Updated 1/4/14 CLPR Physical Exam Rubric 1

CLPR NEURO PHYSICAL EXAM RUBRIC Student Name: _________________________________ Examiner: ________________________ Start time: ______________ End Time: ______________ (20 minutes time max)

GENERAL EXPECTATIONS YES NO PTS

0

Points do not contribute to final score. Points will

be subtracted from final score for any item not satisfied

Student is on time ! ! /3 Student washed hand/applied sanitizer before starting exam ! ! /3

Appropriate attire, grooming, and followed no scent policy, washed hand/applied sanitizer before starting exam, Student’s nails are trimmed to almost no white showing

! !

/3

POINTS EXAM ITEM PERTINENT NEGATIVES EXPECTATION AND POINT BREAKDOWN YES NO PTS

1 General Observation of mental status:

“What is your name? Where are you? What is today’s date?”

“Alert and Oriented x 3”

Asked patient all three questions. ! !

/1

1 Observe Gait “Gait is smooth and well

coordinated” Obvious attempt at observing ! ! /1

2 Toe-Walk and Heel-Walk

“Negative Toe walk and Heel

walk”

Asked patient to perform both types of walk ! !

/2

2 Tandem Walking “Negative Tandem Walking” Asked / demonstrated to patient to perform tandem walking

! ! /2

2 Romberg’s Test “Negative Romberg’s test” Patient in correct position with supportive hand few inches behind patient’s back

! ! /2

2 Pronator Drift “Negative Pronator Drift” Pressed with adequate force ! ! /2

1 Heel-to-Shin “Heel-to-Shin movements are smooth and well coordinated”

Asked patient to perform test using correct language and with eyes closed

! ! /1

1 Rapid Alternating Movements

“Rapid alternating movements are smooth and well

coordinated”

Asked patient to perform test using correct language ! !

/1

2 Point-to-Point Movements

“Point-to-Point movements are intact smooth and well

coordinated”

Student asked patient to perform test using correct language

! ! /.5

Assessed multiple points in space ! ! /.5 Student asked patient to close eyes for one finger-to-nose point

! ! /1

2 Muscle Strength: All muscle strength tests ! ! /2

Updated 1/4/14 CLPR Physical Exam Rubric 2

“Grade 5 muscle strength for all major muscle groups. Grip

strength normal for age and gender.”

-Cervical flex/ext/rot -Shoulder flex/ext -Shoulder abd/add -Shoulder int/ext rot -Biceps/Triceps -Wrist flex/ext -Finger abductors -Grip Strength -Hip flex/ext, -Hip abd/add -Knee flex/ext, -Ankle flex/ext

1 Accessory Nerve (Trapezius)

“Accessory Nerve intact” OR “Cranial Nerve 11 intact” Student performed test ! ! /1

2 Visual Acuity – Snellen Chart

“ Vision is __/20 OU with/without correction”

Student instructed patient to read letters from smallest line possible with one eye open, then repeat with opposite eye reading the line backwards

! !

/1 Student instructed patient to read lowest line possible with both eyes open

! ! /1

2 Visual Fields “Visual Fields are intact and adequate bilaterally”

Student asked patient to close one eye and placed hands at appropriate levels to assess visual field quadrants

! !

/1 4 quadrants were assessed (2 temporal on each eye) ! ! /1

2 EOMs “Extra ocular movements intact

and without nystagmus, convergence is symmetrical”

Asked patient to follow with eyes while drawing an H/bowtie pattern

! ! /.5

Checked bilateral nystagmus ! ! /.5 Convergence and accommodation ! ! /1

2 PERRLA “Pupils are equal, round, and

reactive to light and accommodation”

Shone light into one pupil watching for constriction, then again to watch opposite pupil constrict

! !

/2

2 Fundoscopy “Fundoscopy shows no

papilledema, cupping, or retinopathy”

Raised eyelid to be examined and advanced 20° lateral to center of eye

! ! /.5

Visualized red reflex ! ! /.5 Inspected all areas of retina including macula ! ! /1

2 Gross Hearing “Gross hearing intact bilaterally”

Occluded or had patient occlude one ear ! ! /.5 Whispered a series of 3 numbers/letters ! ! /.5 Asked patient to repeat the numbers

! ! /1

2 Vagus, “Uvula and tongue midline, soft Asked patient to open mouth ! ! /1

Updated 1/4/14 CLPR Physical Exam Rubric 3

Glossopharyngeal and Hypoglossal

nerve

palate elevates symmetrically” and say “aahh” while inspecting pharynx with light Asked patient to stick out their tongue ! ! /1

2 Facial Expressions

“Facial nerve motor function intact” or “Cranial Nerve 7

motor function intact”

Asked patient to smile, baring teeth ! ! /.5 Asked patient to puff out cheeks against resistance and wrinkle forehead

! ! /.5

Asked patient to close eyes and resist them from being opened by student

! ! /1

2 Trigeminal nerve sensory test

“Trigeminal nerve sensory function intact” OR “Cranial

Nerve 5 sensory function intact”

Asked patient to close eyes and indicate where they feel gauze touch their face

! ! /1

Touched forehead, cheek, and jaw of patient bilaterally ! ! /1

1 Masseter and Temporal muscles

“Trigeminal nerve motor function intact” OR “Cranial

Nerve 5 motor function intact”

Asked patient to clench jaw and palpated masseter/temporal muscles

! ! /1

2 Deep Tendon

Reflexes C5, C6, C7, L4, S1

“DTR’s +2 bilaterally at C5, C6, C7, L4, and S1” All reflexes with correct form ! !

/2

1 Babinski “Negative Babinski bilaterally”

Applied pressure to sole of foot and drew line from heel up and across metatarsal heads

! !

/1

2 Sharp/Dull Sense

“Sharp/dull discrimination intact and accurate in the hands and

feet bilaterally

Demonstrated sharp and dull sensations to patient ! ! /.5 Student had patient close eyes ! ! /.5 All 10 fingers and toes on each hand/foot evaluated ! ! /1

2 Vibration Sense

“Vibration sense intact in the hands and feet bilaterally”

Student demonstrated vibratory sense to patient ! ! /.5 Student had patient close eyes ! ! /.5 2-3 fingers and toes on each hand/foot were evaluated ! ! /1

2 Position Sense

“Position sense intact in the hands and feet bilaterally”

Student demonstrated ‘up’ and ‘down’ position to patient ! ! /.5 Student had patient close eyes ! ! /.5 2-3 fingers and toes on each hand/foot were evaluated

! !

/1

Professionalism, Patient Communication & Reporting (5 pts)

Updated 1/4/14 CLPR Physical Exam Rubric 4

Demonstrated sensitivity to potential and actual discomfort associated with the examination. ! ! /0.5 Physical contact demonstrated professional approach to touching and a respectful attitude toward the patient overall. ! ! /0.5

Used appropriate/professional language while speaking with the patient & Instructions to the patient were easily understood ! ! /0.5

Reported pertinent negatives accurately (must have approximately ≥80% correct language for credit) ! ! /3 Reported positive findings accurately (i.e. aware of positive/negative findings as actually observable in the patient and described in appropriate medical terms) (must have approximately ≥80% correct language for credit)

! ! /0.5

Total /5

Final Total Score /50

Notes: