Beruflich Dokumente
Kultur Dokumente
INSTRUCTIONS:
- The instructor will verify all physical findings, either before or after student exam, but will not interrupt
student during exam for anything other than flagrant error or safety violation.
- This checklist must be completed in no more than 20 minutes.
- Some checklist items may be logically combined in performance, though listed separately for grading
purposes.
- Checklist items are listed in a specific order of performance. This order of performance is guided by
logic based on economy of motion, keeping the items related to a single organ system clustered
together, or patient modesty.
- This checklist is divided into several columns. In the column labeled Exam, a general name for the
exam or test being performed in that particular item is given. In the column labeled Behavior, the
behavior which must be demonstrated by the student is stated (inspect, percuss, auscultate, palpate,
etc.) In the column labeled Key Indicators of Performance, pertinent qualifiers are given which
delineate minimal conditions of acceptable performance of the required behavior. In the column
labeled S/U, the instructor will indicate whether or not that behavior was successfully performed.
GRADING CRITERIA:
- Successful completion of this progress check requires successful completion of each major
subdivision, highlighted in boldface type. Criteria for completion of each subdivision are given.
- Behaviors which require verbalization by the student are indicated by the symbol . Examples of
acceptable verbal behavior are given in quotes in the column entitled "Key Indicators of
Performance". Variations on the given example may be used, but the following terms may NOT be
used in verbal description: normal, abnormal, clear
- Some behaviors may be critical items, which are identified by the symbol, **. These are items
which involve patient safety or comfort, or are of such importance that their omission constitutes a
particularly serious error. Failure to successfully complete any critical item will result in an overall
grade of Unsatisfactory for this entire progress check.
- Exceeding the stated time limit will be considered unsuccessfully performance.
-Any unsuccessful completion of a critical item, inadequate performance of a subsections listed items
or exceeding time limits will be deemed a progress check failure and require retesting before moving
in to the next block of instruction.
Student_________________
Preceptor_____________
Date_________________
Pass /
Fail
Time________________
March 2009
646
Bates p497-
The musculoskeletal and neurological systems are closely interwoven, and in usual practice, the examination
of these two systems is performed almost simultaneously. Therefore, for purposes of this checklist, these two
exams are divided into subsections which are listed in a logical order of performance based on minimizing
patient position changes. This means that subsections of musculoskeletal exam may be intermingled with
subsections of neuro exam, but each subsection is graded independently, and each subsection must be
passed in order to successfully complete the entire checklist. ((Bates 9th ed, pgs 497-646)
MENTAL STATUS EXAM: 2 of 3 non-critical AND the critical item must be completed.
(NOTE: During a complete physical, this section is usually done at the very beginning, along with vital signs, and
forms part of the basis for a general impression of the patient)
1.
2.
Exam
Introduce
Consciousness &
orientation &
affect
Long term
memory
Behavior
Introduction
Describe level of consciousness,
orientation to person, place, and time,
and affect
Evaluate long term memory by asking
about well known distant events
3.
4.
S/U
Short term
memory
Intellectual
function
**
CN I
5.
6.
7.
8.
9.
10.
11.
CN II
Visual Acuity
CN III, IV, VI
3.
4.
Behavior
Test patient's discrimination of odors
bilaterally
CN V, sensory
CN V, motor
CN VII
CN VIII
CN IX, X
CN X
CN XI
CN XII
March 2009
646
**
**
**
S/U
**
**
**
**
**
**
**
**
Bates p497-
Behavior
1.
Survey of
dermatomes
Light touch
Vibratory sense
Proprioception
2.
3.
4.
5.
Inspect
Bony palpation
Behavior
2.
Exam
March 2009
646
Behavior
S/U
S/U
Bates p497-
3.
4.
5.
Sitting Exam
Ankles/feet/
toes - active
ROM
Ankles/feet/
toes - passive
ROM
Muscle strength,
lower extremity
(NOTE:
Performed with
patient in sitting
position)
Ankle clonus
6.
7.
8.
- "There is no clonus" OR
- "There are ___ beats of clonus"
Upper Extremities
(Musculoskeletal and Neuro evaluated together in sitting position) 6 of 8 items must be successfully
completed for "S"
Exam
Behavior
1.
Inspect
2.
3.
Bony palpation
Soft tissue
palpation
4.
Shoulder ROM
5.
6.
Elbow ROM
Wrist ROM
Exam
March 2009
646
S/U
S/U
Bates p497-
7.
Hands ROM
Muscle strength,
upper extremity
8.
Behavior
Key Indicators of Performance
Evaluate symmetry of upper and lower - Check bicep, triceps, brachioradialis, patellar, achilles
DTRs (total of five reflexes) and
and plantar reflexes
test Babinski reflex
- "DTRs are 2+ and symmetrical, toes are downgoing"
S/U
**
Heel to shin
(HTS)
Rapid
alternating
movements
(RAM)
3.
Finger to nose
(FTN)
4.
5.
6.
Gaits
Romberg
(Equilibrium)
Behavior
Ask patient to run the heel of one foot
from opposite knee down to great toe,
and then back
Inspect for coordination during RAMs
of upper & lower extremities
S/U
Pronator Drift
(NOTE: Is
usually
performed
Have patient extend arms anteriorly,
simultaneously
palms up, eyes closed, and observe for
with Romberg
maintenance of arm position.
test, but is not
actually a part of
Romberg test)
Bates p497-
Exam
1.
Inspect
2.
3.
Bony palpation
Soft tissue
palpation
Behavior
4.
Spine ROM
S/U
COMMENTS:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
March 2009
646
Bates p497-