Detailed Skill Performance Evaluation Sheet: Neurological Examination

Directions: You will have 20 minutes to complete the skill. All critical (C) steps and 80% of the noncritical steps must be
performed or verbalized. Special tests (S) will be performed if requested by the instructor.
Start: End:
Performed Verbalized

Washes hands and dons appropriate personal protective equipment. C

Introduces self to patient using first and last name. Y/N
Notes general appearance and vital signs. Y/N
Cranial Nerves (CNs)
1. CN I, olfactory: check nasal patency and sense of smell in each nostril separately (Use two different
Y/N Y/N
scents.)
2. CN II, optic: visual acuity (OD, OS, OU) with correction if needed (Use Rosenbaum chart.) Y/N Y/N
3. Visual field screening by confrontation (Stand in front of patient and ask patient to look in your eyes.
Put both hands lateral to patient’s ears. Wiggle fingers and bring hands forward one hand at a time until
patient can visualize. Repeat this in upper and lower temporal quadrants. If you find a defect, check nasal Y/N Y/N
fields--have patient cover one eye at a time. Wiggle fingers of one hand on same side as eye that is
covered and move from ear across face toward opposite ear.)
4. Inspect optic fundi (Refer to Eye skill sheet if needed.) Y/N Y/N
5. CN II, optic; III, oculomotor: size, shape of pupil, and reaction to light (direct and consensual) Y/N Y/N
6. Near reaction (Hold finger or a pencil ~10 cm from patient’s eye, and ask him/her to look alternately
Y/N Y/N
at it and into distance directly behind it.)
7. CN III, oculomotor; IV, trochlear; VI, abducens: extraocular movements (Test lateral, upper, and
lower temporal quadrants by making a large H in air to lead patient’s gaze. Test convergence by asking Y/N Y/N
patient to follow your finger to nose. Remember to instruct patient to keep head still and move eyes only.)
8. CN V, trigeminal (motor): temporal and masseter muscles (Place fingers over temporal and then Y/N
Y/N
masseter muscles, and ask patient to clench teeth, note strength of contraction.)
9. Sensory: light touch sensation on forehead, cheeks and jaw (Have patient close eyes, use a fine wisp of
Y/N Y/N
cotton, and gently touch face in areas of three divisions of nerve randomly—do not stroke.)
10. Corneal reflex (Approach from side; lightly touch cornea with fine cotton wisp as patient looks up
S S
and away.)
11. CN VII, facial: raise eyebrows, frown, close eyes, show teeth, smile, and puff cheeks (Observe face at
rest and during conversation, then ask patient to perform these maneuvers. Have patient close eyes Y/N Y/N
tightly so that you cannot open them.)
12. CN VIII, acoustic (vestibulocochlear): assess hearing (Use finger rub or whispered voice.) Y/N Y/N
13. CN IX, glossopharyngeal; X, vagal: voice quality, movement of soft palate (Listen to patient’s voice,
then have him/her open mouth and say “Ah” while you look with penlight for soft palate and pharynx Y/N Y/N
movement.)
14. Gag reflex (Warn patient what you are going to do, then lightly touch back of throat with tongue
Y/N
blade. Be aware that some patients have sensitive gag reflexes.)
15. CN XI, spinal accessory: shrug shoulders and turn head (Place hands on patient’s shoulders, and ask
him/her to shrug; place hand on patient’s cheek, and have him/her turn head against your hand. Use light Y/N Y/N
resistance for both.)
16. CN XII, hypoglossal: fasciculations, symmetry, deviation, movement, and strength of tongue (Listen
to patient speak; inspect tongue in mouth and then protruded. Have patient move tongue from side to
Y/N Y/N
side. In ambiguous cases, have patient push tongue against inside of each cheek and palpate externally
for strength.)
Coordination
1. Upper extremity: rapid alternating movements/point-to-point movements (Strike hand on thigh, turn it
over, and strike thigh with back of hand. Patient should do this as rapidly as possible. For point-to-point,
Y/N
patient touches your finger then his/her own nose alternately several times while you move finger around.
Watch for smooth and accurate movements. Perform bilaterally.)
2. Lower extremity: rapid alternating movements/point-to-point movements (Holds hand under patient’s
feet, patient taps hands as quickly as possible. For point-to-point, have patient place one heel on opposite Y/N
knee and run it down shin to great toe. Watch for smooth and accurate movements. Perform bilaterally.)
Developed by Albany Medical College, Center for Physician Assistant Studies | Bickley: Bates’ Guide to Physical Examination and
History Taking, Twelfth Edition. Copyright © 2017 Wolters Kluwer Health
 Detailed Skill Performance Evaluation Sheet: Neurological Examination

3. Gait: walk across room, tandem walk (Ask patient to take a few steps away from you, then turn and
Y/N
walk back. Observe posture, balance, arm swing, and leg movement. Have him/her walk heel to toe.)
4. Walk on toes and heels Y/N
5. Hop in place, or shallow knee bend (Elderly or less robust patients can rise from a sitting position and
Y/N
step up onto a sturdy stool to test these motions.)
6. Stance: Romberg and pronator drift (Romberg: Patient stands with feet together and closes eyes.
Observe ability to maintain upright posture without sway. Pronator drift: Patient stands with both arms
Y/N
outstretched, palms up, eyes closed for 20–30 seconds, then gently tap arms downward. Position yourself
to grab a potentially unsteady patient.)
Motor System
1. Observe body position during movement and at rest (Generally integrated with rest of exam.) Y/N Y/N
2. Tremors, tics, or fasciculations (Observe face; ask patient to hold hands out for a few seconds.) Y/N Y/N
3. Inspect muscle size and contour, note symmetry and any atrophy (Pay particular attention to hands,
shoulders, and thighs. For hands, combine with step 2. Then lower gown briefly to look at shoulders and Y/N Y/N
raise gown briefly to look at thighs.)

4. Assess muscle tone, looking for resistance to passive stretch: upper (UE) and lower extremities (LE)
(Patient should be relaxed. UE: Grasp hand with your hand, support patient’s elbow, and flex/extend
fingers, wrist, and elbow, using a circular motion for shoulder--this can all be done with one smooth Y/N Y/N
motion. LE: Place one hand on thigh; grasp foot with other hand and flex/extend knee and ankle on each
side.)
Muscle Strength Testing; Upper Extremities (Must examine both.)
1. Elbows: flexion/extension (Elbows are flexed, thumbs toward patient; apply resistance at wrists while
Y/N Y/N
patient flexes then extends elbow.)
2. Wrists: extension (Patient makes fist, arms out in front; try to push down on hands while patient
Y/N Y/N
resists.)
3. Grip strength (Place middle finger on top of index finger; patient squeezes fingers as hard as possible,
Y/N Y/N
while you attempt to withdraw fingers. Do both sides simultaneously for comparison.)
4. Finger abduction (Patient spreads fingers apart wide; try to force them together by pressing on lateral
Y/N Y/N
aspect of index and fourth fingers.)
5 Thumb opposition (Patient touches thumb to little finger; hook your finger under thumb to resist.) Y/N Y/N
Muscle Strength Testing: Lower Extremities (Must examine both.)
1. Hips: flexion and extension (With patient seated, place hand on thigh, ask patient to raise leg against
resistance. Then slip hand under thigh and ask patient to push down. Bilateral--can do flexion and Y/N Y/N
extension on opposite sides simultaneously.)
2. Hips: abduction/adduction (With patient seated, legs relaxed, place your hands on lateral aspect of
both knees and offer resistance to further abduction. Now move hands to medial aspect of knees and ask Y/N Y/N
patient to adduct against resistance.)
3. Knees: flexion/extension (With patient seated, place hands on shins and ask patient to straighten knee
Y/N Y/N
against resistance, then curl fingers around to grasp lower leg and ask patient to flex against resistance.)
4. Ankles: dorsiflexion/plantar flexion (Place hands beneath both feet; ask patient to press down like
stepping on a gas pedal, then move fingers to dorsal aspect of foot and ask patient to pull up against Y/N Y/N
resistance.)
Sensory System
1. Test for light touch generally and pain distally (Explain steps and expected responses. Touch very
lightly with cotton wisp and do not stroke skin. Next, instruct patient to close eyes and touch with broken Y/N
swab).
2. Vary pace of testing so patient cannot anticipate movements (Stimuli should routinely be applied
Y/N
lightly, and areas should be tested randomly, rather than in a predictable pattern.)
3. Compare symmetry on both sides of body (Basic testing should sample major functional subdivisions
of sensory system. Suggested pattern: Shoulders (C4), inner and outer aspect of forearms (C6/T1),
Y/N
thumbs and fourth fingers (C6/C8), both thighs (L2), medial and lateral aspects of calves (L4/L5), fifth
toes (S1).
Special Tests
Developed by Albany Medical College, Center for Physician Assistant Studies | Bickley: Bates’ Guide to Physical Examination and
History Taking, Twelfth Edition. Copyright © 2017 Wolters Kluwer Health
 Detailed Skill Performance Evaluation Sheet: Neurological Examination

1. Temperature (Use test tubes filled with warm and cold water; can omit if pain sensation is normal.) S Y/N
2. Proprioception: position (Examiner grasps great toe, holding it by its sides; move toe up and down
several times, then pause and have patient identify position. If abnormal, move proximally for further S Y/N
testing.)
3. Vibration (Patient closes eyes; strike a tuning fork and place it over distal interphalangeal (IP) joint of
S Y/N
finger and IP joint of great toe. Ask patient to state when it stops.)
4. Discriminative sensations: stereognosis (Identify an object by feeling it.), graphesthesia (Identify a
number drawn in palm with blunt end of a pen.); two-point discrimination (Find distance where one point
of touch is perceived when two points of pressure are applied.), point localization (Touch patient’s body S Y/N
with patient’s eyes closed; patient opens eyes and points to place touched.), extinction (Simultaneously
touch corresponding areas on body and ask patient where touch is felt.)
Deep Tendon Reflexes
1. UE: biceps (Patient’s arm is flexed, palms down; with your thumb over biceps tendon, strike thumb.),
triceps (Patient’s arm is down or supported by you; strike tendon above elbow.), brachioradialis Y/N
(Patient’s forearm partly pronated; strike radius 1–2” above wrist.)
2. LE: knee jerk (Patient’s knee flexed; tap patellar tendon just below patella.), ankle jerk (Holding
Y/N
patient’s foot in slight dorsiflexion, strike Achilles tendon,)
3. Cutaneous stimulation reflexes: abdominal (Lightly, briskly stroke sides of abdomen in an X pattern
toward umbilicus.), plantar (Stroke lateral aspect of sole from heel to ball of foot, curving medially S Y/N
across ball.)
Special Techniques
Meningeal signs (Patient supine; check neck mobility. Brudzinski sign: flex neck, watch for flexion of hips
and knees; Kernig sign: flex leg at hip and knee, straighten leg, look for pain and increased resistance.);
S Y/N
straight-leg raise (Patient supine, passively raise leg, then dorsiflex foot.), asterixis (Ask patient to “stop
traffic.”), winging of scapula (Ask patient to extend both arms and push against a wall.)
Adequate exposure was obtained for all inspection steps. C
Adequate draping was maintained for all steps. C
Evaluation: #Y = #C =
min. = 57/71 min. = 3
Needs
Comments on quality of performance: Remediation?

Y/N

Developed by Albany Medical College, Center for Physician Assistant Studies | Bickley: Bates’ Guide to Physical Examination and
History Taking, Twelfth Edition. Copyright © 2017 Wolters Kluwer Health