08 H&P Procedural Checklist 09

8/17/2019 08 H&P Procedural Checklist 09

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Practice of Medicine 1 and 2

History & Physical Exam Review

PROCEDURAL CHECKLIST

Student Name:

_________________

PI Name:

__________________

Clinical Skills Training and Assessment ProgramOffice of Medical Education

The University of Virginia School of Medicine

Spring

NOTE: The POM2 History and Physical Examination Assessment Checlist !as last re"ised #$2%$&'(


2/13

STA)T TIME:

Practice of Medicine 1 & 2

Simulated Patient History & Physical Exam Assessment

INTERVIEW: Please assess whether the student examiner addressed each of the following interview items.

Y = Yes, competed N = No, not competed

Initiatin! t"e Inter#ie$ Y N %omments

*( Introduced Sel+ ,y +irst and last name(

2( Identi+ied the -rimary and secondary reasons +or seein. health care(

/( Set a.enda$contracts !ith -atient re.ardin. ho! inter"ie! !ill -roceed(

Information at"erin!: Process'( 0sed concise1 easily understood uestions and comments3 A4OI5E5 6A)7ON(

8( 0sed o-en9ended and closed uestions a--ro-riately3 mo"ed +rom OPEN TO

COSE5(

%( O,tained history in a O7ICA SE;0ENCE3 -ro.ressed +rom -ast to -resent(

3 /9 SE4E)IT>3 '9 =I)ST OCC0)ANCE3

89 CONTET3 %9 MO5I=>IN7 =ACTO)S3 MPTOMS(

*&( Ased -atient uestions relatin. to his$her P+T ME-I%+. 'ITORY(

**( Ased -atient uestions relatin. to his$her /+MI.Y 'ITORY0

*2( Ased i+ -atient !as tain. any ME-I%+TION BP)ESC$OTC(

*/( Ased i+ -atient had under.one any RERIE or had e"er ,een

HOSPITAIDE5(

*'( Ased -atient uestions re.ardin. li+estyle RI /+%TOR(

*8( Re#ie$ of (stems( ;uestioned -atients on AT EAST *& or.an systems: eyes3

ears1 nose1 mouth1 throat3 cardio"ascular3 res-iratory3 .astrointestinal3

musculoseletal3 .enitourinary3 inte.umentary3 neurolo.ical3 -sychiatric3endocrine3 hematolo.ic3 immunolo.ic(

*%( Ased additional foc3sed 43estions a,out the systemBs directly related to the

-ro,lemBs identi+ied in the HPI(


3/13

P'YI%+. E5+MIN+TION: Please assess the student examiner according to the scales below for each of the

following physical examination items.

Y = Yes, competed N = No, not competed

%inica %o3rtes( Y N %omments

• The student !ashed his$her hands in "ie! o+ the -atient(

2( TOO NOTES Bi+ done in a manner that does not inter+ere !ith dialo.ue orra--ort( Chec F>esG i+ no notes !ere taen(

/( The student a--ro-riately dra-ed the -atient throu.hout the -hysical

examination(

'( The student "er,ally demonstrated an a!areness and res-ect +or -atient?s com+ort

le"el throu.hout the -hysical examination(

Vita i!ns

+ = +ttempted atisfactor( 6 = +ttempted 6eo$ atisfactor( % = -id Not +ttempt

Proced3re + 6 % %omments

*( P: Ex should sli.htly +lex -atients arm1 and su--ort arm Bta,le1 hold arm1 etc(

2( P: Ex should chec sie o+ cu++1 locate ,rachial artery ,y -al-ation1 and -lace cu++

snu.ly a,out u--er arm1 centerin. the ,ladder o"er the ,rachial artery J arm should ,e+ree o+ clothin.(

• P: Ex should -al-ate radial -ulse1 and -um- u- ,lood -ressure cu++ until

radial -ulse is no lon.er -al-a,le1 and then ra-idly de+late the cu++1 and !ait/& seconds ,e+ore -roceedin.

Ex should -lace stethosco-e B,ell -re+erred1 dia-hra.m acce-ta,le o"er ,rachialartery1 and -um- u- cu++ 2& to /& mm H. a,o"e -al-a,le systolic -ressure1 and then

release cu++ slo!ly1 at rate o+ 2 J / mm H. -er second1 listenin. +or oroto++ sounds(

Ex should record ,lood -ressure(

'( P0SE: Ex should -al-ate the radial artery +or at least *8 seconds(

8( )ESPI)ATION: Ex should stand in +ront or ,ehind you and o,ser"e your ,reathin. at rest +or at least /& seconds Bnormal rate is *&9*% ,reaths -er minute(

AS Ex !hat your res-iratory rate !as durin. the +eed,ac session(


4/13

'ead, Nec7 & E(es



*9@( >MPH NO5ES: The ex should -al-ate the +ollo!in. lym-h nodes(

*. preauricular J in +ront o+ ears

2. postauricular J ,ehind the ears

/( occipital J ,ase o+ the ,ac o+ the nec

'( posterior cervical J ,ac o+ the sternomastoid muscle

8( cervical/tonsillar J an.le o+ Ka!

%( submandibular J hal+!ay ,et!een an.le o+ Ka! and chin

)OI5: Ex should stand ,ehind Pt !hile seated( Ex should as Pt to ,endhead to neutral -osition or sli.htly +or!ard( T!o +in.ers o+ each hand should ,e

-laced on either side o+ the trachea( Ex should then as Pt to s!allo! Bor to tae a si-

o+ !ater !hile he$she +eels the isthmus( The Ex should then dis-lace trachea to the

le+t and as Pt to s!allo! !hile -al-atin. trachea( )e-eat on the le+t side(

*2( E>E INSPECTION: Ex should as you to loo u-!ard as Ex .ently mo"es theOLE) I5S o+ each eye do!n!ard( In the same !ay1 you should loo do!n!ard

as Ex .ently mo"es the 0PPE) I5S u-!ard( Cranial Ner"e II B"isual acuity is

examined in s-ecial circumstances(

*/( P0PI )ESPONSE: Lith li.hts O==1 Ex should shine a -enli.ht or the li.ht o+the o-hthalmosco-e on each -u-il( Ex should a"oid shinin. the li.ht into ,oth -u-ils

simultaneously and should not allo! you to +ocus on the li.ht(

*'( OPHTHAMOSCOP>: Lith li.hts O==1 Ex should instruct you to loo at a

distant -oint directly in +ront1 and +ocus on that -oint( Ex should -lace his$her hand on

your head to orient himsel+$hersel+( Ex should hold o-hthalmosco-e in ri.ht hand to"ie! your ri.ht eye and le+t hand to "ie! your le+t eye( Ex should ,e.in +rom *&G J

*8G laterally and mo"e in slo!ly1 chan.in. lens stren.th i+ necessary in the -rocess1

and mo"e to *G J /G a!ay +rom the eye until +oreheads almost touch( Ex should as

you to ,rie+ly loo directly into the li.ht at some -oint durin. the exam(

*8( ET)AOC0A) MO4EMENT: Ex should ,e -ositioned in +ront o+ you andreuest that !ithout mo"in. your head1 your eyes +ollo! Ex?s +in.er or a -encil in +our

directions BFHG or FG -attern( Ex should also as you to loo at the ti- o+ your nose(

CNIII, IV, VI


5/13


6/13

pper E8tremit(



*( SHO05E) Ins-ection: Assess symmetry1 de+ormity and discoloration( BExshould state !hat they are ins-ectin. +or

2( SHO05E) Pal-ation: Ex( Pal-ates sca-ular s-ine1 acromion -rocess1acromiocla"icular Koint and ,ici-ital .roo"e Bone side O(

/( SHO05E) )an.e o+ motion: Examiner ass -atient to +lex1 extend1 a,duct B+ullarc1 internally rotate Bel,o! +lexed1 thum, at o--osite sca-ula and externally

rotate Bel,o! +lexed1 hands out at sides or ,ehind head ,oth shoulders(

'( SHO05E) Stren.th: Ex resists -atient !hile -atient shru.s shoulders1 +lexes

shoulder +or!ard and a,ducts shoulder(

#( EOL Ins-ection: Assess symmetry1 de+ormity and discoloration( BEx should

state !hat they are ins-ectin. +or

@( EOL Pal-ation: Ex( Pal-ates lateral e-icondyle1 medial e-icondyle and

olecranon -rocess Bone side O(

*&( EOL )an.e o+ motion: Pt( +lexes1 extends1 -ronates1 Bel,o! at @&1 -alm do!n

and su-inates Bel,o! at @&1 -alm u- ,oth el,o!s(

**( EOL Stren.th: Examiner resists -atient !hile -atient +lexes and extends

el,o!(

*8( L)IST and HAN5 Ins-ection: Assess symmetry1 de+ormity and discoloration(

Assess thenar and hy-othenar eminence( BEx should state !hat they are ins-ectin.+or

*%( L)IST and HAN5 Pal-ation: Examiner -al-ates !rist1 CMC1 MCP and PIP Koints(

*


7/13


*( INSPECTION:

a( Examiner assesses stren.th o+ -roximal hi- muscles ,y asin. -atient to rise

+rom chair(

,( Examiner assesses hi-s1 nees1 anles and +eet +or symmetry1 de+ormity and

discoloration !hile -atient is standin.(

/( HIP Pal-ate: Ex should -al-ate iliac crest and .reater trochanter(

'( HIP )an.e o+ motion: BPassi"e a( =lexion J !ith the -atient su-ine1 the ex should

+lex the -atient?s hi- !ith nee ,ent(

,( Extension B-rone or standin. J ex should extend -atient?s hi-(

c( Adduction and a,duction J !ith -atient su-ine1 ex should adduct and a,duct

-atient?s hi-(

d( Internal and external rotation J !ith -atient su-ine and nee +lexed to @&°1 ex

should internally and externally rotate -atient?s hi-(

@( NEE Ins-ect: Ex ins-ects nee !ith -atient su-ine +or s!ellin. and discoloration(

*&( NEE Pal-ate: Ex should -al-ate -o-liteal s-ace1 ti,io+emoral Koint s-ace

laterally and medially1 and -atella(

**( NEE )an.e o+ motion: Ex ass -atient to +lex and extend nee(

*2( NEE Stren.th: Ex should resist -atient !hile -atient +lexes and extends nee(

*/( NEE S-ecial maneu"ers Bnot reuired:

a( Mediolateral insta,ility J Ex should +lex nee to /&°1 a--ly "arus and "al.us

stress to nee1 assessin. +or medial and lateral laxity(

,( Cruciate li.ament: achman test J Ex should +lex nee to 2&° to /&°1 .ras-

the distal thi.h a,o"e the -atella !ith one hand Bthum, should !ra- o"er thi.h

Kust a,o"e -atella1 .ras-s -roximal ti,ia !ith other hand and -ulls ti,iaanteriorly(

O)

Cruciate li.ament: 5ra!er test J Ex should +lex nee to @&°1 sta,ilie +oot ,y

li.htly sittin. on it1 and -ull ti,ia anteriorly +or anterior dra!er test1 and also -ush -osteriorly +or -osterior test( BEx may choose !hich cruciate test to

-er+orm J ex is res-onsi,le +or only one o+ these(

c( McMurray test Bincluded only +or small .rou- use1 not +or testin. J Ex should

+lex nee com-letely1 encircle Koint s-ace !ith thum, and index +in.er1 rotate

+oot laterally1 and extend nee( Maneu"er should ,e re-eated !ith medial

rotation o+ +oot(

2&( ANE and =OOT Ins-ection: Ex should ins-ect +or s!ellin. and discoloration(

2*( ANE and =OOT Pal-ation: Ex should -al-ate achilles tendon1 lateral and medial


8/13

malleoli and +ore+oot(

2/( ANE and =OOT )an.e o+ motion: Ex should as -atient to dorsi+lex1 -lantar

+lex1 e"ert and in"ert the anle(

2'( ANE and =OOT Stren.th: Ex should resist -atient !hile -atient dorsi+lexes and

-lantar +lexes anle( Ex also resists in"ersion and e"ersion(

%"est and .3n!



*( INSPECTION O= CHEST: Ex should "isually ins-ect Pt?s chest !hile sittin. +or

sha-e and symmetry1 symmetry o+ res-iratory excursion1 -ulsations1 hea"in. andres-iratory e++ort( BEx should state !hat they are ins-ectin. +or

2( THO)ACIC EPANSION: Lhile standin. ,ehind Pt1 Ex should -lace thum,s -arallel and se"eral inches lateral to his$her mid to lo!er s-ine( Pt should then ,e ased

to inhale dee-ly !hile Ex +eels the ran.e and symmetry o+ Pt?s res-irations(

/( TACTIE =)EMIT0S: Lhile standin. ,ehind Pt1 Ex should -lace his$her -almar orulnar sur+ace o+ ,oth hands on Pt?s u--er1 middle1 and lo!er ,ac( Ex should as Pt to

recite a +e! !ords or num,ers Bex( F@@G !hile he$she -al-ates !ith a +irm1 li.ht touch

,oth sides simultaneously(

'( PE)C0SSION: Ex -ercusses o"er -osterior and anterior chest( Ex should

mo"e +rom one side across to the other and do!n

PE)C0SSION TECHNI;0E: Ex -laces middle +in.er1 !hich is hy-erextended1

a.ainst your sin1 li+tin. the rest o+ the stationary hand u-( 0sin. the middle +in.er o+the dominant hand1 Ex should ,ounce it o++ the stationary one(

8( 5IAPH)A7MATIC EC0)SION: Ex should as Pt to Ftae a dee- ,reath and

hold itG !hile Ex -ercusses do!n the sca-ular line o+ s-ine( Ex should then as Pt toFexhale and hold itG as much as -ossi,le !hile he$she -ercusses the ,ac( oth inhale

and exhale -ercussion -rocedures should ,e done on ,oth sides o+ the Pt?s ,ac(

%( POSTE)IO) )EATH SO0N5S: Ex should as Pt to ,reathe dee-ly throu.h

mouth !hile Ex listens to AT EAST ONE =0 )EATH AT EACH POSITION onthe ,ac( Ex should mo"e +rom one side o+ the ,ac across to the other and do!n(


9/13


*( 6070A) 4ENO0S P0SE INSPECTION: Pt should recline to /& to '8 de.rees

+rom horiontal !hile Ex shines his$her -en li.ht o"er ri.ht side o+ the Pt?s nec( BLill

only ,e assessed i+ exam ta,le inclines

2( P)ECO)5IA INSPECTION: Ex ins-ects -recordium Bloos at area and states: FI

am checin. the -recordium +or "isi,le -ulsationsG or similar statement(

/( P)ECO)5IA PAPATION: Ex should use the -almar sur+ace o+ his$her +in.ers to

.ently -al-ate the le+t sternal ,order and the ,ase !hile lyin.(

'( APICA IMP0SE PAPATION: Ex should as Pt to Fexhale and hold itG !hile1 Exlocates the -ulse( Ex may need to roll -t mid!ay to the le+t !hile lyin.(

89#( HEA)T: Ex should listen to the heart in each o+ the +ollo!in. =O0) A)EAS

!hile Pt is lyin. do!n:

8( Aortic area

%( -ulmonic area


10/13


11/13

B-erson1 -lace1 time1 situation( Ex should as a minimum o+ / uestions(

BNOTE: E>E$ CNs II1 III1 I4 and 4I A)E ASSESSE5 IN HNE SECTION

2J


12/13

The Ex should as Pt to ra-idly and re-eatedly touch his$her thum, !ith each +in.er on

the same hand( )e-eat !ith the Pt?s other hand(

2&( MOTO) =0NCTIONS $ COO)5INATION O= OLE) ET)EMITIES: The

Ex should as Pt to run the heel o+ one +oot u- and do!n the shin o+ the o--osite le.(

)e-eat !ith o--osite le.(

AN5 $ O)

The Ex should as Pt to !al a strai.ht line in a heel9to9toe +ashion(

2*( )OME)7 SI7N: Ex should o,ser"e Pt stand !ith his$her arms stretched out in+ront or ,eside him$her !ith eyes closed(

22( 7AIT: The Ex should o,ser"e Pt !al1 turn1 and return(

EN5 TIME:

.O6+. +EMENT:

PI Instructions

n the next page, you are as!ed to provide a global assessment of the student"s history#

ta!ing and physical examination s!ills. $ou should base the global assessments on your overall

clinical evaluation of the student"s history#ta!ing and physical examination s!ills. %his global

rating may not add up to the other ratings in the chec!list. %his is fine.

In addition to chec!ing the appropriate rating, please ma!e a short statement explaining

how you arrived at this rating. &s with all of your ratings, please be as ob'ective and accurate

as possible. %his information will be shared with the student and the Course (irector and will

help identify overall strengths and wea!nesses.


13/13

o9a Ratin!s:

Please assess the student examiner according to the scale below by placing a chec! mar! in the appropriate box for each of the following categories.

= +6OVE +TI/+%TORY 2 = +TI/+%TORY 1 = 6E.OW +TI/+%TORY

R = N+6.E TO R+TE

7i Ratin! %omments

History9Tain.

3 2 1 UR

Clinical Courtesy

3 2 1 UR

4ital Si.ns

3 2 1 UR

Head1 Nec1 Eyes3 2 1 UR

Ears1 Nose1 Throat

3 2 1 UR

0--er Extremities

3 2 1 UR

o!er Extremities

3 2 1 UR

Chest un.s

3 2 1 UR

Heart lood 4essels

3 2 1 UR

A,dominal

3 2 1 UR

Neurolo.ical

3 2 1 UR

Student Name:

_______________

08 H&P Procedural Checklist 09

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