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Currently purchase generic nizagara pills drugs for erectile dysfunction, it and residents generic 25mg nizagara with mastercard erectile dysfunction or gay, and their validity tested using is sometimes disturbing that even the authors of exams administered before and after the train- diagnostic classifcations disagree among them- ing session order nizagara paypal erectile dysfunction most effective treatment. The exercise showed that most par- selves generic nizagara 25mg otc zyrtec impotence, a problem that is sometimes highlighted ticipants were able to signifcantly improve the when various experts render variable diagnoses accuracy of the diagnosis of either primary lung during slide symposia at national and interna- adenocarcinoma or metastastic breast carcinoma tional teaching conferences. Feedback from the the concept of testing the validity of proposed exercise was used to improve on the defnition of diagnostic before publication in a recent study various criteria and the way they were grouped suggesting several evidence based criteria to prior to publication. This chapter continuum of patient care, the application of suggests a systematic approach to the evaluation some of the concepts being illustrated in this of data that could advance the specialty to the chapter will hopefully stimulate some interest in next level. The chapter References also discusses the fact that, unfortunately, pathol- ogists have been reluctant to develop novel para- 1. Evidence-based medicine in knowledge taking advantage of statistical and pathology: an introduction. Evidence Protocol for the examination of specimens from based medicine: what it is and what it isn’t. Eminence, or rather eloquence, or World Health Organization classifcation of thymo- rather economy-based medicine? Int Urogynecol J mas provides signifcant prognostic information for Pelvic Floor Dysfunct. The World Health Organization classifcation of lung presence of isolated tumor cells and micrometastases tumours. Background epithelial neoplasms: a review of current concepts beliefs in Bayesian inference. Object perception classifcation can be simplifed into only 3 categories as Bayesian inference. Generalization, similar- tion of thymomas: transcapsular invasion is not a sig- ity, and Bayesian inference. Molecular classifcation Computerized interactive morphometry of brushing of breast carcinomas by immunohistochemical cytology specimens. Computerized interac- Computerized interactive morphometry as an aid in tive morphometry as a potentially useful tool for the the diagnosis of pleural effusions. A model for uncertainty in pathology: artifcial neural networks computer generated diagnosis. An evidence- works as a prognostic tool for patients with non-small based approach. Neural tion diagnosis of bronchioloalveolar carcinoma and networks as a prognostic tool of surgical risk in lung well-differentiated pulmonary adenocarcinoma: an resections. Evidence-based guide- colorectal adenocarcinoma using probabilistic neural lines for the utilization of immunostains in diagnostic networks and logistic regression. Evidence- blood gas analysis: a College of American Pathologists based guidelines to optimize the selection of antibody Q-Probes study in 665 laboratories. Histologic and treatment of selected soft tissue tumors of the head classifcation of thymic epithelial tumors: comparison and neck. Reproducibility clinicopathologic studies: evaluation of the problem of neuroendocrine lung tumor classifcation. The role of computerized morphometric and based criteria to help distinguish metastatic breast cytometric feature analysis in endometrial hyperpla- cancer from primary lung adenocarcinoma on tho- sia and cancer prognosis. Evaluation and Reduction 14 of Diagnostic Errors in Pathology Using an Evidence-Based Approach Raouf E. Nakhleh Keywords Diagnostic errors in pathology • Evidence-based pathology • Evaluation of diagnostic errors in pathology • Human error in diagnostic pathology A substantial proportion of patients’ diagnoses and tight time constraints, and a hierarchical culture. This comprehensive and has not for the most part taken can easily be demonstrated in cases of cancer as this approach but does offer clues of how errors well as many infammatory conditions such as occur and how they could be addressed. In cancer management, tis- chapter, I will discuss how errors occur in surgical sue diagnosis and staging are the most important pathology and then attempt to adapt to pathology determinants of prognosis and therapy. Likewise, existing proven knowledge used in many indus- determining the level of rejection in allograft biop- tries to reduce errors. The importance of a correct diagnosis in these situations cannot be overemphasized. Errors in Surgical Pathology In attempting to reduce errors many advocate a systems approach . At the heart of this Part of the problem in addressing errors is the approach is the admission that humans are falli- various ways that errors can occur and the vari- ble and will make mistakes and therefore the sys- ous ways that they may be reported (Table 14. This report derived its information from review of amended reports from seven insti- tutions. Where in the test cycle Quality assurance data say that these represent signifcant diagnostic do errors occur? Error reduction efforts, therefore, should Analytic – 25% be focused on the analytic phase of the test cycle Postanalytic – 29–44% 2. Where do the most and the factors in the pre- and postanalytic phase Legal claims signifcant errors occur? Preanalytic – 8–9% that have a strong infuence on determining an Analytic – 90% accurate diagnosis. Specimen identifcation Report defects Errors Within the Different Phases of the Test Cycle Table 14. In Misinterpretation False-negative the next section, most of these errors will be dis- False-positive cussed as to the reason they occur and possible Misclassifcation remedies to help reduce errors. Misidentifcation Patient Tissue Laterality Specimen defects Lost Preanalytic Errors Inadequate Absent or discrepant measurements While all errors in the preanalytic phase of the test Nonrepresentative sampling cycle are potentiality signifcant, by virtue of its Absent or inappropriate ancillary studies potential for catastrophe, specimen misidentifca- Report defects Typographical errors tion stands out as the most important potential Missing or wrong demographic or error . Misidentifed specimens have resulted procedural information in surgical procedures being performed on the Electronic transmission or format wrong site and even on the wrong patient. The remaining errors occur about other department where specimens are genera- equally within the preanalytic (misidentifcation tion. This includes operating rooms, endoscopy and some specimen defects) and postanalytic suits, physicians’ offces, outpatient surgical cen- (report defects) phases of the test cycle. There are other means of evaluating the exis- Problems occur because the vast majority of indi- tence of error which can focus on signifcant viduals that label specimens are usually not errors or errors that have the potential for patient trained by pathology and are not accountable to harm. The system is extremely complex tive yields a completely different picture [8, 9]. To get a handle on this pathologists demonstrate that the vast majority problem, an institution has to bring focus on the (>90%) of these cases are analytic errors, and problem. The Joint Commission has focused on 60–70% of these errors are false-negative results. The third is recommended that specimen identifcation be system includes the pathologists’ individual train- made an institutional goal and not simply a ing, specialization, organization, and individual laboratory goal [10, 12, 13]. Error reduction in this area is addressed col- responsibility of specimen identifcation is lectively with the use of consensus diagnostic cri- shared equally between clinical departments and teria, prudent use of redundant sign-out including pathology. Factors that have been shown to the use of specialists, the use of ancillary testing improve specimen identifcation are twofold . Many First is the introduction of redundant checks such of these topics are also addressed below. Second, the two most often cited postanalytic errors are over time continuous monitoring has been shown incomplete reports and lack of communication to improve specimen identifcation. The reason is for signifcant and unexpected (critical) fndings not clear, but it is thought the continuous moni- [18, 19].
An absorptiometry method for the determination of arterial blood concentration of injected iodinated contrast agent discount nizagara 100 mg free shipping erectile dysfunction how young. Detection of apical Na(+)/H(+) exchanger activity inhibition in proximal tubules induced by acute hypertension purchase nizagara 50 mg without prescription erectile dysfunction treatment los angeles. Quantum Rod Bioconjugates as Targeted Probes for Confocal and Two- Photon Fluorescence Imaging of Cancer Cells nizagara 25 mg overnight delivery erectile dysfunction water pump. Changes in ultraweak photon emission and heart rate variability of epinephrine- injected rats order genuine nizagara erectile dysfunction keywords. Synthesis, photophysical properties, and in vitro studies of photosensitization, uptake, and localization with carboxylic acid-substituted derivatives. Comparison of the lead 168-nm and 220-nm analytical lines in high iron and aluminium matrices by inductively coupled plasma-optical emission spectrometry. Log-normal distribution of physiological parameters and the coherence of biological systems. Optical fiber light-emitting diode-induced fluorescence detection for capillary electrophoresis. Experimental and quantum chemical studies of cooperative enhancement of three-photon absorption, optical limiting, and stabilization behaviors in multibranched and dendritic structures. Multi-site recording and spectral analysis of spontaneous photon emission from human body. Spontaneous ultraweak photon emission from biological systems and the endogenous light field. Experimenteller nachweis ultrschwacher photonenemission aus biologischen systemen. New indication of possible role of dna in ultraweak photon emission from bilogical systems. Hyperbolic relaxation as a sufficient condition of a fully coherent ergodic field. Untersuchungen zum dichte-und zeitablhungigen verhalten der ultraschwachen photonemission von pathenogenetischen welbchen des wasserflohs daphnia magna. Biophoton emission from daphnia magna: a possible factor in the self-regulation of swarming. Photon emission and the degree of differentiation, in photon emission from biological systems. Light stimulated ultraweak photon reemission of human amnion cells and wish cells. A model for the generation of low level chemiluminescence from microbiological growth media and its depletion by bacterial cells. Temperature hysteresis of low level luminescence from plants and its thermodynamical analysis. Coherent photon storage of biological systems, in electromagnetic bio-information. Untersuchungen zum dichte-und zeitablhungigen verhalten der ultraschwachen photonemission von pathenogenetischen welbchen des wasserflohs daphnia magna. Untersuchungen zum dichte-und zeitablhungigen verhalten der ultraschwachen photonemission von pathenogenetischen welbchen des wasserflohs daphnia magna. Gideon Koren, director of the Motherisk resource centre at Toronto’s Hospital for Sick Children, said the side- effect reports suspecting ondansetron of causing birth defects are a “signal that should be looked into. By: Jesse McLean Investigative News reporter, David Bruser News Reporter, Andrew Bailey Data Analyst, Published on Wed Jun 25 2014 Canadian women with severe morning sickness are being prescribed a powerful anti-nausea drug suspected of causing deformities in some babies, a Toronto Star investigation has found. The drug, ondansetron, is approved by Health Canada to treat nausea and vomiting in chemotherapy and surgery patients. It is not approved to treat pregnant women, but some doctors prescribe it “off label” without hard proof it is safe for expectant mothers. So little is known about how ondansetron affects pregnant women that the drug manufacturer says such use is “not recommended” for these vulnerable patients. At least 20 Canadian women treated with ondansetron for vomiting in pregnancy experienced serious suspected side-effects, including two infant deaths and multiple cases of newborns with heart defects and kidney malformations, according to a Star analysis of 2012 records. Curiously, information about these unapproved treatments is not publicly available from Health Canada. The Star discovered this crucial information after analyzing a massive trove of data found in the U. This database holds thousands of publicly available records of side-effects suffered by Canadian patients. Ondansetron is just one of several powerful drugs being prescribed to Canadians for unapproved uses. Off label means a drug is used for a condition or age group for which it hasn’t been approved. There are innovative off-label uses of drugs that have helped patients, but many off-label prescriptions are written with no solid scientific proof that the drug will be safe or effective. In 2012, a Senate committee told Health Canada officials it was concerned about whether the regulator was monitoring the effect of off-label prescriptions on vulnerable Canadians, especially pregnant women. Yet Health Canada, which was criticized by the auditor general in 2011 for poor drug safety monitoring, says it has not reviewed these reported birth defects. The regulator has issued no warnings to prescribers or the public about pregnant women taking ondansetron for morning sickness. In six cases, a suspected side-effect of ondansetron was listed as “fetal growth restriction. Each report is the opinion of the doctor, pharmacist or patient that a particular drug has caused a reaction. Because most women experience nausea and vomiting during the first trimester, they would be taking the drug at the same time the fetus is most vulnerable to developing malformations and deformities. Roughly 10 to 15 per cent of pregnant women receive drugs to treat morning sickness, according to a recent U. GlaxoSmithKline makes a brand-name version called Zofran and several other companies manufacture generics. Glaxo said “the safety of ondansetron for use in human pregnancy has not been established. Ondansetron was not one of the drugs named in the indictment, though Amir Attaran, a University of Ottawa law professor who has studied drug regulations, says Health Canada should not trust any products from the company. On its website, Health Canada says Ranbaxy’s version of ondansetron is approved for sale. The controversial use of ondansetron in pregnant women has been the subject of several studies in the last decade, with conflicting results and scientists from Toronto to Denmark saying more research is needed. A 2011 study suggested the drug doubles the chance of babies being born with cleft palate. Concerns about ondansetron’s safety were briefly placated after a study regarding the risk of adverse outcomes was published in the Feb. The researchers tracked more than 600,000 Danish births using national birth and prescription registries, and found the drug was not associated with a significant increased risk of spontaneous abortion, stillbirth or defect. But the same day the study was presented at a drug safety conference in Montreal, another group of Danish doctors introduced contradictory findingsbased on the same national registries.
Paralysis of the muscles (specially of the stapedius) gives rise to a condition called hyperacusis in which even normal sounds appear too loud discount nizagara online amex erectile dysfunction treatment in islamabad. The mastoid antrum is of considerable importance as it is a frequent site of infection buy generic nizagara 100mg erectile dysfunction from a young age, which may be diffcult to eradicate cheap nizagara 100 mg without prescription erectile dysfunction zinc deficiency. Furthermore buy cheap nizagara 50 mg on line impotence causes and treatment, infection may spread from it to neighbouring structures with serious consequences. Although, it is called the ‘mastoid’ antrum this space lies in the petrous part of the temporal bone. Superiorly, the roof of the antrum is formed by the tegmen tympani that separates it from the middle cranial fossa; and from the temporal lobe of the cerebral hemisphere. Inferiorly, the mastoid antrum is continuous with the mastoid air cells (see below). Anteriorly, below the aditus, the antrum is related to the facial nerve as it descends within its bony canal. Posteriorly, the antrum is close to the posterior surface of the temporal bone (i. Medially, behind the aditus, the antrum is related to the posterior semicircular canal. The lateral wall of the mastoid antrum is related to the suprameatal triangle (44. Anteroinferiorly by the posterosuperior margin of the (bony) external acoustic meatus. Posteriorly by a vertical line drawn as a tangent to the posterior margin of the meatus. The thickness of bone separating the mastoid antrum from the surface of the skull is only about 2 mm at birth, but it increases by about 1 mm for every year of age until it is about 13 to 14 mm thick. These are a series of intercommunicating spaces of variable size present within the mastoid process. Sometimes there are just a few, and are confned to the upper part of the mastoid process. Occasionally, they may extend beyond the mastoid process into the squamous or petrous parts of the temporal bone. In the medial part of the petrous temporal bone in relation to the internal ear, the carotid canal, the auditory tube, and the abducent nerve. Infection can reach the mastoid air cells though the tympanic cavity and the mastoid antrum, and can spread to any of the structures related to them. The auditory tube is also called the pharyngotympanic tube, or the Eustachian tube. Because of this communication air passes into the tympanic cavity (and into the mastoid antrum and air cells). When we suddenly ascend to a higher altitude (as in going up a hill in a car) the air pressure on the outside of the tympanic membrane falls, but that on its inner side remains the same as before. This inequality in pressure gives rise to a change in the quality of sound perceived. However, on swallowing of saliva, and the consequent equalisation of pressure, the sound suddenly returns to normal. The same phenomenon takes place much more acutely during the take off of an aircraft, and can give rise to distress in the ear; more so in persons who have a mild infection. The communication between the pharynx and the middle ear is a path along which infection frequently reaches the middle ear. This occurs more commonly in children, in whom the auditory tube is shorter and wider than in the adult. When this happens air within the tympanic cavity is gradually absorbed and pressure on the outside of the tympanic membrane becomes greater than on the inside. This can give rise to discomfort that can be relieved by introducing air into the auditory tube through a catheter. If obstruction to the auditory tube is prolonged pus can accumulate in middle ear resulting in severe pain. The pus may burst through the tympanic membrane leading to discharge from the ear, and to the formation of a perforation in the membrane. It is for these reasons that the anatomy of the auditory tube is of much practical importance. The lateral end of the bony part opens on the anterior wall of the middle ear (44. The medial end of the bony part opens on the base of the skull (at the lateral end of the groove between the anterior margin of the petrous temporal bone and the posterior margin of the greater wing of the sphenoid bone). The cartilaginous part extends from the medial end of the bony part to the lateral wall of the nasopharynx. The auditory tube is narrowest at the junction of the bony and cartilaginous parts: this part is called the isthmus. The cartilage forming the wall of the auditory tube is not tubular, but consists of a triangular plate that is bent on itself. Its medial end is broad and lies just under the mucous membrane of the lateral wall of the nasopharynx where it forms the tubal elevation. The cartilage consists of a larger medial lamina (facing backwards and medially) and of a smaller lateral lamina (facing forwards and laterally). The cartilaginous part of the auditory tube lies in close relation to the base of the skull in the groove between the anterior margin of the petrous temporal bone and the posterior margin of the greater wing of the sphenoid bone. The interior of the auditory tube is lined by mucous membrane continuous with that of the nasopharynx and of the middle ear. The cartilaginous part of the auditory tube lies in close relationship to the roof of the infratemporal fossa (44. The tensor palati muscle lies immediately to its lateral side, and the levator palati lies immediately medial to it. The part of the tensor palati arising from the tube is believed to be responsible for opening the auditory tube during swallowing. The tensor palati separates the tube from several structures in the infratemporal fossa including the mandibular nerve, the chorda tympani, the middle meningeal artery and the otic ganglion. The middle ear receives several small branches that arise from arteries that lie in its neighbourhood. The veins of the middle ear drain downward (along the auditory tube) towards the infratemporal fossa where they end in the pterygoid plexus. Some veins drain through apertures in the petrous temporal bone to end in the superior petrosal sinus. The lymphatics from the middle ear and the mastoid air cells end in the parotid lymph nodes while those from the auditory tube reach the deep cervical nodes (44. The nerves supplying the mucous membrane of the middle ear, the mastoid antrum and air cells and the auditory tube are derived from the tympanic plexus that lies over the promontory. The tympanic plexus is formed mainly by branches from the tympanic branch of the glossopharyngeal nerve. It also receives some fbres from the sympathetic plexus around the internal carotid artery (caroticotym- panic nerves).
It usually improves spontaneously buy 100 mg nizagara free shipping erectile dysfunction miracle shake, but patients may be left with some facial weakness or aberrant renervation generic 25mg nizagara with mastercard erectile dysfunction doctor in virginia. The evidence for the use of the antivirals cheap nizagara online master card erectile dysfunction trials, aciclovir or valaciclovir nizagara 100mg lowest price impotence kidney disease, is less clear cut. It is important to protect the cornea from trauma and abrasions (artifcial tears, patching eye closed). Other cranial nerves 21 stomach, upper gastrointestinal tract Fasciculation of the tongue is an Box 2 Weber and rinne tests and heart, the supply to the larynx, important sign. Place the tuning fork on the to the good side, and bilateral lesions is tongue fasciculation. Normally it is heard in the centre of the Laryngeal function can be tested by Dysarthria head. This is for a variation in tone, melody and ¦ Bone conduction is better than air usually due to laryngeal disease. Phrases such as ‘yellow lorry’ conduction: Neurological causes include recurrent test the lingual sounds, while ‘baby – Weber test lateralizes to the affected laryngeal or vagal nerve lesions and hippopotamus’ tests the labial sounds. Neurological the abnormalities are classifed in – Weber test lateralizes to the other dysphonia is usually associated with a Table 1. Dysphonia may be Accessory nerve (11th) appreciated from the good ear non-organic and then the cough is This nerve supplies the ¦ Hearing diminished but air conduction usually normal. If the tongue is touching the cornea (not the bilaterally wasted with fasciculations, conjunctiva) with cotton wool; the this is usually a sign of progressive normal response is a brisk contraction bulbar palsy, a form of motor neurone of both orbicularis oculi. Table 1 Type of dysarthria the afferent (ophthalmic branch of the Clinical features 5th) produces loss of the refex. Lesions to the efferent (7th) can impair Spastic Laboured speech, with slow tongue and lip movements the refex on that side but not on the Cerebellar Slurred as if drunk; staccato with other side. The volume of a Lower motor Normal rhythm, diffculty with sound can be compared between ears, neurone, sounds depends on affected for example using a whisper, a tuning neuromuscular muscle groups: tongue – sound fork or a ticking watch. If the hearing junction and muscle t; face – sound b (think is impaired unilaterally, the Weber and ventriloquist); palate – sound c Rinne tests will determine whether or k (as if patient has a bad cold) this is conductive or sensineural (Box 2). Vestibular function is assessed by looking at eye movements, gait and coordination. Other cranial nerves Mouth, tongue and palate (9th, ¦ Trigeminal nerve abnormalities are 10th, 12th) usually sensory and rarely motor. The glossopharyngeal nerve (9th) ¦ Bell’s palsy is the commonest, but not supplies sensation to the posterior the only, cause of lower motor neurone pharynx. Touching this area is normally appreciated and provokes ¦ Hearing loss can be classifed as pharyngeal movement (vagus nerve, conductive or sensineural on bed-side clinical testing. There is no clinically relevant ¦ Dysarthria can be clinically categorized motor output. Weak left side into spastic, cerebellar, extrapyramidal the vagus nerve has many functions: Fig. As with all parts of the examination, attention needs to be paid to the hypotheses thrown up by the history. Position and posture Patients with different types of motor disease assume typical positions. It is worth looking at the position of the patient before examining the limbs at closer quarters. For example, a patient whose arm is held with a fexed elbow, wrist and fngers and whose leg is extended at the knee and ankle has a contralateral hemisphere lesion, typically a stroke. The myasthenic patient has an extended neck to overcome the At the wrist ptosis, and a droopy jaw. Muscle atrophy is most commonly seen distally in the small muscles of the hands and in the feet and tibialis anterior. Atrophy usually refects lower motor neurone abnormalities, though muscles do atrophy from disuse, for example in a longstanding upper motor neurone lesion or with severe muscle disease. Fasciculations are small movements within the muscle At the elbow and refect contraction of a motor unit. They are widespread in anterior horn cell diseases, typically motor neurone disease. They can occur in the absence of neurological disease, and are quite commonly observed in the calves of people without neurological disease. The joint is moved through its range, initially slowly and then at increasing speeds. Spasticity is best found at the extension of the elbow or pronation and supination of the forearm, and is more marked as the joint is moved more rapidly. Power testing At the hip Although traditionally called power testing, what is actually being measured, using your arms and hands as strain gauges, is force. Table 1 Abnormalities of tone reduced tone rigid tone Spastic tone Gegenhalten tone Features Floppy Increased through whole range: with Increase in tone with sudden Patient seems to push voluntarily against breaks – cogwheel, smooth – lead-pipe increase or ‘spastic catch’ examiner K2 Causes Lower motor neurone disease, Extrapyramidal disease, e. Parkinsonism Upper motor neurone disease Diffuse frontal disease Muscle disease, cerebellar disease limbs: motor 23 approach to testing the different Figures 2–8 and 10–14 (pp. The amended Medical Research nerve root and peripheral nerve It is important to isolate the muscle Council scale is used to record power innervation of each muscle. The or muscles that you want to test to and indicates the maximal power muscles routinely tested are shown in avoid trick movements. Box 1 Medical research Council grades for muscle power 5 Full power 4+ Submaximal movement against Triceps resistance Radial nerve 4 Modest reduction of movement Deltoid against resistance C6 C7 C8 Axillary nerve 4? Some movement against resistance C5 3 Moves against gravity but not resistance 2 Moves with gravity eliminated 1 Flicker of movement 0 No movement Fig. Extensor carpi ulnaris Extensor digitorum and radialis Posterior interosseous nerve Radial nerve C7 C8 C7 Fig. Iliopsoas Lumbosacral plexus L1 L2 Gluteus maximus Inferior gluteal nerve L5 S1 (a) (b) K2 Fig. Tibialis anterior Deep peroneal nerve Gastrocnemius L5 Posterior tibial nerve S1 (a) (b) Fig. Peroneus longus and brevis Tibialis posterior Superficial peroneal Posterior tibial nerve nerve L5 S1 S1 (a) (b) Fig. Extensor hallucis longus Deep peroneal nerve L5 limbs: motor ¦ Examination of tone provides useful information about the cause of a motor abnormality. A rapid stretch of the muscle stimulates the muscle spindles and this message is conveyed via the sensory root to the spinal cord at the segmental level of the muscle stimulated. This synapses with the motor neurone that supplies the muscle and leads to contraction of the muscle. If this is interrupted, by either peripheral sensory or lower motor Biceps reflex: C5 neurone lesions, the refex is reduced or lost. If there is an upper motor neurone lesion, the refex is increased because inhibitory factors have been supinator refexes, a fnger on the removed. The muscle is watched for Tendon refexes are important movement in response to this. If the because they provide an objective sign refex is not obtainable then the patient indicating abnormality and some is asked either to clench the teeth or indication as to the level of the make a fst – reinforcement – which abnormality. Refexes can be graded as absent, When testing the refexes it is useful to obtainable with reinforcement (see remind yourself of the segmental level below), reduced, normal, increased and being tested. This how to elicit tendon refexes is most commonly found at the ankle the patient needs to be relaxed, with (up to three beats is normal) and is the muscle to be tested in the middle occasionally found at the knee.