CD 2201 INTRODUCTORY DIAGNOSIS LAB OUTLINE # 1

NEUROLOGICAL:
Bates' 10th pg 663, 696 - 704
A. Student presentation of deep tendon and superficial reflex testing, the plantar
response and clonus pg 590-596;
1. General procedure:
Patient must be relaxed.
Position the limbs properly and symmetrically
Strike the tendon briskly, using a rapid wrist movement
(quick and direct)
Use the pointed end for striking small areas or the flatt ened
over larger areas to give the patient less discomfort
Hold the hammer between our thumb and index finger so
that it swings freely within the limits set by your palm and
other fingers
Always note the speed, force and amplitude of the reflex
response and compare one side with the other
Reflex grading from 0 to 4+
Know the segmental levels of each reflex
If reflexes are symmetrically absent, use of the Jendressik
manoeuvre Reinforcement, a technique involving
isometric contraction of other muscles that may increase
reflex activity.
2. Upper extremity reflexes: biceps, triceps and brachioradialis
3. Lower extremity reflexes: patellar and achilles
4. The Plantar Response: With an object such as the metal end of the reflex
hammer, stroke the lateral aspect of the sole from the heel to the ball of the foot,
curving medially across the ball. Use the lightest stimulus that will revoke a
response, but be increasingly firm if necessary. Toes would normally move into
flexion. Normal response: toes are downgoing.

5. Superficial Reflexes:
i) Abdominal: (SAR)
use the metal end of the reflex hammer to lightly but briskly stroke each quadrant
of the abdomen from lateral to medial (pg. 593). Note contraction of the abdominal
muscles and umbilical movement towards the stimulus. Obesity may mask this
movement and may require digital retraction of the patients umbilicus away from
the side to be stimulated.
ii) Cremasteric:
Slightly stroke the medial aspect of the proximal ipsilateral thigh starting at the
inguinal ligament and go down a few inches. Watch for elevation of the ipsilateral
testes and scrotum (use manikin).
iii) Anal Wink
Use a dull object, such as a cotton swab or metal end of the reflex hammer and
stroke outward in the four quadrants from the anus. Watch for contraction of the
anal musculature (use manikin).
B. Student presentation of pathological reflexes;
1. Babinski Response: is present when there is dorsiflexion of the big toe with
fanning of the other toes during Plantar Response testing. Toes are upgoing.
2. Hoffmans sign: the examiner flicks the distal phalange of the 3rd finger in
extension. Observe for the index finger and thumb to flex in an upper motor neuron
lesion case.
Dynamic Hoffman's sign: have the patient extend the neck multiple times and then
flick the distal phalange of the 3rd finger while holding the proximal end and
observe for flexion of the thumb and index finger.
3. Clonus: Tested when reflexes are hyperactive. Support the knee in a partly
flexed position. Passively plantar flex and dorsiflex the foot a few times while
encouraging the patient to relax. Then sharply dorsiflex foot and maintain it in
dorsiflexion. Look for rhythmic oscillations between dorsiflexion and plantar
flexion (a few beats may be normal).
Can also be performed at the knee by producing a sharp downward
displacement of the patella with the knee in extension. Look for rhythmic
movements of the patella.
C. Instructive feedback:
D. Practice: