Physician Assistant

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Physician Assistant

  1. 1. Summary of Program Assessment– AY 2001/02 Program of__Physician Assistant Program Program – Initiated Where, When, and How Expectatio Observations of When and By Whom Outcome of Dept. or Goal or Objective Monitored n for Student Were Results Analyzed? Analysis Program Follow- Satisfactor Performance up y Performan ce The student will Didactic Year: Pass/Fail How many students Students are assigned to x xx None demonstrate minimal 1.Summer semester-role faculty advisors who are Objective required competency in playing ______exceeded responsible for evaluating wholly Follow-up completing an 2. Spring semester-Nursing __69____met clinical write-ups during satisfied completed on appropriate complete, Home, Emergency Room, ___5__did not meet didactic and clinical year. Objective date___________ interval, or acute other clinical assignments expectations All students are evaluated not wholly Will re- history from patients within local medical ______exempted by a minimum of two satisfied. examine by of any age and either community. Patient history & __74___TOTAL faculty members to Follow-up date___________ sex in any setting. physical write-ups evaluated assure standard met strategy is: by PA faculty Clinical Year: Pass/Fail Student write-ups evaluated by program faculty each rotation Preceptor evaluation form Item 4 & 10 completed for each rotation. ** Addendum1 The student will Didactic Year: Pass/Fail How many students Students directly x xx None demonstrate minimal Summer semester-Practical observed performing Objective required competency in examination excluding neuro ______exceeded physical examination on wholly Follow-up performing, as Fall semester Neurologic ____69__met peers once during satisfied completed on appropriate, a exam practical, ___5 did not meet summer and twice during Objective date___________ complete or partial comprehensive practical expectations fall semesters. Evaluated not wholly Will re- physical examination examination Addendum *2 ______exempted by a minimum of 3 satisfied. examine by of a patient of any age, Addendum *3 ____74_TOTAL different faculty members Follow-up date___________ sex, or condition in Clinical Year Pass/Fail strategy is: any setting. Student evaluation by faculty onsite each semester. Student evaluation by preceptor Didactic Year >75% The student will Faculty evaluation of student How many students Dept. meeting date x xx None demonstrate minimal in each module utilizing case Summary meeting at end Objective required competency in based learning presentation ______exceeded of each semester to wholly Follow-up identifying, ordering, and write up instrument. __69____met evaluate student satisfied completed on performing, and/or Items 3,5,6, &8. See ___5__did not meet performance Objective date___________ interpreting addendum #4 expectations Or not wholly Will re- appropriate, cost Standardized examinations at ______exempted Individual analysis satisfied. examine by effective, routine completion of each module- ___74__TOTAL (describe)? Follow-up date___________ diagnostic procedures, students must score >75% or Students participate in strategy is: based on history and remediate material small group case based physical examination Clinical Year learning facilitated and findings, and be able Evaluated by precepting evaluated by PA program to assist the physician physician Items 4,5,6,7 on faculty in each module. with other diagnostic clinical evaluation instrument. New faculty advisor procedures as directed. * See addendum 1 assigned each semester Standardized examinations at Student evaluation form completion of each rotation- completed by precepting students must score >70% or physician at conclusion of remediate material each rotation.
  2. 2. The student will Didactic Year >75% How many students Dept. meeting date x Objective xx None demonstrate Faculty evaluation of Summary meeting at end wholly satisfied required minimal student in each module ______exceeded of each semester to Objective not Follow-up competency in the utilizing Case presentation _69_____met evaluate student wholly satisfied. completed on development of a and write up instrument. __5____did not performance Follow-up strategy date___________ differential Item 3 See addendum #4 meet or is: Will re- diagnosis and Standardized examinations expectations Individual analysis examine by diagnostic at completion of each ______exempted (describe)? date___________ impression module- students must score ___74__TOTAL Students participate in considering the >75% or remediate material small group case based database. learning facilitated and evaluated by PA program faculty in each module. New faculty advisor assigned each semester Clinical Year Student evaluation form Evaluated by precepting completed by precepting physician Items 4,5,6,7 on physician at conclusion of clinical evaluation each rotation instrument. * See addendum 1 Standardized examinations at completion of each rotation- students must score >70% or remediate material The student will Didactic Year >75% How many students Dept. meeting date Objective wholly xx None demonstrate Faculty evaluation of Summary meeting at end satisfied required minimal student in each module ______exceeded of each semester to Objective not Follow-up competency in utilizing Case presentation ____69__met evaluate student wholly satisfied. completed on identifying, and write up instrument. ____5_did not meet performance Follow-up strategy date___________ performing, and/or Items 3 See addendum #4 expectations or is: Will re- ordering Standardized examinations ______exempted Individual analysis examine by appropriate, cost at completion of each ____74_TOTAL (describe)? date___________ effective routine module- students must score therapeutic >75% or remediate material Students participate in modalities and will small group case based be able to assist the learning facilitated and physician with evaluated by PA program other therapeutic faculty in each module. procedures. New faculty advisor assigned each semester Clinical Year >70% Student evaluation form Evaluated by precepting completed by precepting physician Items 4,5,6,7 on physician at conclusion of clinical evaluation each rotation instrument. * see addendum 1 Standardized examinations at completion of each rotation- students must score >70% or remediate material The student will Didactic Year: >75% How many students Dept. meeting date Objective wholly xx None demonstrate Standardized examinations Summary meeting at end satisfied required minimal at completion of each ______exceeded of each semester to XX Objective not Follow-up competency in the module- students must score __69__met evaluate student wholly satisfied. completed on recognition, >75% or remediate material __5___did not meet performance Follow-up strategy date___________ development and expectations or is: Will re- implementation of ______exempted Individual analysis Develop mechanism examine by effective strategies ___70_TOTAL (describe)? to evaluate student date___________ for incorporating Standardized examinations implementation of health at completion of each health promotion promotion/disease rotation- students must score and disease prevention into >70% or remediate material prevention in rural primary care clinical year other practice. than standardized examinations
  3. 3. The student will Didactic Year >75% How many students Dept. meeting date Objective wholly xx None demonstrate Standardized Summary meeting at end satisfied required minimal examinations at completion ______exceeded of each semester to Objective not Follow-up competency in the of each Module- students _69___met evaluate student wholly satisfied. completed on recognition and must score >75% or ___5__did not meet performance Follow-up strategy date___________ management of remediate material expectations or is: Will re- life-threatening Standardized ______exempted Individual analysis examine by emergencies jointly examinations at completion ____74TOTAL (describe)? date___________ with, and in the of each rotation- students Student evaluation form absence of, the must score >70% or completed by precepting physician remediate material physician at conclusion of Successful completion of each rotation curriculum in Advanced Cardiac Life Support including written exam and testing stations The student will Didactic Year >75% How many students Dept. meeting date xxObjective wholly xxNone required demonstrate Faculty evaluation of Summary meeting at end satisfied Follow-up minimal student in each module ______exceeded of each semester to Objective not completed on competency the utilizing Case presentation _69___met evaluate student wholly satisfied. date___________ ability to and write up instrument. ____5_did not meet performance Follow-up strategy Will re- communicate in a Items 7 See addendum #4 expectations or is: examine by medically Professional and Behavioral ______exempted Individual analysis date___________ professional screening evaluation at end ___74_TOTAL (describe)? manner, both orally of each semester Student evaluation form and in writing, to Clinical Year completed by precepting the patient, the Evaluated by precepting physician at conclusion of family and with physician Items 8,9,10 on each rotation health care clinical evaluation professionals. instrument. * See addendum 1 The student will Didactic Year: Pass/Fail How many students Dept. meeting date xxObjective wholly xxNone required demonstrate Faculty evaluation of Summary meeting at end satisfied Follow-up knowledge of student in each module ______exceeded of each semester to Objective not completed on medical research utilizing Case presentation __69__met evaluate student wholly satisfied. date___________ methodologies and and write up instrument. __5___did not meet performance Follow-up strategy Will re- their application to Items 7 See addendum #4 expectations or is: examine by rural, community Clinical Year ______exempted Individual analysis date___________ based primary care. Completion of Evidence ___74_TOTAL (describe)? Based Medicine Curriculum Precepting physician and Distance Education Module faculty evaluation of and oral presentation to presentation-student preceptor, faculty and peers developed evaluation tool The student will Evaluated by precepting Pass/Fail How many students Dept. meeting date Objective wholly None demonstrate an physician Items 8,9,10 on Summary meeting at end satisfied required appreciation of the clinical evaluation ______exceeded of each semester to XXObjective not Follow-up perceptions and instrument. * See addendum __69__met evaluate student wholly satisfied. completed on reactions to health 1 ___5__did not meet performance Follow-up strategy date___________ problems of the expectations or is: xxWill re- individual patient ______exempted Individual analysis Review didactic and examine by as well as those of __74__TOTAL (describe)? clinical evaluation date__12/31/02_ culturally diverse tools and adapt to population groups specifically evaluate and approach each cultural awareness with sensitivity and an attitude of professional concern The student will Evaluated by precepting How many students Dept. meeting date xxObjective wholly xxNone required demonstrate a physician Items 8,9,10 on Summary meeting at end satisfied Follow-up consistent and clinical evaluation ______exceeded of each semester to Objective not completed on responsible attitude instrument. * See addendum __69__met evaluate student wholly satisfied. date___________ towards the 1 ___5__did not meet performance Follow-up strategy Will re- patient’s welfare expectations or is: examine by and best interests, ______exempted Individual analysis date___________ showing respect for __74__TOTAL (describe)? persons and their autonomy. Physician Preceptor evaluation at the completion of each clinical rotation
  4. 4. Other observations? Unexpected findings? Overall what changes/improvements are planned as a result of the assessments shown in the table? Students are required to have a minimum of 2.5 GPA at end of first summer semester in order to progress into the fall semester. Students are required to have 3.0 GPA in order to progress to clinical year. Students are required to have a 3.0 GPA in order to graduate from PA Program
  5. 5. Addendum 1 PHYSICIAN ASSISTANT IN RURAL PRIMARY CARE PROGRAM LOCK HAVEN UNIVERSITY OF PENNSYLVANIA CLINICAL EVALUATION FORM PLEASE PRINT OR TYPE: Student: Preceptor: Rotation I II III IV V (Circle one) Preceptorship I II Mark the appropriate box under each heading: 1. ATTENDANCE AND PUNCTUALITY Not observed Rarely present/ Often absent/ tardy Sometimes Rarely absent/ Always present/ punctual absent/tardy tardy punctual   2 5 6 7 8 9 10 2. PROFESSIONAL APPEARANCE Not observed Not appropriate for Generally Generally carefully Usually carefully Always carefully the setting appropriate; groomed & appro- groomed & groomed & unresponsive to priately attired with appropriately appropriately suggestions a few obvious ex- attired, with a few attired ceptions; responds minor exceptions to suggestions   2 5 6 7 8 9 10 3. INITIATIVE Not observed Not well motivated; Just getting by; Accepts requests, Accepts requests; Exceptional avoids doing accepts requests generally follows always follows motivation; far whenever possible but often fails to through & some- through & fre- exceeds expec- follow through times volunteers quently volunteers tations   2 5 6 7 8 9 10 4. CHARTS Not observed Disorganized; Incomplete, poorly Generally accurate, Accurate, complete Concise, relevant & inaccurate; material organized record complete & well & well organized; well organized; irrelevant reflects less than organized; requires reflecting good includes subtleties adequate under- minor refinement & understanding of reflecting a clear standing of clarity patients’ problems understanding of patients’ problems the case   4 5 6 7 8 9 10 5. KNOWLEDGE Not observed Unable to discuss Demonstrates fair Discusses Can accurately Reveals extensive common knowledge of pathophysiology for discuss most knowledge of pathological disease; has many most common common disease pathophysiology to processes with gaps in disease entities. entities; knowledge include the accuracy fundamental Limitations evident extends to include common disease concepts in breadth of a few uncommon entities, their knowledge disease entities sequels and other less common disease states  2 4 5 6 7 8 9 10 6. CLINICAL JUDGMENT Not observed Decisions and Demonstrates Errs often but Usually shows Sound logical recommendations sound judgment in usually learns from good judgment thinker; considers often wrong & less than half the mistakes resulting from all factors to reach ineffective cases; doesn’t sound evaluation of accurate decisions; seem to learn from factors contributes in mistakes complex cases  2 4 5 6 7 8 9 10 7. CLINICAL MANAGEMENT Not observed Contributes little to Suggests only Has sound ideas, Reveals good judg- Demonstrates patient routine care most but needs general ment and a solid, sound judgment & management plan of the time; usually assistance with but not usually extensive knowl- fails to follow the clinical extensive edge in clinical patient closely management knowledge base in management; clinical seldom requires management assistance  2 4 5 6 7 8 9 10 8. TEAM PARTICIPATION
  6. 6. Not observed Member of the Infrequently Often sensitive to Almost always Always considers team whose considers feelings, the feelings, sensitive to the the feelings, limi- behavior limitations & limitations and feelings, limitations tations & con- undermines team contributions of contributions of and contributions of tributions of others; effort other team others; occa- others promotes better members sionally has minor relations among problems with team team members members   2 5 6 7 8 9 10 9. PROFESSIONAL RELATIONSHIPS Not observed Behavior is Behavior is usually Maintains Establishes Commands unacceptable to acceptable to acceptable & atmosphere of admiration & colleagues; does colleagues. workable co-worker mutual respect & respect of co- not cooperate; Cooperates when relationships dignity with co- workers; conducts makes poor necessary; makes workers him/herself as a impression little impression true professional   2 5 6 7 8 9 10 10. RELATIONSHIP WITH PATIENTS Not observed Unable to establish Able to establish Generally Good rapport; Excellent rapport appropriate rapport fair rapport; often establishes good listens & com- with even the most with the patients seems to be a lack rapport; has occa- municates his/her difficult patients; of communication sional difficulty concern for the instills confidence communicating patients’ problems in his/her ability   2 5 6 7 8 9 10 Total Possible Total Possible Total Possible Total Total Total Total Total Total Possible Possible Possible Possible Possible Possible N/A 6 28 50 60 70 80 90 100 OVERALL EVALUATION Below Expectations Equaled Expectations Exceeded Expectations 0 5 10 Based on your experience with this student, what grade would you assign? F D C BC B AB A (circle one) 0 15 20 25 30 35 40 5 GENERAL COMMENTS: If you have any reason to question that this student will be able to perform creditably as a PA, please check the box at the right and explain under General Comments. 15 Was this evaluation discussed with the student?  Yes  No PRECEPTOR’S SIGNATURE DATE PHONE NUMBER
  7. 7. Addendum 2- to be inserted- comprehensive practical COMPREHENSIVE PHYSICAL EXAM DONE NOT DONE VITALS 1. Establish heart rate 2. Establish respiratory rate 3. Establish temperature (may give verbal indication) 4. Check BP (with steth. & cuff properly placed in one arm sitting) GENERAL INSPECTION 5. Inspects and verbalizes checking for hygiene, nutrition, habitus, apparent age, distress, eye contact, movement, behavior, accessory muscle use, nasal flaring, resp. pattern and wheezing SKIN 6. Inspects (after exposing) skin of head, neck and extremities (include palms & soles), inspects nails, hair, extremities for trophic changes, peripheral cyanosis, clubbing 7. Palpates skin to check moisture & temperature using dorsal hands/fingers 8. Check skin turgor 9. Check capillary refill (in 2 locations) HEAD, FACE AND NECK Inspect hair, face, eyes, nose, lips, thyroid (while pt. Swallows), neck, trachea 11. Palpate skull, frontal and max. sinuses & facial bones for tenderness 12. Palpate lymph nodes (occipital, preauricular, postauricular, ant/postcervical, supraclavicular, submaxillary, tonsillar, submental) EYES 13. Check gaze, general inspection of external eye structure 14. With light evaluate direct pupil reaction bilat. 15. With light evaluate consensual pupil reaction EYE MOVEMENTS 16. Check convergence and accommodation 17. EOMs (6 cardinal fields) 18. Note nystagmus 19. Check lid lag PE Form Faculty.doc last update 11/01 sj
  8. 8. Assess Vision 20. Check near vision each eye separate 21. Check near vision both eyes together DONE NOT DONE Funduscopic Exam 22. Darkens room 23. Uses right hand right eye right eye 24. Uses left hand left eye left eye 25. Check for red reflex bilat 26. Focuses & examines fundi reporting visualization of background, vessels and disc bilat. 27. Turns light back on EARS 28. Inspect external ears and mastoid area 29. Palpate external ears 30. Inspect external ear canal & TMS w/otoscope bilat 31. Pulls pinna up and back 32. Checks gross acuity bilat. 33. States would do Weber, Rinne if necessary NOSE 34. Palpate nose and check patency 35. Inspect inner nose using speculum & light MOUTH AND THROAT 36. Inspects throat, palate, gums, teeth, buccal mucosa beneath tongue using light and tongue blade 37. Ask patient to say “ah” and notes movement of uvula & palate 38. Checks gag reflex (or gives oral indication) 39. Ask patient to stick out tongue, notes position of same NECK 40. Inspect the carotid arteries 41. Inspect the jugular venous pulsation 42. Palpate the carotid pulse singularly, below the bifurcation 43. Palpate trachea 44. Check strength of neck (SCMS) CN11 by having patient lift shoulders OR turning head against resistance 45. Palpate thyroid from front & back POSTERIOR CHEST AND LUNGS 46. Inspects vertebrae, posterior unilateral lag, A-P diameter, scapula and skin PE Form Faculty.doc last update 11/01 sj
  9. 9. 47. Palpates vertebrae, scapula, paravertebral muscles, inquires about areas of tenderness 48. Performs posterior respiratory expansions upper and lower DONE NOT DONE 49. Performs tactile fremitus, posterior and lateral lobes, side to side 50. Percuss lung fields-posterior and lateral lung fields (axilla), side to side 51. Performs diaphragmatic excursions comparing bilaterally 52. Auscultate lung fields (side-to-side), w/diaph., posterior and lateral lung fields, monitoring patient’s breathing pattern ANTERIOR CHEST, HEART AND LUNGS (patient sitting) 53. Inspect the precordium (pulmonic area, aortic area, tricuspid area, mitral areas), anterior chest and skin, use of diaphragm, muscle tone, intercostal muscles 54. Inspect PMI 55. Palpates costal cartilages, ribs, sternum, xiphoid process, clavicles asking patient about areas of tenderness, also palpate pulmonic, aortic, tricuspid and mitral areas for heaves, lifts and thrills 56. Perform respiratory expansion, upper and lower 57. Perform tactile fremitus including apex, side to side 58. Percuss lung fields including apex, side to side 59. Auscultate lung fields (side to side) w/diaph. including apex 60. Auscultate carotids bilat. 61. Auscultate the Aortic, Pulmonic, Third left interspace (Erb’s point), Tricuspid, and Mitral areas (with bell and diaphragm) Patient Supine 62. Inspect (with tangential light) Carotid arteries 63. Inspect the Internal Jugular Venous pulsation 64. Inspect the Precordium 65. Inspect the PMI 66. Palpate the carotid arteries (singularly, below bifurcation) 67. Palpate the PMI 68. Palpate the pulmonary, aortic, tricus and mitral areas for heaves, lifts and thrills 69. Auscultate (with bell and diaph) carotids and 5 areas of chest 70. In left lateral decubitus position auscultate (with bell) mitral areas and axilla ABDOMEN 71. Inspection for: Scars, Hernias, abdominal distention, peristalsis PE Form Faculty.doc last update 11/01 sj
  10. 10. Auscultation w/bell 72. Peristalsis in 4 Quadrants 73. Aorta, Renal Arteries, Iliac Arteries 74. Venous Hum, Friction Rubs, Hepatic, Splenic rubs Percussion DONE NOT DONE 75. 4 Quadrants - General 76. Liver Span 77. Gastric Bubble 78. Urinary Bladder 79. Spleen Palpation 80. Femoral arteries, compare side to side 81. Light Palpation of 4 Quadrants 82. Deep palpation of 4 Quadrants, Aorta 83. Spleen 84. Inguinal Lymphadenopathy 85. Muscle Tone, Hernias, Abdominal Mass 86. Liver 87. Kidneys PERIPHERAL PULSES Palpate and compare side to side; 88. Radial 89. Brachial 90. Popliteal 91. Posterior tibial 92. Dorsalis pedis MUSCULOSKELETAL Patient Sitting 93. Inspect and palpate c-spine 94. Active range of motion, c-spine (flexion, extension, rotation lateral bending) 95. Evaluate range of motion of TMJ; palpate for crepitus 96. Inspection of hands and wrists for swelling, tenderness, sub-luxation, redness, nodules, deformities or muscle atrophy 97. Active range of motion of wrist (flexion and extension, lateral and medial) 98. Active range of motion of hands (flexion and extension) 99. Palpation of the distal interphalangeal joint, proximal interphalangeal joint, metacarpophalangeal joints and wrist joint 100. Inspection and palpation of elbow joint for swelling, redness, nodules PE Form Faculty.doc last update 11/01 sj
  11. 11. 101. Active range of motion of elbows (flexion, extension, supination and pronation) 102. Inspection and palpation of the sternoclavicular joints, AC joints, subacromial areas, bicipital grooves) DONE NOT DONE 103. Range of motion of the shoulder flexion/extension, external rotation, abduction, internal rotation and adduction Patient Supine 104. Inspect and palpate toes, feet, ankles 105. Active range of motion of ankle (dorsiflex, plantarflex inversion, eversion) 106. Inspection and palpation of ankle joint and MTP joint 107. Active range of motion of MTP joints 108. Inspection of the knees (swelling, atrophy of quads) 109. Bilateral palpation of knees - lateral and medial laxity 110. Inspect and palpate hips 111. Range of motion of the hips (flexion, extension, rotation, abduction and adduction) Patient Standing 112. Inspect the spine laterally for curvature 113. Inspection of spine from behind for pelvic tilt, alignment/scoliosis 114. Palpation of spine and paravertebral muscles and SI joints 115. Range of motion of back (flexion, extension, lateral bending and rotation) MENTAL STATUS EXAMINATION (State an example of how you would evaluate each) 116. Appearance (grooming, dress and hygiene) 117. Psychomotor activity 118. Speech 119. Orientation 120. Intelligence 121. Memory 122. Concentration 123. Abstractions 124. Insight & Judgment 125. Affect CEREBELLAR TESTING 126. Coordinate Movements (Patient Standing) PE Form Faculty.doc last update 11/01 sj
  12. 12. a. Gait/station b. Tandem walking c. Heel and toe walking 127. Rapid Alternating Movements bilateral (Patient Sitting) a. Heel/shin b. Finger-to-nose c. Rhomberg DONE NOT DONE MOTOR TESTING (Bilateral with patient sitting) 128. Inspect muscle size/tone 129. Involuntary movements/passive range of motion 130. Muscle strength (against resistance) a. arm flexors b. arm extensors c. shoulders d. quadriceps e. hamstrings f. foot flexors g. foot extensors h. hip ab/aductors SENSORY TESTING (Bilateral, patient sitting) 131. Dorsal column a. vibration sense 132. Lateral Spinothalamic System a. pain and temperature 133. Cerebral Cortex a. stereognosis b. graphesthesia MUSCLE STRETCH - REFLEX TESTING (Pt. sitting bilateral) 134. Biceps tendon 135. Brachioradialis tendon 136. Triceps tendon 137. Infrapatellar tendon 138. Achilles tendon MISCELLANEOUS 140. Technique & rapport 141. Organization PE Form Faculty.doc last update 11/01 sj
  13. 13. Performance Completed > 90% Excellent/Pass Completed > 80% Good/ Pass Completed > 70% Fair/ Pass Completed < 70% Poor/Fail PE Form Faculty.doc last update 11/01 sj
  14. 14. Addendum 3-to be inserted comprehensive neuro The Complete Neuro Physical Exam Mental Statues, Cranial Nerves, Sensory, Motor, Reflexes & Cerebellar Student’s Name: __________________________________ Date: ________________________ Physical Exams Points Evaluators’ Name: ____________________________________ MS CN Sense Motor Rflx Cere Total Possible 13 18 6 5 10 9 62 Grading & Feedback Criteria Items are not checked as done if: missed 1) The item was not performed, done incorrectly, done incompletely/poorly/inaccurately, or student did not explain what they were performing. 2) The item was performed without regard to patient’s comfort, safety or feelings. Total Total 3) Student, when requested by faculty, was unable to explain the technique or the reason Grade Check One Quality missed Percent (DiffDx) for the exam. (circle) exams Correct Feedback: The rubric below is not the grade but gives quantitative feedback to the student Excellent ≤ 3 ≥ 95% while giving guidelines for the PASS / FAIL grade. Failure requires preparation homework turned in before next exam. The homework is assigned & checked of in comment section. Pass Good 4-9 ≥ 85% Fair 8--14 ≥ 75% Comments & Homework Assignment : Fail Poor ≥ 15 <75% Homework handed in date? ______________ PE Form Faculty.doc last update 11/01 sj
  15. 15. Mental Status Exam Category Test Done Notes/ Method / DiffDx Level of Consciousness See note 1 below Posture and Motor Behavior abnormal: tense, restless, crying, pacing, handwringing, agitated, slumped, singing, expansive Hygiene: DiffDx: Dress, Grooming and 1) deteriorate in depression, schizophrenia and dementia. Appearance & Personal 2) fastidiousness in obsessive-compulsive d/0 Behavior 3) onesided-neglect: parietal cortex lesion opposite side. Observe Facial Expressions Expressions of anxiety, depression, apathy, anger, elation Parkinsonism: facial immobility Manner, Affect, and Paranoid: anger, hostility, suspiciousness, evasiveness Relationship to Persons and Manic: elation, euphoria Things Schizophrenia: flat affect, remoteness Dementia: Apathy, dull affect with detachment Anxiety, Depression Quantity, Rate & Loudness talkative/quiet. Comments spontaneous or only responsive to questions. Listen Depression: slow Manic: Rapid & loud Articulation & fluency of 5) Repetition Repeat a phrase of one syllable words ; “no ifs, ands, or buts.” Language Speech & words: Combined Multiple Test: 5) Repetition 1) Name pen & card 1) Naming 2) Command to take card 2) Word comprehension & pen 3) Reading comprehension 3) Read card out loud 4) Writing) 4a) Follow instructions 4b) Writes sentence in instruction Mood Question on mood Psych Depression, suicidal, contentment, elation, anger, rage, violent Thought Processes Logic, relevance, organization, coherence. (bates, pg 114). Thought Content Compulsions, obsessions, phobias, anxieties, feelings of unreality, feelings of depersonalization, delusions. See note 4 below Perceptions Illusions, hallucinations Perceptions Thought & Insight & Judgment Method: “If you found an addressed envelop on the street with a stamp, what Listen in History Pursue if suspicious Psych would you do?” Psychosis, Demential F n u n n v o e c s Orientation 1) Ask: Time, Place Person Delerium t t i i i PE Form Faculty.doc last update 11/01 sj
  16. 16. Attention 1) Digit span OR 2) Serial 7’s OR 3) Spelling Backward Remote Memory Inquire birthdays, anniversaries, social security number, names of schools Inquire attended, jobs, historic events DiffDx: Dementia Recent Memory Inquire today’s weather, appointment times, tests just done (not breakfast) New Learning Ability remember 3 words and after few minutes repeat Information and Vocabulary name last 4 presidents, five large cities, president/vice president/governor inquire Higherr Cognitive DiffDx: poor intelligence Calculating Ability inquire 4+3=?, 5X6=? and harder Functions Abstract Thinking 1) stitch in times saves nice/ don’t count your chicken before they hatch 1) Proverb meaning OR 2) apple and orang/ cat and mouse/ child and dwarf/ church and theeater/ piano 2) Similarities and violin/ wood and coal Constructional Ability 1) Copy figures OR DiffDx: dementia, parietal lobe damage, mental retardation 2) Draw clock face with numbers and hands. Note 1 : Levels of Consciousness a) Alertness b) Lethargy: appears drowsy but opens eyes, looks and responds to questions but then falls asleep. c) Obtundation Opens eyes, looks, responds slowly 7 mildly confused. d) Stupor Arouses only to painful stimuli. e) Coma no arousal to even painful stimuli Note 2: 3 Disorders of Speech 1. The voice Aphonia (loss of voice, ?laryngeal nerve), Dysphonia (volume: laryngeal tumors, inflammation) 2. Articulation Dysarthria: motor lesions, parkinsonism, cerebellar dz. 3. Aphasia Producing or understanding language Wernicke’s (oral & visual comprehension impaired) Broca’s (compreshension partially intact) PE Form Faculty.doc last update 11/01 sj
  17. 17. Cranial Nerve Exam Nerve & Fiber type Done Test Notes/ Method / DiffDx Smell Test) Inspect nares, check patency first. Eyes closed, alternate nostrils. Acceptable: coffee, soap, vanilla, lemon. Do not use I Olfactory S irritants like ammonia (stimulates trigeminal nerve) DiffDx: tumor, infective/inflammatory, DM neuropathy, parkinson’s, huntington’s chorea Visual Acuity Schnellen Chart. Corrected and uncorrected. Must do OS, OD & OU Visual Fields screen by confrontation. individual eyes tested. Temporal, Medial, superior and inferior fields screened. II Optic S Fundoscopy Ocular Fundi: Optic atrophy, loss of retinal venous pulsation, papilledema hemorrhages or exudates, cotton wool spots (retinal infarcs) , nicking Color Vision Identify 2 colors in the room. Or Ishihara color plates. Pupillary Reaction Size: Equal Shape: Round P Reaction to Light: Reactive. Check both direct and Consensual. III Oculomotor PERRLA (Pupils Equal, Round, Reactive to Light & Accommodating.) M 1) Extraocular Movements EOM: 6 cardinal directions. “SO4 LR6 “(Superior oblique=4th, Lat. Rectus=6th, rest=3rd) 2) Lid Muscle (observe) Nystagmus: horizontal, vertical, rotary or mixed Lid Muscle (observe): IV Trochlear M DiffDx: Ptosis (3rd nerve palsy, Horner’s syndrome, myasthenia gravis) VI Abducens M Coma Corneal reflexes Have pts look to opposite side. lightly touch corneal. do not touch eyelashes or conjunctiva. Facial Sensation 3 branch areas: Ophthalmic, Maxillary and Mandibular branches. S sharp, dull. Confirm abn. with temp & light touch. V Trigeminal Note: 2nd cervical is sensory for back of head. DiffDx: trigeminal neuralgia (“tic Douloureux) Jaw Movements palpate: temporal & masseter muscles with teeth clench M Note: Jaw reflex could be tested which also tests sensory component. Facial Movements symmetry, equal range of movement. 1. raise both eyebrows Supplies anterior 2/3 oftongue for taste. 2. frown DiffDx: Bell’s Palsy M 3. close eyes tight (pry) VII Facial 4. show upper & lower teeth. 5. smile 6. puff out both cheeks Taste Test Anterior 2/3 of tongue. Faculty may ask student to describe technique and defer formal S testing. Following order: anterior to posterior: sweet, salty, sour, bitter. (See CN9) VIII Auditory S Gross Hearing test Finger Rub PE Form Faculty.doc last update 11/01 sj
  18. 18. 1. Lateralization Unilateral conductive hearing loss. Weber Test 2. Air-Bone Conduction M: mastoid (fold ear forward) then in front. Rinne Test Conductive hearing loss: BC=>AC Sensorineural hearing loss: AC>BC Vestibulo- coma 1) Caloric Hot – Cold Ear Lavage. S 2) Balance Balance also measured by Cerebellar tests: Romberg, Point-to-point, nystagmus cochlear S (taste test see 7th CN) Posterior 1/3 of tongue Glosso- IX Swallowing IX difficult to test and seldom necessary. Supplies posterior 1/3 of tongue taste. pharyngeal M Rise of Palate Ask: say “ah” or to yawn. Should rise centrally. X Vagus S coma Gag Reflex Spinal 1) Shoulder Shrug 1) shoulder shrug (Traps) XI M Accessory 2) Neck Movements 2) push head against hand laterally (SCM) Tongue symmetry Inspect tongue. XII Hypoglossal M Tongue position Atrophy fasciculations (amyotrophic lateral sclerosis, polio) V MS Voice and Speech VII exam X XII Sensory Exam Done Test Notes/ Method / DiffDx Observation Observation Symmetry, Atrophy Light Touch Lightly touch skin with wisp of cotton. Sample many dermatomes. anesthesia: absence to touch sensation hypesthesia: decreased sensitivity hyperesthesia: increased sensitivity Pain (Sharp/Dull) analgesia: absence of pain Primary hypalgesia: decreased sensitivity Sensory hyperalgesia: increased sensitivity Functions pass Temperature / Deep Pressure Only done if pain sensation not intact. Temperature: Include if pain sensation not clear Deep Pressure: Firmly squeeze calf, traps or biceps Vibration Start distal, proximal if abnormal. DiffDx: peripheral neuropathy. (DM, ETOH) PE Form Faculty.doc last update 11/01 sj
  19. 19. Proprioception Start distal, proximal if abnormal. Position of Joint: Big toe. should sense with <10 degree. Stereognosis Pts. eyes closed in all tests. Identify: Coin, key, pencil, cotton ball. Discriminative Distinguish head from tail on coin. (Cortical) This is sufficient screen. Proceed if abn. Sensations Graphesthesia Number Identification: draw large number in palm Two-point discrimination open paper clip. find minimal. Nml < 5mm on finger pads. Alternate single & double stimuli, should be able to differentiate. (Do Any 3) Point Localization Pt. closes eyes. Touch a spot on trunk or legs and ask pt. to identify verbally or by point. Extinction Simultaneously touch same spot on opposite legs. Ask pt. “where am I touching”. Should identify both. General 1. Systematic by dermatome Samples dermatomes from cervical through sacral. 2. Side to side 3. Proximal to distal Motor Exam Done Test Notes/ Method / DiffDx Position of Body Observe Gait & Stance limps, Involuntary Observe Tics: Observe Movements Fasciculation: ALS, anxiety Fibrillation: upper motor neuron, CVA Myoclonus Chorea Athetosis Size Upper arm 1. Observe atrophy / hypertrophy (Girth) 2. Measure Measure / Test Forearm Thigh Calf Strength Active ROM Against resistance or gravity if not possible Tone Passive Range of Motion Palpates muscle group throughout full range of motion Reflex Exam Done Reflex Spinal Level Notes/ Method / DiffDx Biceps C 5, 6 Place thumb or finger on bicep tendon. Reflexess Tendon Deep Triceps C 6, 7 Sitting, Lying or hanging at 90 deg. Brachioradialis C 5, 6 PE Form Faculty.doc last update 11/01 sj
  20. 20. Patellar L 2, 3, 4 lying or sitting Achilles S1 dorsiflex the foot ! sitting or lying (rest on shin of other leg) Superficial Abdominals T (7) 8, 9 ( 10 ) Absent in central and peripheral nervous disorders. T 10 , 11, (12) pass Cremasteric Reflex T12, L1,2 Stroke inner thigh (male) prox. to distal. Testicle and scrotum should rise. Latin: Cremaster=to suspend Superficial Reflexes Plantar response L 5, S 1 * lateral heel to ball curving medially. (Babinski) Normal: “Downgoing” Abnormal (positive): “Up going”: Big toe dorsiflex and other toes fan < 2 year: nml = up-going. Abnormal = CNS corticospinal tract lesion, pyramidal tract disease drug or etoh intox., postictal. pass Anal reflex S2,3,4 “Anal Wink” R/O: Cauda equina lesion Ankle Clonus Tell student, “Patient has hyperactive reflexes. What additional test should you do?” Clonus sustained clonus (> few beats) = central nervous system disease. Reflex Grades: 4+ Hyperactive with sustained clonus (rhythmic oscillation between flexion and reported accurately extension) or drawn correctly 3+ Brisker than average 2+ Average; normal 1+ Somewhat diminished; low normal 0 No response Normal range: 0 – 3. But attention if recent change or differences between sides. Others Abnormale: +4, or changes from normal. 0 is must be further explored. *hyperactive suggest: CNS disease. Clonus confirms *diminished/ absent: lost sensation, relevant spinal segment damage, peripheral nerve damage, neuromuscular dz. *Slow relaxation of reflex = hypothyroidism Reinforcement techniques Isometric contraction of other muscles, etc: used appropriately Arm reflexes: clench teeth or squeeze thigh with opposite arm Leg reflexes: lock fingers and pull Abdomen: Pull naval away and feel PE Form Faculty.doc last update 11/01 sj
  21. 21. Cerebellar Exam Function Done Test Notes/ Method / DiffDx Rapid Alternating Face Tongue wiggle test Wiggle tongue rapidly side to side or protrude and retract rapidly. Movements DiffDx: weakness (myasthenia gravis, bulbar palsy), rigidity (parkinsonism) Arms 1. Knee pat test Observe speed, rhythm, and smoothness. 2. Finger – finger test Dysdiadochokinesis (lack of regular rhythm & force of repeated motion.) Legs Foot tap test Coordination Arms Nose-finger-nose test Their index finger between your index finger and their nose, then overhead. Both dominant and non-dominant Dysmetria: overshooting or undershooting targets. Legs Heels shin test Heel to opposite knee, down shin. (repeat with eyes closed) Equilibrium Rhomberg test 20 – 30 seconds. Arms to side, feet together. First eyes opened then close eyes. finally push to check recovery. Hop in place Hop on one foot. DiffDx: weakness, lack of position or cerebellar dysfunction. Pronator Drift 20 – 30 seconds. Arms straight forward, palms up & eyes closed. Then tap arms briskly – should return to position. Gait Ataxia: gait lacks coordination with reeling and instability. 1) Walk across room 2) Heal to toe (“tandem Gait disorders: walk”) 1) Scissoring gait: bilateral spastic paresis of legs 2) Steppage gait: foot drop. 3) Tabetic (posterior-column: neurosyphilis). Lifts legs high and forcibly brought down. heel stamps ground. 4) Cerebellar ataxia: wide-based, unsteady with short shuffling steps. Tendency to fall to either side. 5) Sensory ataxia: Assoc. w/ loss of position from polyneuropathy or post. column damage. throw feet forward and outward. Watch ground for guidance. Unsteady and wide. 6) Truncle ataxia Cerebellar findings MS Speech (Mental): Listen to speech Dysarthria: slurred speech – tongue dysfunction. from other CN Eyes (Cranial Nerves): exams Nystagmus Sources: 1) Bates, Edition 7, 1999 2) Willms: Physical Diagnosis: Bedside Evaluation of Diagnosis and Function. 1994 3) Perkin: Mosby’s Color Atlas and Text of Neurology. 1998 PE Form Faculty.doc last update 11/01 sj
  22. 22. Addendum 4- Short Form Behavioral Assessment LHUP Physician Assistant Program Behavioral & Professional Evaluation Assessment Student: _______________________ Date: ____________ Evaluation Team Members: ____________________ ___________________ ____________________ ___________________ ____________________ ___________________ i Candidates for the Master of Health Science Degree and the certificate as a physician assistant must have the abilities and skills in five areas including communication, motor, conceptual, integrative and quantitative, and behavioral and social. Technologic compensation can be made for some handicaps in certain of these areas, but a candidate should be able to perform in a reasonably independent manner. Technical Standard Meets Areas of Concern Does not meet Observation *Communication Motor Skills Intellectual Behavioral Attendance Other Characteristics Professionalism Attitude English Language Ability Empathy Attendance & Punctuality Clinical Behavior **Personality Traits * The candidate is able to speak, hear, observe patients, elicit information, describe changes in mood, activity, and posture, and perceive nonverbal communications. communicate effectively and sensitively with patients. Communication includes not only speech but also reading and writing. The candidate must be able to communicate effectively and efficiently in oral and written form with all members of the health care team. **Personality Traits: This section is not for diagnostic purposes, it is to help identify patterns of behavior that may be problematic, i.e., currently, or potentially may, interfere with the student’s performance as a professional physician assistant. If identifiable patterns of behavior are perceived, the student should be directed to counseling or other appropriate mental health professional for definitive assessment PE Form Faculty.doc last update 11/01 sj
  23. 23. Addendum 4 (2)- Long Form Behavioral Assessment Student_________________________________________ Date of Assessment_______________________________ Signatures of Persons Making in Behavioral Assessment: _____________________________________________ _________________________________________________ _____________________________________________ _________________________________________________ _____________________________________________ _________________________________________________ Technical Standards Does Not Areas of Concern Meets Technical Standard Meet Observation: The candidate is able to observe demonstrations and experiments in the basic sciences, including but not limited to physiologic and pharmacological demonstrations, microbiological cultures, and microscopic studies of microorganisms and tissues in normal and pathologic states observe and inspect a patient accurately at a distance and close at hand. Observation necessitates the functional use of the sense of vision and somatic sensation. It is enhanced by the functional use of the sense of smell. Communication: The candidate is able to speak, hear, observe patients, elicit information, describe changes in mood, activity, and posture, and perceive nonverbal communications. communicate effectively and sensitively with patients. Communication includes not only speech but also reading and writing. The candidate must be able to communicate effectively and efficiently in oral and written form with all members of the health care team. Motor: Candidates should have sufficient motor functions to elicit information from patients by palpation, auscultation, percussion, and other diagnostic maneuvers. Do basic laboratory tests (urinalysis, CBC, etc.), carry out diagnostic procedures (proctoscopy, paracentesis, etc.), and read EKGs and x-rays. Execute motor movements reasonably required to provide general care and emergency treatment to patients. Examples of emergency treatment reasonably required of physicians are cardiopulmonary resuscitation, the administration of intravenous medication, the application of pressure to stop bleeding, the opening of obstructed airways, and suturing of simple wounds, and the performance of simple obstetrical maneuvers. Such actions require coordination of both gross and fine muscular movements, equilibrium, and functional use of the senses of touch and vision. Intellectual-Conceptual, Integrative and Quantitative Abilities: These abilities include measurement, calculation, reasoning, analysis, and synthesis. Problem solving, the critical skill demanded of physician assistants, requires all of these intellectual abilities. In addition, the PE Form Faculty.doc last update 11/01 sj
  24. 24. candidate should be able to comprehend three-dimensional relationships and to understand the spatial relationships of structures. Behavioral and Social Attributes: A candidate must possess the emotional health required for full utilization of his/her intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities attendant to the diagnosis and care of patients, and the development of mature, sensitive, and effective relationships with patients. Candidates must be able to tolerate physically taxing workloads and to function effectively under stress. They must be able to adapt to changing environments, display flexibility, learn to function in the face of uncertainties in the clinical problems of many patients. Demonstrate compassion, integrity, concern for others, interpersonal skills, interest, motivation Attendance, punctuality, participation and performance are integral responsibilities of all professionals Professionalism Unacceptable Areas of Concern Acceptable Trait/Behavior Altruism (the best interest of others, not self-interest, comes first) Accountability (takes responsibility for own actions) Excellence (conscientious effort to exceed ordinary expectations) Duty (free acceptance of a commitment to service) Honor and Integrity (the consistent regard for the highest standards of behavior and the refusal to violate one’s personal and professional codes) Respect for Others (the essence of humanism) Attitude Unacceptable Areas of Concern Acceptable Attitude: I already know it all (just give me my degree) On time Talks in class Not a team player Listens attentively and maintains appropriate and direct eye contact when communicating with faculty and peers Initiates communication which is appropriate and timely Asks relevant and understandable questions Uses discretion regarding questions asked and/or statements made during class PE Form Faculty.doc last update 11/01 sj
  25. 25. Responds to faculty, staff and peers readily and tactfully Uses body posture and gestures that suggest attentiveness, approachability and acceptance Refrains from revealing negative feelings through tone of voice or body language Recognizes effects of own non-verbal communication upon others Adjusts verbal and non-verbal communications to others Reacts in a positive manner to questions, suggestions, and/or constructive criticism Recognizes that once a negotiated decision has been reached, further discussion or action may be non- productive Demonstrates positive attitude toward learning Is on time for all scheduled classes and labs, including timely return from breaks Relies on personal resources before approaching others for help Demonstrates cooperation with and mutual respect for peers Communication: Communication problems have been linked to the following behavior problems. If a student manifests any of the following behaviors a communication disorder should be considered Unacceptable Areas of Concern Acceptable Communication Behavior: difficulty with listening, difficulty following directions, difficulty comprehending assignments, difficulty using conversational skills, inability to express feelings appropriately, avoidance of participation in groups, a reliance on behavioral actions or facial PE Form Faculty.doc last update 11/01 sj
  26. 26. expressions to communicate intent rather than the linguistic forms the individual may be capable of using English Language Ability: Unacceptable Areas of Concern Acceptable Language Ability written spoken comprehension Empathy: The process of taking on the role or perspective of another; which promotes reciprocity in social relationships; becoming sensitive to peer expectations; is a function of the observer's ability to discriminate between the various affective states experienced by others. Unacceptable Areas of Concern Acceptable Attribute Avoids or is able to jettison, stereotypes, bias and prejudice (racial, cultural, sexual/gender, etc), ethnocentricity Demonstrates understanding of sensitivities of diverse peoples Demonstrates sympathy toward others Demonstrates compassion toward others PE Form Faculty.doc last update 11/01 sj

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