An abnormality in any one pelvic organ may easily produce signs, symptoms, or abnormal findings in another. But it must be remembered that abnormalities of pelvic organs, some of which are very serious, may be absolutely asymptomatic, so during the pelvic examination the physician should take advantage of the opportunity to incorporate any additional important details of the history. The patient should not douche for at least 24 hours prior to the pelvic examination, and it is essential that the patients bladder be emptied immediately prior to the pelvic examination. The dorsolithotomy position is the most practical position, and the knee-chest position may be used when the urethra or the anterior vaginal wall must be carefully inspected.
The mons veneris structure is part of vulva ahead of the public tubercle, richly containing lipid tissue.
The labia majora are usually plump and well formed, in elderly patients the skin of the vulva is atrophic and in some instances, if this condition is exaggerated, it results in shrinking and fibrosis. White, slightly raised plaques are seen commonly in this age group.
In the nonpapous individual, the labia minora lie together in the midline. If there is relaxation or laceration of the perineal muscles, they gape and fall to either side.
The size and development of the clitoris normally may be quite variable. True enlargement of the organ is obvious and represents some type of masculinization. Inflammatory conditions of the clitoris or its prepuce are uncommon but may appear as cellulitis or abscesses.
The tissue of the vestibule between the inner surfaces of the labia minora, of which the clitoris forms the anterior boundary, is the most common site of the granulomatous and ulcerative venereal lesions in younger women and of malignant changes in the elderly. Within the vestibule, the skin is soft and much more delicate than that of the labia majora. It is devoid of hair follicles but does contain sweat and sebaceous glands that may become inflamed or cystic. The lesser vestibular glands and the periurethral glands secrete mucus. These are often involved in acute and chronic gonorrhea, at times they are infected by nonvenereal organisms.
2. internal genitalia
The vagina is a passage between internal and external genitalia. The hymen or hymeneal remnants appear just inside the introitus. In the virgin this structure is quite variable, both in its thickness and in its restriction of the opening of the vagina. It normally will admit one finger. As the fingers are introduced into the vagina, any firmness, induration, or tumefaction of the vaginal walls is noted.
The position, mobility, size, shape, and consistency of the uterus is palpated bimanually. The vagenal fingers should first survey the anterior vaginal fornix. The uterus in its usual position of anteflexion is palpable here. It is normally firm, and softens and become easily compressible in early pregnancy. Irregular enlargement of the uterine body is suggestive of fibroid tumors (leiomyomata). In approximately 20% of women the uterus is normally retrodisplaced. The normal size of uterus in nonpregnant adults is 18.104.22.168cm.
Palpation of the tube, generally referred to as the uterine adnexa, is the most difficult part of the pelvic examination. It should be stated that the normal tube is not palpable. Acute tubal infection invariably involves the ovary.
Palpation of the ovary is also very difficult. The ovary is about 431cm, in size and normally is sensitive to pressure. It is best palpated by the vaginal fingers. It lies deep in the pelvis above the lateral fornix of the vagina. Ovarian tumors may be cystic, solid, or mixtures of both elements. Marked tenderness is a characteristic finding in acute inflammatory change cause by tubo-ovarian infection.
Anus and rectum
The terminal gut is formed by rectum, anal canal and anus. Rectum is approximately 12 to 15 cm in length and extends from the sigmoid colon to the anal canal. The anal canal is approximately 2.5 to 4 cm long and the outlet of anal canal is the anus. The anal verge is the junction between anal and perianal skin. The dentate line is a true mucocutaneous junction located 1 to 1.5 cm above the anal verge. A 6- to 12-mm transitional zone exists above the dentate line, in which the squamous epithelium of the anoderm becomes cuboidal and then columnar epithelium. The columns of Morgagni are 8 to 14 mucosal folds located just above the dentate line that are surrounded by anal crypts. The anorectal ring is 1 to 1.5 cm above the dentate line and is the palpable upper border of the anal sphincter complex. The rectum is behind the prostate in male and behind the uterus and vagina in female.
Most disorders affecting the anorectum can be diagnosed by history and physical examination. Data shows the rectal carcinoma within 7 cm to anus accounts for 42.2%, so examination of anus and rectum is essential to the diagnosis of early rectal carcinoma. Doctors should explain the necessity of the examination to the patients because the patients always feel uncomfortable or nervous during the examination.
(1) the inverted knee-chest position.
This position can be used while examming the prostate.
(2) the left lateral lying position.
Patients can be examined while lying on their left side and it is always used in older patients and female.
(3) the squatting position.
This position is always used to examine hemorrhoids and rectum polyp.
The rectal examination begins with inspection of the perianal area for skin lesions. Pay attention to the skin lesion, ulceration, abscess and so on. The inspection should be made carefully for several abnormalities as follows:
Atresia and stricture of anus: usually seen in congenital deformity.
Trauma and infection of anus: usually causing scar and abscess.
Anal fissure: representing denuded epithelium of the anal canal overlying the internal sphincter. The characteristic presentation is pain and tenderness because of the position below the mucocutaneous juncture.
Hemorrhoids: The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed. Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse. Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external) or both of them (mixed). ①Internal hemorrhoids are a plexus of superior hemorrhoidal veins above the mucocutaneous junction which are covered by mucosa. ②External hemorrhoids occur below the mucocutaneous junction in the tissues beneath the anal epithelium of the anal canal and the skin of the perianal region. ③The mixed hemorrhoids have characters both of internal and external hemorrhoids. Rectal bleeding, protrusion, mucoid discharge may be found in hemorrhoids.
Anorectal fistula: The concept of anorectal fistula is that the two openings of perianal skin and rectum are connected by a hollow tract, usually due to pyogenic infection or, less commonly, to granulomatous disease of the intestine, to tuberculosis or to Crohn’s disease.
Proctoptosis: also named hedrocele, with partial or whole extrophia of rectal wall out of the anus.
Digital rectal and anal examination is easy to carry out, and is important to diagnosis. In addition to palpating for masses or conditions of the anal canal and lower rectal segment, other structures such as the prostate, cervix, coccyx, and the pubococygeus muscle may be felt. Sphincter tone, stenosis of the anal canal, and the presence of blood on the examining finger should be noted. Using a well-lubricated gloved finger, the examiner places the finger on the anus and, while applying gentle pressure, asks that the patient bear down as if having a bowel movement. This maneuver facilitates entry of the finger into the rectum. A normal rectal response includes tightening of the anal sphincter around the finger. The examiner should palpate circumferentially around the length of the fully inserted finger for masses.
Common abnormal changes
extensive tenderness: seen in anal fissure anal infection;
tenderness with cystic feeling: seen in abscess:
soft, smooth, elastic tumor: seen in proctopolypus;
truly firm tumor: seen in rectal cancer;
mucus or blood stain on examining finger: seen in inflammation or invasive disease.
Endoscopic examination is usually anoscopic examination and proctosimoidoscopy. Size, shape, position, bleeding, ulceration and other characters of lesions must be inspected and noted carefully.
Chapter 7 Spine and Extremities
Diseases of spine often present with pain abnormalities of posture or configuration, and limited activity.
Curvature of Spine
Four curvatures including cervical, thoracic, lumbar and sacral vertebrae can be seen in human when observe laterally, characterized as shape “S”. Lateral curvature may not be inspected in normal people.
Kpphosis or gibbus
This condition usually occurs in thoraoispine. The causes as follows are common:
rachitis:It is seen more in children.
Osseous retrogrde degeneration
Others: trauma, dysplasia, or spondylous osteochondritis.
It is divided into three types as scoliosis of thoracic, lumber, and thoracolumbar segment, based on the developing site; or it can be divided into posture and organic scoliosis, based on the nature of the disease.
posture scoliosis: The bending of this type is not fixed, especially on early stage. It will be corrected by changing posture. The common causes are: (a) false posture in maturity of child hood; (b) the unilateral lower extremity is much shorter than the other side; (c) prolapse of intervertebral cartilages; (d) poliomyelitic sequelae.
Organic scoliosis: The character of this condition is that it can not be corrected by changing posture.
Activity of spine
Normal activity: The normal active ranges of cervical and lumbar vertebrae are as follows:
left and right
The common causes of limited activity of cervical vertebrae are: (1) cervicomuscular strain; (2)proliferative arthritis; (3) tuberculosis or cancer; (4) fracture or trauma of cervical vertebrae.
The common causes of limited activity of lumbar vertebrae are: (1) strain of lumbar muscles; (2) proliferative arthritis; (3) tuberculosis or cancer; (4) fracture or trauma of lumbar vertebrae; (5) prolapse of intervertebral cartilages.
Pressing and Percussive Pain
The common causes are tuberculosis of spine, prolapse of intervertebral cartilages, fracture, or trauma
The inspecting methods include direct and indirect percussion. Positive of this sign will indicate some diseases of spine as tuberculosis, fracture, or prolapse of intervertebral cartilages. The percussive pain site usually hints the disease site.
Extremities and articulus
Examination of the extremities is conducted primarily by inspection and palpation. The two methods will be considered together. Normally any two comparable extremities are nearly symmetric. Asymmetry, when present, may be attributed to atrophy, congenital defects, or traumatic deformities.
koilonychia: an abnormality seen in malnutrition, such as iron deficiency anemia.
Acropachy: In this condition the tips of the fingers are bulbous, resembling the ends of drumsticks, and there is excessive curvature of the nails in all directions. The presence of this clubbing finding should prompt a diligent search for disease, such as:
acromegaly: In acromegaly, the hands are large, the fingers broad, and the palms wide. This is termed a spade hand.
Genua varus and valgus: The two conditions may be common in Glissons disease and Kaschin-Becks disease.
Pes varus and pes valgus: commonly seen in congenital defects and central myelitis sequela.
Fracture and abarticulation: These conditions can cause limited movements, tenderness, and redden area.
Pes planus or flatfoot: It is a common deformity and is classified as first-, second-, or third-degree, depending on the amount of relaxation in the plantar arch.
Muscle atrophy: Muscle atrophy may be unilateral or bilateral. Atrophy usually follows lower motor neuron paralysis but may be caused by disuse resulting from previous injury disease.
Varicose veins of lower extremities: Tortuous, dilated, and elongated superficial veins are commonly encountered in adult patients, especially women. They are referred to as varicose veins and may be accompanied, by varicose ulcers and bronze pigmentation termed stasis dermatitis.
Edema: Edema is one of the most common causes of enlargement of the legs. When edema is present, the tissues will pit (indent) if the examiner presses them with his thumb. Edema may be limited to the feet or ankles or may extend to the knees or even the thighs. Bilateral edema in the lower extremities may result from congestive heart failure, portal cirrhosis, nephritis, and pressure on the inferior vena cava caused by ascites or an intra-abdominal tumor mass. Unilateral edema in the lower extremities may result from varicose veins, thrombophlebitis (inflammation of veins), lymphangitis, and enlargement of the regional lymph nodes compressing the femoral veins. Patients who have a hemiplegia often develop edema of the paralyzed leg as the result of stasis cause by disuse.
Unusual Movements and Abnormalities
unusual movements of the upper and lower extremities are in most instances manifest by disturbances of gait, movement tremor, rest tremor, liver flap, and so on (details in Chapter 9).
Normally all the articuli will remain their special conformation and function well unless they are disease. Any joint deformity should be described with regard to its location, general appearance, range of movement, swelling, redness, warmth, tenderness, and crepitation.
Abnomalities of wrist joints are commonly seen in diseases as follows:
tendovaginal synovitis: Soft and nodular changes with tenderness are present in perijoint area. Usually this condition is caused by rheumatoid arthritis or tuberculosis.
Ganglion cyst: more common in dorsal or radialis lateral of the wrist joints. It is often present as nonpainful apophysis.
Tendovaginal fibrolipoma: more common in dorsal surface of the wrist joint. The characteristic presentation is round, nonpainful, soft, movable masses.
Others: parenchyma, fractures, or trauma in or near the wrist joint area, resulting in deformity of the joints.
fusiform joints: The fusiform deformity is a symmetrical change with redness, pain in primary stage, and deformation, unusual movements in advanced stage. It is often seen in rheumatoid arthritis.
Claw hand: clawlike configuration of hands is often present in patients with paralysis of ulnar and median nerves. This deformity is characterized by hyperflexion of the phalangeal joints and metacarpal joints.
Others: Senile arthritis is characterized by firm nodules in distant phalangeal joints.
Asymmmetry of the articulationes genu with redness, swelling, fever, tenderness, and unusual movements are often due to inflammation by acute rhenmatic arthritis. Effusion of cavum articulare can be diagnosed by palpation characteristically as floating patella phenomenon.
Rigdity, hypertrophia, or deformity of joints, and nodular tophi due to irregular bony erosions caused by hyperuricaemia are present in gout. The most commonly involved joints are the great toe, ankle, tarsus, and knee. In 40% it involves more than one joint.
Movement range and tenderness should be detected during the active and passive movement of each joint.
Normal Movement Range
articulationes humeri: Flexion of this joint is about 90 with extension 45 , abduction 90, extorsion 30, and intorsion 80.
Articulationes cubiti: The only movement forms are flexion and extension.
Wrist joints: Extension of this joint is about 40, with flexion about 50-60, abduction 15, and endoduction 30.
Phalangeal joints: Every phalangeal joint can be extended straightly.
Articulationes coxae: Regiones femoris anterior will cling to abdominal wall when this joint is flexed. Otherwise, extension is about 30, with abduction 60, endoduction 25, both extorsion and intorsion 45.
Articulationes genu: Regiones femoris posterior will cling to gastrocnemius when this joint is flexed. Extension movement can be made at 180.
Articulationes talocruralis: Dorsiflexion of this joint is about 35, with downflexion 45, and both extorsion and intorsion 35.
Pain, spasm of muscles, inflammation, adhesion, and diminished movement of involved joints can be caused by diseases of joints, such as infection, gout, fracture, trauma, or dislocation.
Training Manual For The Neurological Examination
The examination of the neurological system includes five main sections: General Examination, Cranial Nerve Examination, Motor System Examination, Sensory System Examination and Reflex Examination.
It mainly checks the state of consciousness(see the detail in the chapter on unconciousness)
2.Cranial Nerve Examination
It checks 12 cranial nerves in sequence.
2.1. Olfactory Nerve(Ⅰ)
In testing olfactory sense,one nostril is occluded while the patient sniffs an unknown substance. Readily available and nonpungent materials such as soap,tabacco, and coffee are used.
2.2 Optic Nerve(Ⅱ)
Cranial Nerve Ⅱ is the optic nerve. There are three main aspects to this nerve: visual acuity, visual fields, and fundi opticus.
Check the visual acuity
When we check visual acuity,we are really checking the vision of the macula
lutea(the yellow spot).Usually we use the nearsighted test in neurology(each eye separately).The distance of the patient’s eye from the printed material should be about 30 cm.
Decrease in vision
The number of fingers
The movement of the fingers
The reaction to the light(if he can not ,the patient is considered to be blind(total loss of vision)
Check the visual fields
A visial field is the maxium scope of vision when the patient is looking
straight ahead. In clinics we usually use gross testing to see if the patient’s visual fields are within normal parameters. Normal visual fields are about 90 temporallly,60 nasally, 60 superiorly, and 70 inferiorly.
Check the optic fundi
The optic fundi should be examined with an ophthalmoscope.
The presence of a sharp disc outline (abnormal: Swelling, edema of the optic disc,optic atrophy)
The presence of spontaneous pulsation of the veins on the disc.
2.3 Oculomotor Nerve(Ⅲ), Trochlear Nerve (Ⅳ) and Abaucens Nerve(Ⅵ)
2.3.1 Eye movements
Cranial Nerves Ⅲ,Ⅳ and Ⅵ supply the muscles of eye movement and are tested as a unit. Eye movements are tested by having the patient’s eyes follow the finger of the examiner while keeping his head stationary. Move the finger laterally from side to side, vertically up and down, left up and down, right up and down when lateral gaze is reached. Inspect for nystagmus and limitation in eye movement. Ask if the patient has double vision.
limitation of the eye’s upward and downward movement
Loss of function of Cranial Nerve Ⅳ results in:
weakness of internal rotation , gaze downward and inward
Loss of function of Cranial Nerve Ⅵ results in:
the eye’s deviation inward ( lateral rectus muscle weakness)
The lateral movement of eyeball is decreased.
2.3.2 Pupillary size and reaction to light
The size of the pupils is compared with each other.The reaction to light is tested by swinging the light beam from the patient’s side onto the pupil and watching for pupillary constriction in the eye being tested(direct light reflex) and in the other eye(consensual light reflex). Normally the pupils constrict quicklly both directly and consensually.
2.3.3 Pupillary reaction to convergence and accommodation reflex
Ask the patient to look at your finger and bring your finger in from a distance of 1 meter to within a few centimeters of he patient’s nose.The eyes should converge and the pupils constrict in a normal person.
2.4. Trigeminal Nerve(Ⅴ)
2.4.1 Trigeminal nerve is divided into three divisions:
The first division, ophthalmic nerve, conducts sensation from the forehead and eye.
The second division, maxillary nerve, conducts sensation from the middle portion of the face and nostrils.
The third division, mandibular nerve, carries sensation from the lower jaw.
Check the sensation of touch and pain ,temperature in the face
Test each area supplied by the three divisions for sensitivity to light touch (cotton), pain (pinprick) , cold and hot water ,comparing bilaterally.
The corneal reflex ,which is mediated through the ophthalmic division, is tested
by touching the cornea lightly with cotton twisted into a point.The cotton should be introduced away from the direction of gaze to minimize blinking.Prompt patial or completed closure of the eyelids bilaterally is the normal response.
2.4.4 Check muscle strength of masseter (motor fibers of trigeminal)
Masseter and temporalis muscle are tested by having the patient close his jaw against resistance of the examiner’s hand placed against the chin with the patient clenching his jaw or chewing. The Pterygoid muscles move the jaw forward and to the contralateral side. In testing these muscles ,the patient moves his jaw to the contralateral side and resists the examiner’s attempt to push it to the opposite side. In pterygoid weakness, the opened jaw tends to deviate to the side of the weak muscles.
2.5.1 Check the movement of facial nerve
The moter portion of the seventh cranial nerve innervates all the facial muscles, the platysma,and the stylohyoid. During the initial interview, the patient’s facial movements have been observed and gross weakness such as inability to smile or close the eyelids will be apparent.The frontalis muscle is tested by asking the patient to look upward and to wrinkle his forehead.To test the orbicularis oculi, the patient closes his eyes tightly and resists the attempt to try them open. The lower facial muscles are tested by having the patient show his teeth, purse his lips, and blow the cheeks out .The platysma is seen to contract when the patient makes a vigorous effort to show his teeth.
Lesions of the corticobulbar tracts at any point above the facial nucleus will produce contralateral lower facial weakness with sparing of the forehead movement because of bilateral cortical representation of upper facial muscles.
In nuclear or peripheral seventh nerve lesions, the entire facial musculature on the same side is weak.
Check the sense of taste
The sensory portion mediates taste from the anterior two-thirds of the tongue.The sensation of taste is tested with sodium chloride(salty),sugar(sweet),quinine(bitter) and vinegar (sour).The patient protrudes his tongue, which must be moist,and with a wet applicator one of these substances is gently rubbed on one side of the tongue.The patient is instructed not to withdraw the tongue until he identifies the substance as sweet,sour, bitter, or salty.
2.6 Vestibulocochlear Nerve(Ⅷ)
Auditory acuity can be tested crudely by rubbing thumb and forefinger together about 2 inches from each ear. If there are complaints of deafness or if the patient cannot hear the finger rub, proceed to the following tests.
2.6.1 Rinne Test
Hold the base of a lightly vibrating high-pitched (512Hz)tuning fork on the mastoid process until the sound is no longer perceived, then bring the still vibrating fork up close to the ear. Normally—or if the hearing loss is sensorineural—air conduction is greater than bone conduction and the patient will again hear the tone. If there is significant conductive loss, the patient will not be able to hear the air-conducted tone longer than the bone-conducted tone.
2.6.2 Weber Test
Lightly strike a high-pitched(512Hz)tuning fork and place the handle on the midline of the forehead.If there is conductive loss, the tone will sound louder in the affected ear;if the loss is sensorineural, the tone will be louder in the unaffected ear.
2.6.3 Vestibular Funtion
Vestibular funtion needs to be tested only if there are complaints of dizziness or vertigo or evidence of nystagmus.
2.7 Glossopharyngeal Nerve(Ⅸ), Vagus Nerve(Ⅹ)
Some useful tests for detectiion of deficiencies in motor funcuion of the palate,pharynx, and larynx are described below.Sensory function needs to be checked if one suspects cranial neuropathy or a brain stem lesion.
2.7.1 Palatal Elevation
Ask the patient to say "ah." Look for full and symmetric palatal elevation.If one side is weak, it will fail to elevate and will be pulled toward the strong side.
2.7.2 Gag reflex (afferent Ⅸ,efferent Ⅹ)
Gently touch each side of the posterior pharyngeal wall with a cotton swab and compare the vigor of the gag.
2.7.3 Sensory funtion
Lightly touch each side of the soft palate with the tip of a cotton swab.
2.7.4 Voice Quality
Listen for hoarseness or "breathness", suggesting laryngeal weakness.
2.8 Accessory Nerve(Ⅺ)
Press a hand against the patient's jaw and have the patient rotate the head against resistance. Pressing against the right jaw tests the left sternocleicomastoid and vice versa.
Have the patient shrug shoulders against resistance and assess weakness.
2.9 Hypoglossal Nerve(Ⅻ)
The hypoglossal nerve supplies extrinsic and intrinsic muscles of the tongue. Atrophy of one side of the tongue,fasciculations, and deviation of the protruded tongue toward the atrophied side indicate a lesion of the hypoglossal nucleus or nerve. Strength of the tongue is estimated by the amount of force exerted as the tongue is pressed laterally against a wooden blade.
3. Motor System Examination
This includes 6 aspects; myotrophy, involuntary movement, muscle tone, muscle
strength, coordination, gesture and gait.
Observe the patient’s muscle size(atrophy or hypertrophy). If atrophy is present or suspected, the circumference of limbs should be measured bilaterally; record the point at which the measurement is taken.
3.2 Involuntary movement
Observe if there is any involuntary movement.
Resting tremor(4-6 per second)
Choreic movements----irregular, spontaneous movements usually involving more than one joint.
3.3 Muscle tone
Tone is defined as resistance of muscle to passive movement at a joint.Tone can be decreased, normal, or increased. The hardest part of evaluating tone is getting the patient to relax.Check muscle resistance to passive movement of the upper limbs and the lower limbs by flexion and extention at the elbows,wrists, and shouldrs or at knees and ankles.Palpate muscle tone.
3.4 Muscle Strength
Strength is measured by the ability to contract the muscle against force or gravity. The classic grading system scores as follows:
1, palpable contraction but little visible movement;
0, no contraction.
Ask the patient to perform flexion and extension of every joint against resistance given by examiner. Pay particular attention to the relative strength of the sides and the differences between proximal and distal groups. Special attention shoud be paid to any area that strength of dorsiflexion and plantar or the feet, extension and flexion of the wrist and forearm, and abduction of the shoulders.
Musculus triangularis strength
Flexor carpi muscle and extensor carpi muscles strength
Strength of the flexor muscle of the fingers
Strength of the palmar intercoatales musculi
Strength of the dorsal intercostales musculi
Strength of the musculus iliopsoas
Strength of the musculus quadriceps
Strength of the musclus femoris posterior
Strength of the musclus tibialis anterior
Strength of the musclus gastrocnemius
Strength of the musclus extensor hallux
Strength of the musclus flexor hallux
This examine cerebella function.
Rapid and repeated movement
Tandem gait test
Every patient must be observed standing and walking.Standing, starting to walk, stopping, and turning should each be assessed and the associated movements of the limbs noted with each maneuver.
4. Sensory System
This can be divided into examination of superficial sensation, deep sensation and combined sensation.Sensory testing is usually done with patient’s eyes closed. Compare the sensation of the two sides and the differences between proximal and distal areas.
4.1 Superficial sensation
Examine pain sensation
The skin is usually touched in an irregular fashion either with the sharp end of the pin or the dull head, and the patient responds with “sharp” or “dull.”
Examine temperature sensation
For temperature testing, one test tube is filled with cold water ane another with warm water.The patient responds with either “cold” or “warm”
The patient’s ability to detect small passive movements is tested by holding a finger or toe between the examiner’s fingers.The digit is moved up or down irregularly and the patient responds with “up”,”down”,or “I don’t know”.
Examine position sensation
Examine vibration sensation
Placeing a tuning fork over bone mechanically intensifies the stimulus.Usually the vibrating fork is placed over the sternum,elbows,fingers, iliac crest,knees, ankles, and toes and determine whether the patient can feel the vibration.
4.3 Combined Sensation
Two point distinction (discrimination):A pair of calipers or a compass with dull points is used to test two-point discrimination.
One point sensation of two opposite stimuli (Bilateral simultaneous stimulation)
5. Reflex System
Reflexes are graded as follows;
(-) absence of the reflex
(+) hypoactive without movement of the joint; may be normal or abnormal
(++) physiological or normal
(+++) hyperactive without clonus, may be normal or abnormal
(++++) hyperactive with transient clonus
(+++++) markedly hyperactive with sustained clonus; it is pathological