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CLPR NEURO PHYSICAL EXAM RUBRIC Student Name: _________________________________ Examiner: ________________________ Start time: ______________ End Time:

______________
GENERAL EXPECTATIONS

(20 minutes time max)


YES NO PTS

Points do not contribute to final score. Points will be subtracted from final score for any item not satisfied
EXAM ITEM

Student is on time Student washed hand/applied sanitizer before starting exam Appropriate attire, grooming, and followed no scent policy, washed hand/applied sanitizer before starting exam, Students nails are trimmed to almost no white showing
PERTINENT NEGATIVES EXPECTATION AND POINT BREAKDOWN

! ! !

! ! !

/3 /3

/3
YES NO PTS

POINTS

1 1 2

General Observation of mental status: Observe Gait Toe-Walk and Heel-Walk Tandem Walking

What is your name? Where are you? What is todays date? Alert and Oriented x 3 Gait is smooth and well coordinated Negative Toe walk and Heel walk Negative Tandem Walking

Asked patient all three questions. Obvious attempt at observing Asked patient to perform both types of walk Asked / demonstrated to patient to perform tandem walking Patient in correct position with supportive hand few inches behind patients back Pressed with adequate force Asked patient to perform test using correct language and with eyes closed Asked patient to perform test using correct language Student asked patient to perform test using correct language Assessed multiple points in space Student asked patient to close eyes for one finger-tonose point All muscle strength tests

! ! !

! /1 ! ! /2 /1

! /2

2 2 1 1

Rombergs Test Pronator Drift Heel-to-Shin Rapid Alternating Movements

Negative Rombergs test Negative Pronator Drift Heel-to-Shin movements are smooth and well coordinated Rapid alternating movements are smooth and well coordinated

! ! ! ! ! ! ! !

! ! ! /1 ! /1 ! /.5 ! ! ! /1 /2 /.5 /2 /2

Point-to-Point Movements

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

Muscle Strength:
Updated 1/4/14

CLPR Physical Exam Rubric

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 Student performed test Student instructed patient to read letters from smallest line possible with one eye open, then repeat with opposite eye reading the line backwards Student instructed patient to read lowest line possible with both eyes open Student asked patient to close one eye and placed hands at appropriate levels to assess visual field quadrants 4 quadrants were assessed (2 temporal on each eye) Asked patient to follow with eyes while drawing an H/bowtie pattern Checked bilateral nystagmus Convergence and accommodation Shone light into one pupil watching for constriction, then again to watch opposite pupil constrict Raised eyelid to be examined and advanced 20 lateral to center of eye Visualized red reflex Inspected all areas of retina including macula Occluded or had patient occlude one ear Whispered a series of 3 numbers/letters Asked patient to repeat the numbers Asked patient to open mouth ! ! /1

Accessory Nerve (Trapezius)

Accessory Nerve intact OR Cranial Nerve 11 intact

! /1

Visual Acuity Snellen Chart

Vision is __/20 OU with/without correction

! /1

Visual Fields

Visual Fields are intact and adequate bilaterally

! ! ! ! ! !

! /1 ! ! ! ! ! /2 /.5 /.5 /1 /1

EOMs

Extra ocular movements intact and without nystagmus, convergence is symmetrical

PERRLA

Pupils are equal, round, and reactive to light and accommodation Fundoscopy shows no papilledema, cupping, or retinopathy

! ! ! ! ! ! !

! ! ! ! ! ! ! /1 /1 /.5 /.5 /1 /.5 /.5

Fundoscopy

Gross Hearing

Gross hearing intact bilaterally

Vagus,
Updated 1/4/14

Uvula and tongue midline, soft

CLPR Physical Exam Rubric

Glossopharyngeal and Hypoglossal nerve

palate elevates symmetrically

Facial Expressions

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

Trigeminal nerve sensory test Masseter and Temporal muscles Deep Tendon Reflexes C5, C6, C7, L4, S1 Babinski

Trigeminal nerve sensory function intact OR Cranial Nerve 5 sensory function intact Trigeminal nerve motor function intact OR Cranial Nerve 5 motor function intact DTRs +2 bilaterally at C5, C6, C7, L4, and S1 Negative Babinski bilaterally

1 2

and say aahh while inspecting pharynx with light Asked patient to stick out their tongue Asked patient to smile, baring teeth Asked patient to puff out cheeks against resistance and wrinkle forehead Asked patient to close eyes and resist them from being opened by student Asked patient to close eyes and indicate where they feel gauze touch their face Touched forehead, cheek, and jaw of patient bilaterally Asked patient to clench jaw and palpated masseter/temporal muscles All reflexes with correct form Applied pressure to sole of foot and drew line from heel up and across metatarsal heads Demonstrated sharp and dull sensations to patient Student had patient close eyes All 10 fingers and toes on each hand/foot evaluated Student demonstrated vibratory sense to patient Student had patient close eyes 2-3 fingers and toes on each hand/foot were evaluated Student demonstrated up and down position to patient Student had patient close eyes 2-3 fingers and toes on each hand/foot were evaluated

! ! ! ! ! ! ! !

! ! !

/1 /.5 /.5

! /1 ! /1 ! ! /1 ! /2 /1

! ! ! ! ! ! ! ! !

! /1 ! ! ! ! ! ! ! ! /.5 /.5 /1 /.5 /.5 /1 /.5 /.5

Sharp/Dull Sense

Sharp/dull discrimination intact and accurate in the hands and feet bilaterally

Vibration Sense

Vibration sense intact in the hands and feet bilaterally

Position Sense

Position sense intact in the hands and feet bilaterally

! /1

Professionalism, Patient Communication & Reporting (5 pts)


Updated 1/4/14 CLPR Physical Exam Rubric

Demonstrated sensitivity to potential and actual discomfort associated with the examination. Physical contact demonstrated professional approach to touching and a respectful attitude toward the patient overall. Used appropriate/professional language while speaking with the patient & Instructions to the patient were easily understood Reported pertinent negatives accurately (must have approximately !80% correct language for credit) 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) Total

! ! ! ! !

! ! ! ! !

/0.5 /0.5 /0.5 /3 /0.5 /5

Final Total Score /50 Notes:

Updated 1/4/14

CLPR Physical Exam Rubric