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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
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