5, S1, S2. Scratch sole of the foot from heel to toe, along lateral border and then medially. This scratching is done with blunt portion of hammer. Perform this on both sides. Normal response is plantar flexion of all toes (Babinski sign).

89. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 6. Cremasteric reflex This is performed in men. The inner aspect of the upper thigh is stroked lightly from below upwards. In the normal male this results in an elevation of the testes on the same side. Its absence may indicate an upper motor neural lesion.

90. VI) ASSESSMENT OF REFLEXES SUPERFICIAL REFLEX 7. Anal reflex or Anal wink A reaction of the external anal sphincter muscle when the adjacent skin is briefly and briskly stimulated. A normal reflex is a contraction of the sphincter also known as anal wink.

91. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX # Jendrassik Maneuver- by this manual, gamma motor neuron discharge is decreased and reflex is obtained properly

92. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 1. Biceps (C5, C6; Musculocutaneous nerve) Patient’s arm should be partially flexed at the elbow with palm down. Place your thumb or finger firmly on biceps tendent. Strike your finger with reflex hammer. You should feel the response even if you can not see it.

93. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 2 . Triceps reflex (C6,C7; radial nerve) If patient is seated; support upper arm and let forearm hang free. If patient is lying down, flex arm at elbow and hold it close to chest. Strike the triceps tendon above the elbow.

94. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 3. Supinator reflex or wrist jerk reflex (C5, C6) Tab is given just above the head of radius. Doctor can see the contraction of brachioradialis muscle.

95. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 3. Supinator reflex or wrist jerk reflex (C5, C6) Tab is given just above the head of radius. Doctor can see the contraction of brachioradialis muscle.

96. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 4 . Knee reflex (L2, L3, L4; Femoral nerve) Have patient sit or lie down with knee flexed. Strike patellar tendon just below patella. Note contraction of the quadriceps and extension of the knee.

97. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 5. Ankle reflex (S1, S2; Tibial nerve) Dorsiflexion foot at ankle. Strike Achilles tendon. Watch and feel for planter flexion at the ankle.

98. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 6 . Test for clonus- (rhythmic oscillations of flexion/extension at the ankle) Support knee in a partially flexed position. With patient relaxed, quickly dorsiflexion foot. Observe for rhythmic oscillations.

99. VI) ASSESSMENT OF REFLEXES B. DEEP TENDON REFLEX 7. Assign grade on scale of 0-4 Deep tendon reflexes are graded on- 0 – no response 1+ – diminished (hypoactive) 2+ - normal 3+ - increased (may be interpreted normal) 4+ - hyperactive (hyperreflexia)