Direct Observation Learner Expectations

Neurology Direct Observation of Physical Examination Skills Learner Expectations

Scenario: You will be asked to perform the complete neurological examination on a patient in a clinic.

Note: Do not examine the patient over the gown. Physical exam maneuvers performed over the gown will result in partial or no credit for the item.

The student is expected to demonstrate the following behaviors:

• Greeting the patient/Establishing initial rapport

  • Student introduces self, using first and last name and role

  • Student states the primary purpose of the encounter

  • Student actively verifies the patient’s name and date of birth

  • Student washes hands before the physical examination

• Mental Status

  • Student assesses orientation to person, place AND time

  • Student performs one test of attention (e.g. serial 7s, spell “WORLD” backward, recite days of week / months of year backward, count backward 20 – >1)

  • Student assesses multiple domains of language, including naming (of 2+ objects); repetition (of a sentence or phrase); comprehension (ability to follow a multistep command that crosses the midline)

  • Student assesses immediate and delayed recall of a list of 3 words

• Cranial Nerves

  • Student assesses visual fields in four quadrants and at eye level

  • Student assesses visual acuity in each eye

  • Student assesses pupillary reflexes one eye at a time

  • Student assesses complete extraocular movements including horizontal, vertical, and oblique directions, as well as convergence

  • Student compares all 3 divisions of cranial nerve V (sensory) on both sides of the face, assessing one side at a time

  • Student assesses cranial nerve VII (facial nerve) by evaluating at least one upper facial muscle (eye closure or brow elevation) and at least one lower facial muscle (smile or frown or puff out cheeks)

  • Student assesses cranial nerve IX & X (palatal elevation)

  • Student assesses nerve XI (shoulder shrug)

  • Student assesses cranial nerve XII (stick out tongue)

• Motor

  • Student assesses motor strength in at least one proximal and at least one distal muscle group in both upper extremities against resistance one muscle group and one side at a time (proximal muscles include those moving the shoulder and elbow; distal muscles include those moving the wrist and fingers)

  • Student assesses motor strength in at least one proximal and at least one distal muscle group in both lower extremities against resistance one muscle group and one side at a time (proximal muscles include those moving the hip and knee; distal muscles include those moving the ankle)

• Coordination

  • Student demonstrates at least one cerebellar assessment in both upper extremities (rapid alternating movements or finger-to-nose over at least 3 repetitions)

  • Student demonstrates at least one cerebellar assessment in both lower extremities (heel-to-shin, at least 3 repetitions)

• Reflexes

  • Student assesses biceps reflexes in both upper extremities using a reflex hammer and with patient’s arms supported

  • Student assesses brachioradialis tendons in both upper extremities using a reflex hammer and with patient’s arms supported

    • Student assesses triceps reflexes in both upper extremities using a reflex hammer and with patient’s arms supported

  • Student assesses patellar reflexes in both lower extremities using a reflex hammer and with legs dangling

  • Student assesses ankle reflexes in both lower extremities using a reflex hammer and with legs dangling

  • Student assesses plantar reflexes in both lower extremities using end of reflex hammer and without causing any patient discomfort

• Sensory

  • Student assesses sensation to light touch on both sides

  • Student compares sensation to cold temperature on both sides and in both upper and lower extremities using the metal handle of reflex hammer or a tuning fork

  • Student compares presence of vibratory sensation on bony prominence on both sides and in both upper and lower extremities using a tuning fork

  • Student assesses sensation to joint position on both sides and in both upper and lower extremities

• Station and Gait

  • Student performs test for Romberg appropriately

  • Student assesses natural gait (walking)

  • Student assesses tandem gait

• Closing the encounter

  • Student washes hands after the physical examination

  • Student shows consideration for patient comfort by active inquiry