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Interservice Physician Assistant Program

Musculoskeletal and Neurologic

PHYSICAL EXAMINATION PROGRESS CHECK

INSTRUCTIONS:
- The instructor will verify all physical findings, either before or after student exam, but will not interrupt

student during exam for anything other than flagrant error or safety violation.
- This checklist must be completed in no more than 20 minutes.
- Some checklist items may be logically combined in performance, though listed separately for grading
purposes.
- Checklist items are listed in a specific order of performance. This order of performance is guided by
logic based on economy of motion, keeping the items related to a single organ system clustered
together, or patient modesty.
- This checklist is divided into several columns. In the column labeled Exam, a general name for the
exam or test being performed in that particular item is given. In the column labeled Behavior, the
behavior which must be demonstrated by the student is stated (inspect, percuss, auscultate, palpate,
etc.) In the column labeled Key Indicators of Performance, pertinent qualifiers are given which
delineate minimal conditions of acceptable performance of the required behavior. In the column
labeled S/U, the instructor will indicate whether or not that behavior was successfully performed.
GRADING CRITERIA:
- Successful completion of this progress check requires successful completion of each major

subdivision, highlighted in boldface type. Criteria for completion of each subdivision are given.
- Behaviors which require verbalization by the student are indicated by the symbol . Examples of
acceptable verbal behavior are given in quotes in the column entitled "Key Indicators of
Performance". Variations on the given example may be used, but the following terms may NOT be
used in verbal description: normal, abnormal, clear
- Some behaviors may be critical items, which are identified by the symbol, **. These are items
which involve patient safety or comfort, or are of such importance that their omission constitutes a
particularly serious error. Failure to successfully complete any critical item will result in an overall
grade of Unsatisfactory for this entire progress check.
- Exceeding the stated time limit will be considered unsuccessfully performance.
-Any unsuccessful completion of a critical item, inadequate performance of a subsections listed items
or exceeding time limits will be deemed a progress check failure and require retesting before moving
in to the next block of instruction.

Student_________________

Preceptor_____________
Date_________________

Pass /
Fail
Time________________

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Bates p497-

The musculoskeletal and neurological systems are closely interwoven, and in usual practice, the examination
of these two systems is performed almost simultaneously. Therefore, for purposes of this checklist, these two
exams are divided into subsections which are listed in a logical order of performance based on minimizing
patient position changes. This means that subsections of musculoskeletal exam may be intermingled with
subsections of neuro exam, but each subsection is graded independently, and each subsection must be
passed in order to successfully complete the entire checklist. ((Bates 9th ed, pgs 497-646)

MENTAL STATUS EXAM: 2 of 3 non-critical AND the critical item must be completed.
(NOTE: During a complete physical, this section is usually done at the very beginning, along with vital signs, and
forms part of the basis for a general impression of the patient)

1.
2.

Exam
Introduce
Consciousness &
orientation &
affect
Long term
memory

Behavior
Introduction
Describe level of consciousness,
orientation to person, place, and time,
and affect
Evaluate long term memory by asking
about well known distant events

3.

4.

Key Indicators of Performance


- I am PA-S ________

S/U

"Patient is alert and oriented x 3; speech, dress, and


behavior are appropriate"
- Example: "Name the last 3 presidents in order"

Short term
memory

Evaluate recall of 3 unrelated words at


approximately 5 minutes

- "I'm going to give you 3 words to remember, and I'll


ask you what they are later in the exam. The
words are..."
- "What were those words I asked you to remember?"
- Full credit for short term memory is given when
words are recalled between 5-15 minutes.

Intellectual
function

Evaluate level of intellectual function


using serial 7's or serial 3's

- "Count backward from 100 by 7s"

**

CRANIAL NERVES: All 11 items must be successfully completed for S


Exam
1.
2.

CN I

5.
6.
7.
8.
9.
10.
11.

Key Indicators of Performance


- Do not use alcohol pads or ammonia ampules.

CN II

Visual Acuity

- Visual acuity is ____

CN III, IV, VI

Evaluate for conjugate extraocular


movements, noting presence or
absence of nystagmus

- Evaluate in 6 cardinal positions.


- Move through positions slowly enough to elicit
nystagmus, if it exists
- "EOMs are full range, without nystagmus"

3.

4.

Behavior
Test patient's discrimination of odors
bilaterally

CN V, sensory
CN V, motor
CN VII
CN VIII
CN IX, X
CN X
CN XI
CN XII

March 2009
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Ask patient to verbalize when


touched lightly on the face
Palpate muscles of mastication during
jaw clench
Inspect for symmetry of facial
movement
Test auditory acuity
Inspect for presence of gag reflex
Inspect for midline rise of uvula/soft
palate on phonation
Test shoulder shrug and SCM
strength against resistance
Inspect tongue for midline position
without deviation

- Must palpate both temporal and masseter muscles


- Must include muscles in forehead and lower face with
at least 3 movements
- Use masked whisper or rub fingers together.
- Use tongue blade.
- Uvula is midline and the soft palate rises
symmetrically.

-Must have patient protrude tongue


- Tongue is midline, without deviation..."

**

**

**

- Patient's eyes must be closed


- All 3 branches must be tested bilaterally

- Must rotate head

S/U
**

**
**
**
**

**
**

**

Bates p497-

SENSORY EXAM: 4 of 5 items must be successfully completed for "S"


(The sensory exam is normally performed with patient in supine position.)
Exam

Behavior

1.

Survey of
dermatomes

Test patient's discrimination of sharp


vs. dull tactile stimulation of
representative paired dermatomes.

Light touch

Test patient's recognition of a light


tactile stimulus.

Vibratory sense

Test patient's discrimination of


vibration over most distal joints of
thumbs and great toes.

Proprioception

Test patient's awareness of body


position in space using digits of
hands and feet.

2.
3.

4.

5.

Key Indicators of Performance


S/U
- Patient's eyes must be closed.
- Check the 3 branches of the trigeminal nerve.
- Check at minimum, lateral and medial aspects of
upper arms and forearm, and radial, median, and
ulnar nerves.
- Check a minimum of 3 paired locations on trunk and
abdomen. (nipple, umbilicus, and iliac crest levels)
**
- Must check a minimum of medial and lateral aspect
on each thigh and lower leg, and 3 locations on foot.
(medial aspect of great toe, middle toe, and lateral
aspect of 5th toe)
- When using a dull stimulus, follow up with a sharp
stimulus in the same location.
- Patient's eyes must be closed.
- Check at a minimum the same locations tested in
sharp/dull survey of dermatomes.
- Patient's eyes must be closed.
- Tuning fork must be vibrating lightly so as to provide
tactile, not auditory stimulation: use 128 tuning
fork.
- Patient's eyes must be closed.
- Must grasp finger or toe from the sides, so pressure of
examiner's fingers does not provide additional
spatial cue to patient.

Test patient's recognition of small,


familiar objects placed in either hand.
OR
Stereognosis
- Patient's eyes must be closed.
Test patient's recognition of numbers
drawn with your finger on his/her
palms.
Ask the patient what the 3 words
Short Term memory
- Patient should be able to recall the 3 words.
were.

Lower Extremities: 6 of 8 items must be completed for S


Exam
1.

Inspect

Inspect soft tissue and joint alignment

Bony palpation

Palpate iliac crests, greater trochanter


of the femur, patella/suprapatellar
pouch, femoral epicondyles, lateral
and medial malleoli of the ankles,
MTP and IP joints of toes

Key Indicators of Performance


- "Hips, knees, ankles and toes are symmetrically
aligned without atrophy, deformities, fasciculation,
or tremors; there is no swelling or discoloration.
- Technique for palpating MTP joints is to compress the
forefoot laterally and medially between thumb and
fingers
- "There is no swelling, bogginess, heat or tenderness
over joints and bony prominences"

Behavior

Key Indicators of Performance

2.

Exam
March 2009
646

Behavior

S/U

S/U
Bates p497-

3.
4.

5.

Palpate prominent muscles of thighs


- "There is no heat or tenderness; muscle tone is
and lower legs, palpate popliteal fossa,
symmetrical without spasm; there are no nodules or
Achilles tendon
popliteal cysts"
Instruct patient to bend knee to chest
- Perform bilaterally.
and pull it firmly against abdomen
Hips/knees ROM
- As leg is returned to resting position, cup your hand
(flexion of hip & knee), then passively
over knee to detect crepitus.
internally & externally rotate.
Soft tissue
palpation

Sitting Exam

Move the patient to the SITTING


position.

Ankles/feet/
toes - active
ROM

Instruct patient to draw a circle in the


air with each foot, rotating about the
ankle, then flex and extend toes

Ankles/feet/
toes - passive
ROM

Passively take ankles through ROM,


evaluating tibiotalar, subtalar, and
transverse tarsal joints independently;
flex the toes on the MTP joints

Muscle strength,
lower extremity
(NOTE:
Performed with
patient in sitting
position)

Apply resistance against patient's


movement of major lower extremity
muscle groups

Ankle clonus

Briskly dorsiflex patient's ankle,


observing for any clonus

6.

7.

8.

- Dorsiflex and plantarflex


- Stabilize ankle with one hand, and with the other,
grasp the heel and invert & evert the foot
- Stabilize heel with one hand, and with the other, invert
and evert the forefoot

- Evaluate hip flexion, adduction, abduction, knee


flexion and extension, ankle flexion and extension, **
great toe extension
- Must evaluate bilaterally.
(all but hip flexion may be done simultaneously)
- "Muscle Strength is __over 5" (assess strength using 0
to 5 scale)

- "There is no clonus" OR
- "There are ___ beats of clonus"

Upper Extremities
(Musculoskeletal and Neuro evaluated together in sitting position) 6 of 8 items must be successfully
completed for "S"
Exam

Behavior

1.
Inspect
2.

3.

Bony palpation

Soft tissue
palpation

4.
Shoulder ROM

5.
6.

Elbow ROM
Wrist ROM
Exam

March 2009
646

Inspect soft tissue and joint alignment


Palpate sternoclavicular joints,
clavicles, acromioclavicular joints,
bicipital grooves, scapulae, olecranon
processes, epicondyles, joints of wrists
and fingers

Key Indicators of Performance


- "Shoulders, elbows, wrists, and fingers are
symmetrically aligned without atrophy, deformities,
fasiculation or tremors; there is no swelling or
discoloration.
- "There is no swelling, bogginess, heat or tenderness
over joints and bony prominences"

- "There is no heat or tenderness; muscle tone is


Palpate prominent muscles of shoulder
symmetrical without spasm"
girdles and upper extremities

S/U

Instruct patient to:


- raise arms vertically (flexion)
- place hands behind head, elbows out
(ext. rotation, abduction)
- place hands behind small of back
(int. rotation, adduction, extension)
Instruct patient to flex, extend, and
(with elbow flexed to 90)
pronate/supinate
Instruct patient to flex, extend, abduct
and adduct wrists
Behavior

Key Indicators of Performance

S/U

Bates p497-

7.

Hands ROM

Instruct patient to extend and spread


(abduct) digits, then make fist (flex
and adduct)

Muscle strength,
upper extremity

apply resistance against patient's


movement of major upper extremity
muscle groups

8.

- Must evaluate shoulder adduction and abduction,


biceps, triceps, wrist extension and flexion, finger
**
spread, pincer grip (thumb to forefinger), and grip.
- Must evaluate bilaterally (may be done simultaneously)
- Muscle strength is ___ over 5.

DEEP TENDON REFLEXES: Must successfully complete 5 of 6 reflexes for "S"


Exam
1.
DTRs

Behavior
Key Indicators of Performance
Evaluate symmetry of upper and lower - Check bicep, triceps, brachioradialis, patellar, achilles
DTRs (total of five reflexes) and
and plantar reflexes
test Babinski reflex
- "DTRs are 2+ and symmetrical, toes are downgoing"

S/U

**

CEREBELLAR EXAM: 5 of 6 items must be successfully completed for "S"


Exam
1.
2.

Heel to shin
(HTS)
Rapid
alternating
movements
(RAM)

3.
Finger to nose
(FTN)
4.
5.
6.

Gaits
Romberg
(Equilibrium)

Behavior
Ask patient to run the heel of one foot
from opposite knee down to great toe,
and then back
Inspect for coordination during RAMs
of upper & lower extremities

Key Indicators of Performance

S/U

- Evaluate bilaterally with eyes closed.


- Ask patient to rapidly alternate forearm pronation and
supination, lifting hand completely between each
placement.
- Then ask patient to rapidly tap feet against your palms.

- With patient's eyes open, perform this test while


Ask patient to alternately touch your
shifting your finger position.
finger and his/her nose at patients full - Then have patient close his eyes while you keep your
arm extension.
finger in a fixed position.
- Evaluate bilaterally to full arm extension.
Inspect for balance, coordination, and - Evaluate bipedal gait ("normal" walking), tip-toe
muscle strength while patient walks
walking, heel walking, tandem walking (field
short distances.
sobriety test), and cornering (turning around).
Inspect for balance while patient
- Be prepared to protect patient from a fall if balance is
stands, eyes closed, heels and toes
impaired. Have patient station keep with eyes open
together.
for 5 sec, then close eyes and hold for 20-30 sec.

Pronator Drift
(NOTE: Is
usually
performed
Have patient extend arms anteriorly,
simultaneously
palms up, eyes closed, and observe for
with Romberg
maintenance of arm position.
test, but is not
actually a part of
Romberg test)

- Must have patient maintain position for at least 30


seconds.

SPINE: 3 of 4 items must be successfully completed for "S"


March 2009
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Bates p497-

Exam
1.
Inspect
2.
3.

Bony palpation
Soft tissue
palpation

Behavior

Key Indicators of Performance


- Inspect laterally and posteriorly.
Inspect soft tissue and joint alignment,
- "Spine is without deformity; there is symmetry of
specifically noting curvature of spine
scapulae, shoulder and iliac height; there is no
and symmetry of back
muscle atrophy, swelling or discoloration."
- Include cervical spine
Palpate spinous processes
- "There is no swelling, heat or tenderness over joints
and bony prominences"
- Include neck muscles
- "There is no heat or tenderness; muscle tone is
Palpate paravertebral muscles
symmetrical without spasm."

4.
Spine ROM

Instruct patient to put spine through


range of motion

S/U

- Must include flexion, extension, lateral bending, and


rotation of cervical and lumbar spine
- Stabilize patient's pelvis during all lumbar maneuvers
except flexion

THE INSTRUCTOR MAY WISH TO VERIFY YOUR FINDINGS WHEN YOUR


PERFORMANCE CHECK IS COMPLETE.

COMMENTS:
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March 2009
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Bates p497-