SLU CLINICAL SKILLS ASSESSMENT PHYSICAL EXAMINATION CHECKLIST

NAME____________________________________________GROUP ___________ SEC________ DATE___________________________________

PRECEPTOR_______________________________________ ENCOUNTER NO. _____________

S=Satisfactory, US=Unsatisfactory, ND=Not Done

S US ND MANEUVERS TO BE DONE ON ALL PATIENTS S US ND

__ __ __ Notes general appearance, level of __ __ __ Hearing acuity (CN VIII) General Assessment
consciousness, orientation
__ __ __ Inspect skin, nails, capillary refill __ __ __ Rinne
__ __ __ Radial pulse-rate/minute __ __ __ Weber Attention to patient comfort:
__ __ __ Blood pressure-one arm sitting __ __ __ CN IX, X (agh) Excellent Poor
__ __ __ Respiratory rate/minute __ __ __ CN XI Shrug shoulders 5 4 3 2 1
__ __ __ Temperature __ __ __ CN XII tongue out and to sides
__ __ __ Inspect conjunctiva, sclera __ __ __ Neck ROM
__ __ __ Pupillary reaction to light (CN II, III) __ __ __ Auscultate at apex, LLD, with bell Efficiency of exam:
__ __ __ Inspect oral cavity __ __ __ Auscultate heart sitting Excellent Poor
__ __ __ Palpate Neck Nodes __ __ __ Palpate axillae 5 4 3 2 1
__ __ __ Examine Thyroid __ __ __ Palpate breasts
__ __ __ Carotid arteries auscultate and palpate __ __ __ Draping:
__ __ __ Observe jugular veins-JVP estimate __ __ __ Tactile fremitus-posterior-3 sites/side Excellent Poor
__ __ __ Palpate precordium for PMI __ __ __ Palpate or percuss spine 5 4 3 2 1
__ __ __ Auscultate heart 4 areas-supine, with __ __ __ Vocal fremitus or pectoriloquy
diaphragm
__ __ __ Auscultate heart 2 areas-supine, with bell __ __ __ Egophony (E-A change) Overall skills level:
__ __ __ Inspect thorax __ __ __ Percuss costo-vertebral angles Excellent Poor
__ __ __ Percuss lungs-posterior-3 sites/side __ __ __ Auscultate renal arteries-left & right 5 4 3 2 1
__ __ __ Auscultate lungs posterior and anterior __ __ __ Determine liver span
__ __ __ Abdominal inspection __ __ __ Palpate spleen Attitude:
__ __ __ Auscultate abdomen for bowel sounds __ __ __ Palpate Inguinal nodes Excellent Poor
__ __ __ Palpate abdomen for __ __ __ Palpate femoral pulses 5 4 3 2 1
organomegaly/tenderness/masses
__ __ __ Inspect lower extremities and joints __ __ __ Auscultate femoral bruits
__ __ __ Palpate for edema __ __ __ Joint ROM Upper Extremities Significance of elicited findings:
__ __ __ Palpate leg pulses-DP,PT __ __ __ Joint ROM Lower Extremities Excellent Poor
__ __ __ __ __ __ Muscle strength-lower extremities 5 4 3 2 1
__ __ __ __ __ __ Babinski reflex
__ __ __ __ __ __ Cerebellar-FTN or RAM or HTS
__ __ __ OPTIONAL: __ __ __ Gait-normal, tandem, walk on heels & toes
__ __ __ Examine scalp __ __ __ Romberg
__ __ __ Visual fields (CN II) __ __ __ Pronator Drift
__ __ __ Extraocular movement (CN III, IV, VI) __ __ __ Back mobility-6 directions
__ __ __ Examination of nose and sinuses __ __ __ Mental Status-orientation
__ __ __ Fundoscopic exam __ __ __ Rectal Exam
__ __ __ Otoscopic ear exam __ __ __
__ __ __ CN V motor and sensory 3 branches __ __ __
__ __ __ CN VII- forehead, frown/ smile __ __ __

SCHOOL OF MEDICINE
Saint Louis University

HISTORY CHECKLIST

NAME_____________________________________________________ GROUP________SEC_______ Date________________________

PRECEPTOR __________________________________________ ENCOUNTER NO. ____________

A. HISTORY RATING SCALE

(Please encircle score)
1. Identifying Data 5 4 3 2 1
Includes at least age, sex, race, place of birth, marital status, occupation and religion
2. Chief Complaint 5 4 3 2 1
Is it a REPRESENTATIVE symptom causing the major discomfort of the patient?
3. History of Present Illness 5 4 3 2 1
Nature of Symptoms: Is it a clear, chronological account of the problem for which the patient is
seeking care?
4. Attributes of key symptoms: 5 4 3 2 1
Are the principal symptoms describes fully in terms of 1. LOCATION, 2.QUALITY, 3. QUANTITY OR
SEVERITY, 4. TIMING (onset, duration, frequency), 5. SETTING, 6. AGGRAVATING OR RELIEVING
FACTORS, 7. ASSOCIATED MANIFESTATIONS
5. Past Medical History 5 4 3 2 1
6. Social and Occupational History 5 4 3 2 1
7. Family History 5 4 3 2 1
8. Review of Systems 5 4 3 2 1
Includes a comprehensive review of organ systems RELEVANT to the diagnosis

SCORE:
History
Physical Exam
TOTAL