Physical examination
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Physical examination

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    Physical examination Physical examination Presentation Transcript

    • PHYSICALEXAMINATIONwww.drjayeshpatidar.blogspot.com
    • Objectives of Health AssessmentDescribe prehospital physicalexamination techniquesDescribe examination equipmentDescribe the general approach to thephysical examinationOutline the steps of the comprehensivephysical examinationwww.drjayeshpatidar.blogspot.in
    • ObjectivesDetail the components of the mentalstatus examinationIdentify abnormal findings in the mentalstatus examinationOutline steps in the general patientsurveyDistinguish between normal andabnormal findings in the general surveywww.drjayeshpatidar.blogspot.in
    • ObjectivesDescribe examination techniques forspecific body regionsIdentify normal and abnormal findings inthe body region examinationDescribe examination techniques specificto children and older adultswww.drjayeshpatidar.blogspot.in
    • Health AssessmentComponent of Health assessmentHealth HistoryPhysical assessmentwww.drjayeshpatidar.blogspot.in
    • PurposesEstablish a nurse- client relationship.Gather data about the client‟s general healthstatus, integrating physiologic, psychological,cognitive, socio cultural, development andspiritual dimensions.Identify client‟s strengths.Identify actual and potential health problem.Establish a base for the nursing process.To evaluate the physiological outcome of care.www.drjayeshpatidar.blogspot.in
    • Techniques of Physical Examinationwww.drjayeshpatidar.blogspot.in
    • Health HistoryHealth history is a collection of subjectiveand objective data that provide a detailedprofile of the client‟s health status.www.drjayeshpatidar.blogspot.in
    • History TakingIDENTIFICATION DATA OF THE PATIENTPatients name:-Age: - Sex-Hospital Name:-File No./MLC No.:-Source providing history:-Date/ Time of admission-www.drjayeshpatidar.blogspot.in
    • OPD No.:-IPD No.:-Ward-Bed No.:-Doctor‟s Unit:-Provisional Diagnosis-Surgery done/Date of Surgery:-Name of the Surgery:-Residential Address-www.drjayeshpatidar.blogspot.in
    • Mother Tongue:-Marital Status-Educational Status: -Occupation-Monthly incomewww.drjayeshpatidar.blogspot.in
    • DETAILS OF ADMISSION:-Arrived via wheel chair / stretcher /ambulatory: -LOC – Conscious / Semiconscious /UnconsciousFrom admitting room / emergency room.home / any others:-www.drjayeshpatidar.blogspot.in
    • ORIENTATION TO THE UNIT:-Use of telephone / TV / call lights:-Visiting hours:-No Smoking:-Patient is informed that hospital is notresponsible for the personal belongings: -Yes/NoValuable handed over to (Write relationshipWith patient)Written consent:-www.drjayeshpatidar.blogspot.in
    • BASELINE DATAWeight:- Height:- Abdominal Girth:-Temperature: - Oral: -Axilla: - Rectal:-Respiration:-Pulse: -Blood Pressure:-www.drjayeshpatidar.blogspot.in
    • REASON FOR ADMISSION(Onset, duration, earlier treatments)ALLERGIES AND MEDICATIONSDrugs / Foods / dyes / Others:-Sign and symptoms:-www.drjayeshpatidar.blogspot.in
    • VICESAlcohol/ Tobacco/Cigarette/Drug Abuse:-Amount of intake/Day:Duration of intake (Since when) andfrequency of intake (How often in a day?):-www.drjayeshpatidar.blogspot.in
    • LEISURE ACTIVITIES /RECREATIONALACTIVITIES (IN HOSPITAL)PATIENTS ROUTINES HABITS (INHOSPITAL)www.drjayeshpatidar.blogspot.in
    • FAMILY INFORMATION-Name of Family Members-Relationship with patient-Age-Type of Family-Education-Occupation-Marital Status-Health Statuswww.drjayeshpatidar.blogspot.in
    • Family Income per Year:Family interpersonal relationship / AnyFamily Disharmony:-Family History of illness: (Hypertension,DM, Cancer, Arthritis, etcwww.drjayeshpatidar.blogspot.in
    • ENVIRONMENTAL BACKGROUND1) HOUSINGType of house:-Lighting :-Ventilation:-Water facilities:-Sanitation:-2) PETS/ANIMALS3) FOOD HYGIENE PRACTICES:4) PERSONAL HYGIENE PRACTICES:www.drjayeshpatidar.blogspot.in
    • 5) COMMUNITY RESOURCESa) Transport: -b) Health facilities:-c) Educational Facilities :-PAST MEDICAL HISTORYHypertension, DM, Cancer, Respiratory,Arthritis, stroke and others:PAST SURGICAL HISTORYPRESENT MEDICAL HISTORY;-www.drjayeshpatidar.blogspot.in
    • CURRENT MEDICATION:-Current MedicationDose/FrequencyRouteLast Dose TakenLABORATORY/OTHER INVESTIGATION:-DateInvestigations NameNormal FindingsPatient’s Findingswww.drjayeshpatidar.blogspot.in
    • SPECIAL ASSISTIVE DEVICESWheel Chair / Braces / Crutches /Walkers / others:-Contact lenses / Hearing aid / Prosthesis /Glasses:-Dentures:- Total / Partialwww.drjayeshpatidar.blogspot.in
    • PSYCHOSOCIAL HISTORYAny recent stress?Who is with the patient in the hospital?Does the patient have anybody who willgive financial support if needed?Who will care for the patient at home?Calm: Yes / NoAnxious: Yes / Nowww.drjayeshpatidar.blogspot.in
    • Skills of Physical AssessmentInspectionPalpationPercussionAuscultationOlfactionwww.drjayeshpatidar.blogspot.in
    • InspectionVisual assessment of the patient andsurroundingsFindings that may be significant:– Patient hygiene– Clothing– Eye gaze– Body language– Body position– Skin color– Odor .www.drjayeshpatidar.blogspot.in
    • Nurse observe body partPay attention to client, watching allmovement & looking carefully at any bodypart.It help to know physical characteristics.Quality of inspection depend on thenurse‟s willingness to spend time during ajob.www.drjayeshpatidar.blogspot.in
    • If the emergency response was to thepatients home, make a visual inspectionfor– Cleanliness– Prescription medicines– Illegal drug– Weapons– Signs of alcohol usewww.drjayeshpatidar.blogspot.in
    • PrinciplesMake sure good lighting is available.Position and expose body parts so that allsurface can be viewed.Inspect each area of size, shape,colour,symmetry, position and abnormalities.If possible, compare each area inspected withthe same area on the opposite side of the body.Use additional light to inspect body cavities.Do not hurry inspection. Pay attention to detail.www.drjayeshpatidar.blogspot.in
    • PalpationA technique in which the hands and fingers areused to gather information by touch.Palmar surface of fingers and finger pads areused to palpate for– Texture– Masses– Fluid--And assess skin temperatureClient should be relax and positionedcomfortably because muscle tension duringpalpation impair its effectiveness.Asking the patient to take deep & slow breath.www.drjayeshpatidar.blogspot.in
    • Types of PalpationLight palpationDeep palpationBimanual palpationwww.drjayeshpatidar.blogspot.in
    • Light PalpationThe nurse apply tactile pressure slowly,gentely and deliberately.The nurse‟s hand is placed on the part tobe examined and depressed about 1-2cm.www.drjayeshpatidar.blogspot.in
    • Deep PalpationIt is done after light palpation.It is used to detect abdominal masses.Technique is similar to light palpationexcept that the finger are held at a greaterangle to the body surface and the skin isdepressed about 4-5 cm.www.drjayeshpatidar.blogspot.in
    • Bimanual PalpationIt involve using both hand to trap astructure between them. This techniquecan be used to evaluate spleen, kidney,breast, uterus and ovary.Sensing hand – Relax & place lightly overthe skin.Active hand – Apply pressure to thesensing hand.www.drjayeshpatidar.blogspot.in
    • Deep Bimanual Palpationwww.drjayeshpatidar.blogspot.in
    • PercussionPercussion involve tapping the body with thefingertips to evaluate the size, border andconsistency of body organs and todiscover fluid in body cavity.www.drjayeshpatidar.blogspot.in
    • PercussionUsed to evaluatefor presence of airor fluid in bodytissues– Sound wavesheard aspercussion tones(resonance)www.drjayeshpatidar.blogspot.in
    • Methods of PercussionMediate or Indirect PercussionImmediate PercussionFist Percussionwww.drjayeshpatidar.blogspot.in
    • Mediate or Indirect Percussion It can be performed by using the fingeron one hand as a plexor (Striking finger)and the middle finger of the other hand asa pleximeter (the finger being struck). Used mainly to evaluate the abdomen orthorax.www.drjayeshpatidar.blogspot.in
    • Immediate PercussionUsed mainly to evaluate the sinus or aninfant thorax.It can be performed by striking the surfacedirectly with the fingers of the hand.www.drjayeshpatidar.blogspot.in
    • Fist PercussionUsed to evaluate the back and kidney fortenderness.It involves placing one hand flat againstthe body surface and striking the back ofthe hand with a clenched fist of the otherhand.www.drjayeshpatidar.blogspot.in
    • Sounds Produced by PercussionSound : TympanyIntensity : LoudPitch : HighDuration : ModerateQuality : DrumlikeCommon location : Air containing space,enclosed area, gastric air bubble, Puffed out cheekwww.drjayeshpatidar.blogspot.in
    • Sounds Produced by PercussionSound : ResonanceIntensity : Moderate to LoudPitch : LowDuration : LongQuality : HollowCommon location : Normal lungswww.drjayeshpatidar.blogspot.in
    • Sounds Produced by PercussionSound : Hyper ResonanceIntensity : Very LoudPitch : Very LowDuration : Longer than resonanceQuality : BoomingCommon location : Emphysematous lungswww.drjayeshpatidar.blogspot.in
    • Sounds Produced by PercussionSound : DullnessIntensity : Soft to moderatePitch : HighDuration : ModerateQuality : ThudlikeCommon location : Liverwww.drjayeshpatidar.blogspot.in
    • Sounds Produced by PercussionSound : FlatnessIntensity : SoftPitch : HighDuration : ShortQuality : FlatCommon location : Musclewww.drjayeshpatidar.blogspot.in
    • AuscultationAuscultation is listening to sound produce by thebody.Through auscultation the nurse note thefollowing characteristics of sound. Frequency or the number of oscillationgenerated per second by a vibrating object. Loudness – Loud or soft Quality – Blowing or Gurgling Duration – Length of time that sound vibrationlast. Short / medium / long.www.drjayeshpatidar.blogspot.in
    • AuscultationBest performed in a quiet environmentRequires a stethoscope– Body sounds produced by movement of fluids orgases in patients organs or tissuesNote:– Intensity– Pitch– Duration– Qualitywww.drjayeshpatidar.blogspot.in
    • StethoscopeUsed to evaluate sounds created bycardiovascular, respiratory,and gastrointestinal systemsPosition stethoscope betweenindex and middle fingerswww.drjayeshpatidar.blogspot.in
    • OlfactionWhile assessing a client, the nurseshould be familiar with the nature andsource of body odors.www.drjayeshpatidar.blogspot.in
    • Preparation for ExaminationInfection control : If patient have anyopen skin lesions and any drainage. Nursehas to maintained infection control andavoid infection.- use gloves- use apron- use mask- use gownwww.drjayeshpatidar.blogspot.in
    • EnvironmentPrivacyWell equipped examination roomAdequate lightingSound proofed roomComfort environmentExamination tablewww.drjayeshpatidar.blogspot.in
    • EquipmentAll necessary equipments for procedure.www.drjayeshpatidar.blogspot.in
    • Physical preparationBladder and Bowel eliminationDraped properlyDressed properlyPositioningwww.drjayeshpatidar.blogspot.in
    • Psychological preparationExplain procedureIf both are opposite sex then third personis necessary.Observe facial expressionClient should free from anxious feeling.Clarify client doubt.www.drjayeshpatidar.blogspot.in
    • General examination1.Gender and race :Example – Skin cancer is 20% higher inwhite than black people. Prostate canceris higher in African American than whiteAmerican.2. Age : old age people and childrens aremore prone to get infection.www.drjayeshpatidar.blogspot.in
    • 3. Signs of distress :Pain, Difficulty in breathing4. Body type : Thin, Fat5. Posture : Standing. Upright position,Knee flexed6. Gait : Co-ordination proper or not, personnormally walk with the arms swingingfreely at the sides, with the head and faceleading the body.www.drjayeshpatidar.blogspot.in
    • 7. Body movement :- Movement are purposefully.- If any part is immobile.8. Hygiene and grooming :- Personal hygiene maintain or not.- Cosmetic used or notwww.drjayeshpatidar.blogspot.in
    • 9. Dress : culture, life style, socio economicstatus. It should be appropriate accordingto weather condition.10. Body odor :- Unpleasant odor- Poor hygiene- Bad breath- Poor oral hygienewww.drjayeshpatidar.blogspot.in
    • 11. Affect and mood :- Feeling‟s to other- Emotionally expression- Mood appropriate as per situation12. Speech :Pressure, tone, speed.www.drjayeshpatidar.blogspot.in
    • 13. Client abuse : any problem duringgrowing and serious health problem duringchildhood.14. Substance abuse :- Drugs- Alcohol- Smoking- Ganjawww.drjayeshpatidar.blogspot.in
    • Vital signsTemperaturePulse rateRespiratory rateBlood pressurewww.drjayeshpatidar.blogspot.in
    • Temperature MeasurementOral temperatureHold thermometerfirmly under tongueTell child to “kiss”Caution to avoidbiting www.drjayeshpatidar.blogspot.in
    • Axillary TemperatureHold arm downfirmlyShould beapproximately 1 Fless than coretempwww.drjayeshpatidar.blogspot.in
    • Rectal TemperatureRisk of perforationAvoid inuncooperative, orimmuno-suppressedpatientStabilizethermometerwww.drjayeshpatidar.blogspot.in
    • PulseRateRhythmQualityConsider ECG monitoringwww.drjayeshpatidar.blogspot.in
    • RespirationsAdult rate– 16-24 breaths per minuteObserveFeel for chest movementAuscultatewww.drjayeshpatidar.blogspot.in
    • Blood PressureLocationswww.drjayeshpatidar.blogspot.in
    • Blood Pressure CuffSphygmomanometerMeasures systolicand diastolic bloodpressureManual or electronicwww.drjayeshpatidar.blogspot.in
    • AnthropometryHeightWeightAbdominal girthMid arm circumferencewww.drjayeshpatidar.blogspot.in
    • Height and BuildDescriptions include:– Average, tall, short, lanky ( long & thin ),muscularMay also be affected by age and lifestylewww.drjayeshpatidar.blogspot.in
    • WeightObserve general appearance– Obese to emaciatedRecent changes may be key finding– Recent weight loss or gainwww.drjayeshpatidar.blogspot.in
    • Head to toe ExaminationHair: Hair type :Terminal Hair : long, thick, found on axillaand pubic area.Vellus Hair : small, soft, found all overbody except palm or sole.www.drjayeshpatidar.blogspot.in
    • Colour:Distribution:Quantity:Shiny:Dry:Curly:Using dye:Alopeciawww.drjayeshpatidar.blogspot.in
    • Bittle hairWith puberty hair colour, distribution andamount change.HirsutismLubrication of hairwww.drjayeshpatidar.blogspot.in
    • ScalpUnusual scalpLesionsLumpTraumaMoleLicewww.drjayeshpatidar.blogspot.in
    • DandruffReaction with shampooWigUsing chemical for pediculosis treatmentUsing chemical to colorwww.drjayeshpatidar.blogspot.in
    • Fore HeadLesionsMarkHead injurywww.drjayeshpatidar.blogspot.in
    • EyesVisual activity:Visual field:Eye movement:Eye structure:Shape:Symmetry:Reactive to lightRedness and swellingEye chart reading ( snellen‟s chart )www.drjayeshpatidar.blogspot.in
    • Discharges:Eye alignment:Eye brows:Eye lids:Use of glasses or contact lenses:Corneal reflexLacrimal functionOphthalmoscope used to see anyabnormalities in eyeswww.drjayeshpatidar.blogspot.in
    • EarsStructure:Symmetry:Obstruction:Position and alignment:Size:www.drjayeshpatidar.blogspot.in
    • Shape:Discharge:Inflammation:Hearing AID:Otoscope is used to see internal earstructureHearing activity:Weber‟s test:Rinne test:www.drjayeshpatidar.blogspot.in
    • NoseShape:Size:Lesions:Inflammation:Deformity:Edema:www.drjayeshpatidar.blogspot.in
    • Mucus colour:Patency of Nair:Epistaxis:Discharge:Polyp‟s:DNS:Pen light and nasal speculum is used tosee nosewww.drjayeshpatidar.blogspot.in
    • SinusFrontal sinusMaxillary sinuswww.drjayeshpatidar.blogspot.in
    • LipsColour:-Cherry :carbon-monoxide poisoning-Pallor: Anemia-Cyanosed: Respiratory or cardiac problemwww.drjayeshpatidar.blogspot.in
    • DrynessSmoothnessCrack lips With mouth closed the nurseview the lips from end to end.Remove lipstick before examination of lips.www.drjayeshpatidar.blogspot.in
    • TeethArrangement:Dental hygiene:Loose teeth:Colour of teeth:Halitosis:Dentureswww.drjayeshpatidar.blogspot.in
    • Upper molar should rest directly on thelower molar with upper incisors slightlyoverriding the lower incisors.Dental caries – discoloration of the enamelwww.drjayeshpatidar.blogspot.in
    • GumsColour:Edema:Gingivitis:Ulcer:Healthy gums are pink, smooth and moist.Spongy gums bleed easily ( vit-cdeficiency )www.drjayeshpatidar.blogspot.in
    • Oral mucosaColor: Pinkish redmoist/dry:Ulcer:Lesion:Leuckoplakia: thick white patches becauseof smoking and alcohol.www.drjayeshpatidar.blogspot.in
    • TongueThe client first relax the mouth and sticks thetongue out halfway.Slightly rough on the top surface and smoothalong the lateral margin.Under surface of the tongue and floor of themouth are highly vascular.Observe for cyst, lesions, swelling and noduleon the back side of tongue.Examination of tongue : Protrude the tongue,grasp the tip and gently pulls it to one side.www.drjayeshpatidar.blogspot.in
    • Movement:Shape:Ulcer:Lesions:Protrude of tongue:Taste of tongue:Colour:Moist:Glossitis:www.drjayeshpatidar.blogspot.in
    • PalateExtend the Head backward and open the mouthand inspect hard palate & soft palateHard palate: Anterior part of palateShape: Dome shapeColour: WhitishSoft palate: Posterior part of palateShape: „C” shapeColour: Light pinkwww.drjayeshpatidar.blogspot.in
    • PharynxProcedure : Extend his neck slightly, openthe mouth widely and say „ah‟. Placetongue depressor on the middle third oftongue. Use penlight for inspection.Inspect for edema, ulcer, inflammation,lesions.Gag reflexDysphagiawww.drjayeshpatidar.blogspot.in
    • NeckExamine the anatomical position of neck.Function of sternocleidomastoid muscle :the nurse ask the client to flex the neckwith the chin to the chest.Function of the trapezius muscles :movement of the head sideway so that theear moves toward the shoulder.Neck should move freely without any pain.www.drjayeshpatidar.blogspot.in
    • Movement of neck :Stiff ness:Swelling:Neck muscle:ROM:Lymph nodes : With the client‟s chin raisedand head tilted slightly, the nurse firstinspect the area where lymph nodes aredistributed.Inspect for size, shape, inflammation andmobility.www.drjayeshpatidar.blogspot.in
    • Thyroid glandIt lies anterior lower neck, in front of neck andboth side of trachea.Inspect for visible mass of thyroid gland,symmetry and fullness at the base of neck.Give water then see for bulging of the gland.Palpation : Client flex the neck forward andlaterally toward the side being examined. Theclient hold a cup of water and take a sip toswallow.www.drjayeshpatidar.blogspot.in
    • Anterior Part : using the pads of the indexand middle finger, the nurse palpate theleft lobe with the right hand and right lobewith left hand.Posterior Part : Both hand of the nurse arekeep around the neck with two finger ofeach hand on the side of trachea.www.drjayeshpatidar.blogspot.in
    • BreastFemale:– Symmetry– Pain:– Lump:– Discharge:– Swelling:– Trauma:– History of breast disease:– Surgery:www.drjayeshpatidar.blogspot.in
    • Male:-Lump:-Swelling:- Gynecomastiawww.drjayeshpatidar.blogspot.in
    • Thorax & LungThorax size:Thorax shape:Chest movement:Respiratory rate:Rhythm:Breathing pattern:www.drjayeshpatidar.blogspot.in
    • Breathing sound:Chest pain with breathing:Cough:Productive & Nonproductive:Hemoptysis:www.drjayeshpatidar.blogspot.in
    • Cardio vascular systemApical pulse: To find the apical pulse the nurselocate the 5th ICS just to the left to the sternumand move the fingers laterally, just medial to theleft mid- clavicular line.Redial: Rt…………….. Lt…………….Heart rate:Rhythm:www.drjayeshpatidar.blogspot.in
    • Perfusion:Edema: because of heart failureSite of edema:Cyanosis or Pallor: Because of MIFatigue: Because of decrease cardiacoutputwww.drjayeshpatidar.blogspot.in
    • Gastro- intestinal systemAbdomenSize:Shape:Abdomen distention:Surgical mark:www.drjayeshpatidar.blogspot.in
    • Stool frequency / Character:Last movement :Ostomy present:Bowel soundwww.drjayeshpatidar.blogspot.in
    • Reproductive systemUrinary complain:Discharge:Anuria:Haematuria:Dysuria:Urinary Incontinence:Urinary Retention:www.drjayeshpatidar.blogspot.in
    • Urine last voided:Catheter present:Any other:Male– Opening of penis:– Penile Discharge:If „Yes‟ describewww.drjayeshpatidar.blogspot.in
    • Female-LMP:-Vaginal discharge:-If „Yes‟ describewww.drjayeshpatidar.blogspot.in
    • SkinColour:Rashes:Lesion:Surgical scar:Abnormal growth:Secretion:If „Yes‟ then describe:www.drjayeshpatidar.blogspot.in
    • MusculoskeletalROM:Weakness / paralysis / contracture / jointswelling / pain /other:Extremity strength:www.drjayeshpatidar.blogspot.in
    • Wrist ExtensionFlexionwww.drjayeshpatidar.blogspot.in
    • Elbow FlexionExtensionwww.drjayeshpatidar.blogspot.in
    • Shoulder AbductionAdductionwww.drjayeshpatidar.blogspot.in
    • KneeExtensionKneeFlexionwww.drjayeshpatidar.blogspot.in
    • DorsiflexionPlantarflexionwww.drjayeshpatidar.blogspot.in
    • SpineCurvature of spine observe for:Lordosis: Increase lumber curvatureScoliosis: Lateral spinal curvatureKyphosis: Exaggeration of posteriorcurvature of thoracic spinewww.drjayeshpatidar.blogspot.in
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    • Mental statusMemory:Knowledge:Thinking:Judgment:Insight:www.drjayeshpatidar.blogspot.in
    • Neurological ExaminationOrientation – To place / person / timeLevel of conscious - confused / alert /restless / lethargic / comatoseCo-ordination to walk:Equilibrium test:Sensation test: PainTemperatureVibrationTouchwww.drjayeshpatidar.blogspot.in
    • Romberg Testwww.drjayeshpatidar.blogspot.in
    • Pronator Drift Testwww.drjayeshpatidar.blogspot.in
    • ReflexesBiceps:Triceps:Patellar:Achilles:Planter:Gluteal:www.drjayeshpatidar.blogspot.in
    • BicepsIdentify biceps tendon have patient flexelbow against resistance while you palpateantecubital fossaPlace arm so it‟s bent ~ 90 degreesPlace one of your fingers on tendon andstrike it.Reflex : Flexion of arm at elbow.www.drjayeshpatidar.blogspot.in
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    • TricepsFlex client‟s arm at elbow, holding armacross chest or hold upper armhorizontally. Strike triceps tendon justabove elbow.Reflex : Extension at elbow.www.drjayeshpatidar.blogspot.in
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    • PatellarHave client sit with leg hanging freely overside of table. Tap patellar tendon justbelow patella.Reflex : Extension of lower leg.www.drjayeshpatidar.blogspot.in
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    • AchillesHave client assume same position as forpatellar reflex. Slightly dorsiflex client‟sankle by grasping toes in palm of yourhand. Strike Achilles tendon just aboveheel at ankle malleolus.Reflex : Planter flexion of foot.www.drjayeshpatidar.blogspot.in
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    • Planter:Have client lie supine with legs straightand feet relaxed. Take handle end ofreflex hammer and stroke lateral aspect ofsole from heel to ball of foot, curvingacross ball of foot toward big toe.Reflex : Planter flexion of all toes.www.drjayeshpatidar.blogspot.in
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    • Gluteal:Have client assume side lying position.Spread buttocks apart and lightly stimulateperineal area with cotton applicator.Reflex : Contraction of anal sphincterwww.drjayeshpatidar.blogspot.in
    • Thank Youwww.drjayeshpatidar.blogspot.in