GKT CLINICAL SKILLS PHYSICAL EXAMINATION PATIENT EDUCATOR PROGRAMME

CLINICALLY RELEVANT ANATOMY 123 ULNAR NERVE ENTRAPMENT
LONG ISLAND BHM CONCURRENT CLINICAL PLEASE COMPLETE
PSYCHOLOGY AND CLINICAL LANGUAGE SCIENCES UNIVERSITY OF READING

(INSERT AGENCY NAME) REPRODUCTIVE HEALTH PROGRAM CLINICAL POLICIES AND
006-17%20Clinical%20Psychiatrist%20%20Board%20%20037869
1 COURSE TITLE CLINICAL PRACTICUM IN AUDIOLOGY 2 2

GKT CLINICAL SKILLS: PHYSICAL EXAMINATION PATIENT EDUCATOR PROGRAMME

GKT CLINICAL SKILLS: PHYSICAL EXAMINATION PATIENT EDUCATOR PROGRAMME.

NEUROLOGY EXAMINATION.

Systems Check List.

Order Of Examination

General appearance

Higher Function

Cranial Nerves

Motor System

Sensory System

Stance and Gait

Appropriate introduction to patient giving your own name and checking the name of the patient
Explain the purpose and main steps of the examination
Gain verbal consent to proceed with the examination

Invite the patient to ask questions at any point during the examination

Wash hands before the beginning of the examination
General Appearance

In individual cases it may be better to focus the examination on the affected part. It may well be more convenient to examine stance and gait before examining the patient in the couch.

HIGHER FUNCTIONS

The student should check whether you are left or right handed.
The student should establish that you are alert and able to give a clear history. If relevant they should be able to perform the Mini Mental State Examination.

CRANIAL NERVES (CN 1-12)

CN1.The student should ask if you can appreciate taste and smell. They should be able to know how to test these by firstly asking you to close your eyes then sniff the room air and say whether you can smell at all then ask you to sniff a couple of basic smells such as coffee or peppermint. These can be presented in small containers for you to smell in each nostril in turn.
CN2.The student should ask you if you have reduced vision in either eye. They should use a Snellen chart to test your sight and if you wear distance glasses they can be worn. They must test each eye seperatley. The student should know to have the 3 meter chart 3 meters away and the 6 meter chart 6 meters away. They may also want to use a pinhole …………………
The student should ask you if you have any reduced vision in either eye. They should test this by asking you to look directly into their eyes. They must sit directly in front of you for this. They should stretch both arms out and waggle one or both forefingers asking you to say which one they are moving. You must be asked to look straight ahead into their eyes for accuracy during this test. Then they should ask you to cover one eye and look into their opposite eye. Then the student should extend out their arms and waggle their fingers from and extended arm to a narrowed position and ask you to tell them when their fingers come into your path of vision. This should be tested on one side then the other in smooth movements both high and low and with full extension of their arm and then with their arm moving in towards your point of central vision.
Using an opthalmoscope. The student is looking at your fundus (the inner most point of your eye). They should ask you to remove your glasses and they too should remove theirs. The student should ask you to fix your eye on a distant point or object. It is sometimes helpful if they suggest something what you are to loom at and is
Observe for pstosis, pupil size, squint, proptosis
Test for pupillary response to light
Test for pupil near response
Ask if the patient has double vision
Examine the range of horizontal and vertical eye movements
Check for nystagmus
Check for any numbness and altered sensation to the face
Test corneal reflex (this must not tested on the patient educator)
Test jaw jerk with hammer
Inspect face at rest for symmetry
Ask patient to close both eyes tightly and check for burying of the eyelashes
Ask patient to show their teeth and whistle
Assess hearing bilaterally
Examine external ear using auroscope
Test for gag reflex (this must not be performed on the patient educator)
Ask patient to say “ah” to observe the soft palate movement
Ask patient to shrug both shoulders against resistance
Ask patient to turn head bilaterally against resistance
Protrude tongue and move from side to side

MOTOR SYSTEM

27.The student should make sure that you are comfortable, the back of the couch should be raised and your upper body exposed. The student should observe your torso and will be looking for any obvious abnormalities, skin changes, deformity, wasting and involuntary movements. (If the student is just doing the “Limb” section of the neuro examination then they should also check whether you are right or left handed). The student should ask you to lean forward so that they can observe your back, especially around the shoulder. The student should look at your hands, especially observing your thumb. The student should also observe your legs and look over your thigh muscles for quadracep wasting and then at your feet. The student may also ask you to flex your foot to help them look for the oyster muscle. This can be seen on the outside edge of the foot just under the ankle bone when the foot is slightly flexed.

The student should ask you to close your eyes and extend your arms out in front of

you with your palms down and then palms up. The student will be looking for any

irregular movements of your hands and fingers.

UPPER LIMB

Tone

The student should hold your arm and support it at the elbow then take your hand in theirs and turn it repetitively. They must make sure you are relaxed and not moving your hand yourself. They will be looking for any “catches” in your wrist movement and may want to increase the speed at which they turn your hand to find this. The student may ask you to raise your opposite arm to help bring out any signs of rigidity in the hand being tested.

Power

Test the following muscle groups in order and compare each side as you progress

Shoulder abduction. The student should ask you to extend your arm out with you’re elbow slightly bent and then ask you to resist their attempt to push your arm down. They need to put pressure on your upper not lower arm.
Elbow flexion. The student should ask you to bend your elbow making a “punch fist”. They will ask you to resist their attempt to straighten it out by putting pressure on your lower arm.
Elbow extension. The student should ask you to bend your elbow and make a “punch fist”. They will ask you to resist their attempt to bend it by putting pressure under your lower arm.
Wrist extension. The student should ask you to extend your wrist and then ask you to resist their attempt to try to bend it.
Finger extension. The student should ask you to spread your fingers out straight and then resist their pressure over your knuckles to push them down. The student should use the outside edge of their hands.

34. Grip. The student should ask you to curl your fingers around their own and ask you resist their attempt to open your grip.

35.First dorsal interosseous. The student should ask you to extend out your fingers and then ask you to resist their pressure to push them together. The student should test each finger in isolation from the other.

Abductor pollicis brevis. The student is looking at your thumb movement. The student should ask you to open your hand flat out with the palm upwards and then ask you lift your thumb vertically and resist their pressure to try to push it back to the horizontal.

Power is graded on a scale of 1-6 with 1 being complete paralysis and 6 being normal power. The student should be able to test your muscle power against gravity and also where gravity is excluded. An exercise to demonstrate this is to ask you to bend your elbow and raise your lower arm up to 45%. You should have your wrist palm side up and make a fist and then be asked to see if you can move your wrist up against gravity. Then you should turn your wrist over and see if you can move your wrist down with the aid of gravity.

Biceps reflex. Your arm should be relaxed and bent by the side of your body. The student should feel for your bicep tendon with their forefinger first then tap lightly with the reflex hammer over the tendon. The student should make sure he/she has a light grip of the hammer and uses it in a relaxed way making sure they get the “wobble” effect with the hammer before hitting the tendon.

Triceps reflex. Your arm should be relaxed and bent by your side, a little further across your body than when testing for your bicep reflex. The student should support your elbow with one hand and tap over the triceps tendon with the hammer. There is no need for the student to feel for the tendon first but they should make sure they hit the tendon and not the muscle immediately above. (If a response cannot be found then the student may ask you to clench your teeth just as they strike the tendon with the reflex hammer. The timing for this needs to be precise)
Wrist (brachioradialis) reflex. Your arm should be in the same position as for biceps and the student should feel for the tendon first just above your wrist then strike with the hammer.
Knee reflex. Your knee should be bent at 90% and the tendon felt just beneath the kneecap before the student strikes with the hammer. The student should support the underneath of your knee. (If a response cannot be found then the student may ask you to clasp your hands and try to pull apart as they strike with the reflex hammer)
Ankle reflex. Your foot should be in the mid position at the ankle with your knee bent and the thigh externally rotated on the couch. The student should stretch your foot up, keeping check that you are relaxed, and then hit the Achilles tendon with the hammer.
Plantar response. The student should use an orange stick or pencil for this. Your foot should be flexed up and a line drawn with the stick starting from the outside edge of the sole of the foot at the heel and continuing round to the big toe. The student should use moderate to firm pressure. Only if the toe extends up is this considered a positive response, known as a Babinski response. Curling down is normal.

LOWER LIMB

The student should ask you to expose your lower limbs and lie back on the couch, supported by a pillow. They should look for any obvious abnormality, skin changes, deformity, wasting and involuntary movements. The student should check to see if you have any pain in your lower limbs. The student should check you are relaxed and comfortable throughout. Both legs should be tested in sequence throughout examination.

Tone

Roll leg on the couch and test for quadriceps catch. The student should roll your leg gently on the couch and then with their hand placed directly under your knee lift it up quickly so that it flexes.

Power

Test the following muscle groups in order and compare each side as you progress-

Hip flexion. The student should ask you to raise your straight leg up above 45% and you should be asked to resist their pressure to lower it. The student should put pressure on your thigh and not your shin.
Hip extension. The student should ask you to keep your leg flat on the couch and not let them push it up from underneath the calf or thigh.
Knee flexion. The student should ask you to bend your knee and resist them trying to straighten your leg out against their pressure on your thigh.
Knee extension. The student should ask you straighten out your leg with your knee relaxed and resist their pressure under your thigh to bend it.
Ankle dorsiflexion. The student should ask you to flex your foot and resist their pressure on the front of your foot to push it down.
Ankle planter flexion. The student should ask you to push your foot down (like putting your foot hard down on the accelerator pedal) and resist their pressure to push it up.
Ankle eversion. The student should ask you to move your foot out from the ankle against resistance on the outside of your foot.
Ankle inversion. The student should ask you to move your foot from the ankle inwards against pressure on the inside of your foot.
Extensor hallucis longus. The student should ask you to raise your big toe up away from the other toe digits.

Co-ordination

The student should raise the back of the couch and make sure you are sitting up comfortably with your lower body covered with a blanket if needed.

Finger-nose-finger exercise. The student should ask you to extend out one arm and with your forefinger touch their extended finger then touch your nose. This needs to be repeated at pace and with the student moving the position of their finger in multiple directions. Your arm should be extended some way away from your body.
Rapid alternating hand tapping movement. The student should ask you to rapidly tap one of your hands onto the other with a twisting (flapping) movement. The supporting hand should be still. This can be done either with your hand resting on your body or raised just in front of you.
Heal to shin test. The student should get you to raise one leg up so that your heel is against the knee of the opposite leg. You should then trace a line with your heel down the shin of your leg to your foot then raise the leg up and start back at the knee. Constant contact with the leg should be maintained.

Sensory system

55.Note if the patient has noticed any altered sensation in any part of the body using

a) light touch, b) vibration, c) joint position, d) pinprick bilaterally.

Light Touch. The student should use a cotton wool ball and demonstrate to you how it feels by lightly touching you with it just above the shoulder blade or on your forehead (their touch should not be so light as to tickle, remembering that one touch is better then a wispy movement). They should check on the sensation you feel when touched by the cotton wool. The student should then use the cotton wool to touch you in multiple places from your foot working their way up to your chest. You should be asked to indicate if you have any areas of a lack of sensation. It is not enough to test on only a couple of areas.

Vibration. The student should again demonstrate the sensation of the tuning fork against your collarbone or forehead. The student should strike the tuning fork on the side of the bed only if they explain to you first what they are doing. Otherwise they should use their fingers to set the vibrations going. They should ask you to tell them whether you can feel the vibration when the fork is placed on your toe. They may ask you to tell them both when you feel the vibrations and when they cease. The tuning fork should be tested on your wrist, elbow then shoulder blade.

Joint position. The student needs to isolate the end of your finger (the one nearest the thumb) and hold it either side of the end joint with their fingers. Then you should be asked to tell them with your eyes closed when they are moving your joint up or down. They should establish you know what the movements are before they ask you to close your eyes. The same movement should be done with the big toe. They must hold the toes on the outside edge and not on the top and bottom.

Pinprick. The student should use a neuro tip and follow the same pattern as for the light touch with the cotton wool. They should make sure that you are comfortable with the sensation of the pinprick before they start the test. They should ask you if you feel a dull or sharp sensation throughout. The student should dispose of the neuro tip in the sharps bin as soon as this part of the examination is complete.

STANCE AND GATE

Ask patient to rise from their chair without using their hands and stand still with their feet together.
Ask patient to walk across the room turn round and walk back
Ask the patient to walk across the room with one foot directly in front of the other in a heel to toe movement.
Ask the patient to walk across the room on their toes.
Ask the patient to walk across the room on their heels.
Ask the patient to stand with their feet together with eyes open and then with them closed. The student should be ready to catch you when you close your eyes in case you fall.

1 NEONATAL RESPIRATORY DISTRESS INCLUDING CPAP CLINICAL LEARNING RESOURCE
1066 DEMENTIA RESEARCH GROUP PILOT STUDIES INDEPENDENT CLINICAL ASSESSMENT
10AP17] CLINICAL AND ENDOSCOPIC COMPARISON OF THE SINGLE USE

Tags: clinical skills:, programme, clinical, educator, physical, patient, skills, examination