Do you check reflexes ever and which ones?

[Angry Birds]

Do you check reflexes ever and which ones? And what do you use to check them? Your steth? Hand?

I always thought this was like bowel sounds, but after studying for boards, I am thinking I might need to check these a bit more (read: at all)... Thoughts?

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[EM2018orBUST]

Just an ms4 but i usually check patellar and Achilles if there’s any back injury/pain or LE weakness. And I consider all reflexes as part of my full neuro exam. Never really had any pertinent positives but I’d be checking for spinal cord pathology. I have a reflex hammer because I was tricked into getting one as part of the med student equipment package before starting school and I just keep it in my clinical bag. I have no problem using a stethoscope if needed though.

 

[Petypet]

all back pains get patella looking for hyperreflexia, and have seen hyporeflexia in guillain-barre.

 

[theseeker4]

2nd year resident here, i try to do patellar and Achilles in back pain patients, especially new back pain. Probably should do brachial for cervicle radiculopathy as well.....

 

[GeneralVeers]

I check it on back pain patients.....not to really find out anything but because patients expect it. Furthermore it gives me evidence when I document "normal reflexes" so that when they complain about lack of pain meds/admission for their chronic back pain, I can say I did a thorough exam and there is no emergency.

 

[gamerEMdoc]

Patellar/achilles in back pain.

And generally i check for clonus and hyperreflexia in the undifferntiated tox case.

 

[xaelia]

Geez, I can't remember the last time I checked reflexes.

Would only think to do for focused neurologic complaints or legitimately concerning back pain, though an altered/undifferentiated toxicologic presentation above is a reasonable idea.

The question generally remains, as with most physical examination, is whether your findings are reliable and whether they falsely reassure you in the setting of real underlying pathology, or whether they mislead you into additional low-value investigations. Unreliable tests for rare diseases are worse than useless.

 

[Angry Birds]

Geez, I can't remember the last time I checked reflexes.

Would only think to do for focused neurologic complaints or legitimately concerning back pain, though an altered/undifferentiated toxicologic presentation above is a reasonable idea.

The question generally remains, as with most physical examination, is whether your findings are reliable and whether they falsely reassure you in the setting of real underlying pathology, or whether they mislead you into additional low-value investigations. Unreliable tests for rare diseases are worse than useless.

Truth be told, this is the only reason I posted this thread: to justify my laziness.

 

[jrlob91]

Ms4 here. Attending I’m with always checks. 11 yr old on Keppra who “wasn’t feeling right” presented the other day, reflexes completely absent. Had keppra toxicity. Reflexes are very valuable in some situations.

 

[Fox800]

Patellar/achilles in back pain.

And generally i check for clonus and hyperreflexia in the undifferntiated tox case.

Exactly this, with my stethoscope.

 

[Tenk]

Just the bulbocavernosus reflex on pretty much everyone. Dunno why my press ganeys are so low....

 

[swamprat]

Ive had diminished reflexes in GBS and transverse myelitis. However both also had weakness that were focal so they were getting imaging/LPs so I can't say it helped my clinical decision making.

 

[deleted547339]

Ha.

 

[Angry Birds]

Yes, always! And with a tendon hammer.

Everything is easier in hindsight but I recall a man who came ED twice with vague worsening lower limb weakness, had a little bit of a chronic background that threw off the two providers that saw him previously, plan was for FM follow, no redflags identified etc. He was seen the 3rd time when absent Achilles and patellar reflexes were noted, this raised the antenna big time for the 3rd provider. GBS diagnosed. I’d get the noids if I documented reflexes present without doing them all, but from my time as a medical resident I’d be suspicious that they’re not being be done even half the time.

Are you an EM resident/attending? You'd be the first walking around with a tendon hammer.

 

[emergentmd]

Just if I think about GBS b/c I sound smarter when I admit to medicine. Never for back pain. If they have back pain and normal strength then not sure what reflexes tell me. If strength down, MRI.

 

[shoal007]

Agree. Gbs and tox only time I consider reflexes. Anal exam, strength and sensory plus history sufficient for back pain.

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[Hercules]

Ms4 here. Attending I’m with always checks. 11 yr old on Keppra who “wasn’t feeling right” presented the other day, reflexes completely absent. Had keppra toxicity. Reflexes are very valuable in some situations.

PGY-13 here living in one of the chronic pain/opiate capitals of the nation. I definitely do not do an extensive reflex test in every chronic back pain patient (I might not have time to run the codes if I did). Something has to make my spidey sense tingle before I'm doing complete reflexes and mri.


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[Angry Birds]

PGY-13 here living in one of the chronic pain/opiate capitals of the nation. I definitely do not do an extensive reflex test in every chronic back pain patient (I might not have time to run the codes if I did). Something has to make my spidey sense tingle before I'm doing complete reflexes and mri.


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Lol @ pgy-13.

I appreciate that the guy gave the disclaimer of “ms4 here.” It annoys me when people here don’t do that. Some of us here are only looking for input from our colleagues. For me that means ER attendings and senior residents.

(This is not directed towards jrlob91, who had the sense to give the necessary disclaimer. )

 

[Apollyon]

All the time. My department is slow, so I can do it. I use a hammer. I was literally distraught when I lost my hammer (which I'd had from med school), and had to buy this POS from Amazon, from Pakistan.

Invariably, the pts laugh when I elicit the brachioradialis, and say, "that's $180 grand of med school for ya!"

 

[gro2001]

Are you an EM resident/attending? You'd be the first walking around with a tendon hammer.

I once brought a tuning fork to work as an intern and my senior resident inquired whether my patient was a piano.

 

[Vandalia]

Do you check reflexes ever and which ones? And what do you use to check them? Your steth? Hand?

When appropriate. How is that for an answer?

As already mentioned, there are a couple of situations where it is relevant, but in EM, the vast majority of the time, if I decide I need to check reflexes, I have also pretty much decided that imaging is necessary.

The one exception to this is what I heard someone once describe as the "therapeutic physical exam." That is, the usually older person who just needs reassurance. "Listening to the heart" and "checking reflexes" are part of the stereotypical physical exam, and sometimes I include it just to reassure the patient that everything is OK. But then, I am literally, "old school."

One final point: if you didn't check reflexes, don't say that you did. It is a temptation in this age of "checklist physical exam", but it is just not worth it. It doesn't have to be the exam you learned as an MS-2, but just make sure you are not reporting normal reflexes on a prosthetic limb.

 

[WilcoWorld]

Geez, I can't remember the last time I checked reflexes.

Would only think to do for focused neurologic complaints or legitimately concerning back pain, though an altered/undifferentiated toxicologic presentation above is a reasonable idea.

The question generally remains, as with most physical examination, is whether your findings are reliable and whether they falsely reassure you in the setting of real underlying pathology, or whether they mislead you into additional low-value investigations. Unreliable tests for rare diseases are worse than useless.

My practice is the same as gamerEMdoc.
I appreciate your points and would respond that:
1 - I am checking to find an abnormal finding that would increase my suspicion in an otherwise low probability case, rather than a normal finding that would reassure me in a high probability case.
2 - One reason to check reflexes frequently is so I can recognize abnormal when I see it.

 

[Angry Birds]

I'm sorry, but I'm wholly not interested in any response that challenges my preconception and desired course of (in)action.

 

[xaelia]

I think we've at least established the reasonable standard of care from our informal survey of docs is: they're not mandatory.

 

[dchristismi]

The other situation where I check is if I'm worried about preeclampsia - an OB once specifically asked me to check, and lets just say that "brisk" was an understatement. Made enough of an impression that I will check them if it's in my differential, but otherwise, yeah, I'm like most of you - sometimes back pain, sometimes to just reassure the patient that they're ok, but mostly don't.

 

[Janders]

So i do it for special cases of course--- eclampsia, certain toxidrome, focal neuro complaints.

I do them on some back pains, I can't say I universally do them on walkie-talkie-musclar ache low back pain without radiculopathy every time...

The last time I meaningfully did them was about a week ago-- nice lady checks in with the "tingling" in the legs, seems fine but the spideysense goes off that she's a normal person who wouldn't come and wait in my ER late at night for 'nothin. Got her to stand up, she was fine, but I tried to get her on her tip-toes and she couldn't. Weak ankles. Patellars were fine, weak ankle jerks.

Anyway I was worried about atypical GBS (sensory predominate or one of the myriad sub variants I've vaguely heard of). So I shipped her to tertiary. Seemed fine the first 2 days, ddx was more myelopathy / anxiety. Then she got classic GBS, diaphragm weakness, intubated etc... nasty disease.

Probably would have shipped her based on the in ability to tip-toe walk but the quiet ankle jerks sealed it in my mind.

 

[TooMuchResearch]

So i do it for special cases of course--- eclampsia, certain toxidrome, focal neuro complaints.

I do them on some back pains, I can't say I universally do them on walkie-talkie-musclar ache low back pain without radiculopathy every time...

The last time I meaningfully did them was about a week ago-- nice lady checks in with the "tingling" in the legs, seems fine but the spideysense goes off that she's a normal person who wouldn't come and wait in my ER late at night for 'nothin. Got her to stand up, she was fine, but I tried to get her on her tip-toes and she couldn't. Weak ankles. Patellars were fine, weak ankle jerks.

Anyway I was worried about atypical GBS (sensory predominate or one of the myriad sub variants I've vaguely heard of). So I shipped her to tertiary. Seemed fine the first 2 days, ddx was more myelopathy / anxiety. Then she got classic GBS, diaphragm weakness, intubated etc... nasty disease.

Probably would have shipped her based on the in ability to tip-toe walk but the quiet ankle jerks sealed it in my mind.

Hmm...reminds me someone I sent home at 2 am last night. Though he could toe and heel walk. His wife seemed pretty sharp, I'm sure she'll bring him back .

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[turkeyjerky]

Hmm...reminds me someone I sent home at 2 am last night. Though he could toe and heel walk. His wife seemed pretty sharp, I'm sure she'll bring him back .

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Reminds me of a patient I had a few years ago. Had vague back pain and BLE parenthesis and numbness a few weeks after a flu like illness. No reflexes and 1/5 strength throughout legs. Ended up signing out AMA and walking out of the hospital two days later when they stopped giving dilaudid. I think you'll be fine

 

[DocEspana]

Like everyone else - when something seems off or when they're a chronic pain patient who I know hasn't had a "real exam in ages. Often I'm the one not giving the real exams for their back pain, but if I haven't done one in a while and it looks like none if the "overworks everyone" people hasn't seen them in a bit I will check reflexes to make sure their back pain is still something I can chalk up as benign chronic opiate deficiency.

It should concern me the amount of the time my "something isn't right" patients have abnormal findings, but I chalk it up to good instincts and not that I should be checking more often in those who seem remarkably routine.

Also I use my penlight. It's long and built tough enough to double as a police truncheon.

 

[LabMonster]

You do them when you need a more in depth neuro exam. Period.

 

[n2b8me]

after the spine surgeon or neurologist ask me "what are their reflexes?"

 

[alpinism]

Reminds me of a patient I had a few years ago. Had vague back pain and BLE parenthesis and numbness a few weeks after a flu like illness. No reflexes and 1/5 strength throughout legs. Ended up signing out AMA and walking out of the hospital two days later when they stopped giving dilaudid. I think you'll be fine

Ahh my favorite patients.

Come in with some combination of vague symptoms plus the mandatory new onset numbness or weakness.

Finish seeing them and start putting in orders.

Waiting for nurse in 3,2,1...

Hey um the pt in rm 4 is requesting something for pain.

Oh really you don't say!!??