CLPR HEENT PHYSICAL EXAM RUBRIC Student Name: _________________________________ Examiner: ________________________ Start time: ______________ End Time:

______________ (20 minutes time max)

YES NO PTS
/3 /3

GENERAL EXPECTATIONS

Points will be subtracted from final score for any item not satisfied
EXAM ITEM

Student is on time Student washed hand/applied sanitizer before starting exam Appropriate attire, grooming, and followed no scent policy, washed hand/applied sanitizer before starting exam, Students nails are trimmed to almost no white showing
PERTINENT NEGATIVES EXPECTATION AND POINT BREAKDOWN

! ! !

! ! !

/3

POINTS

YES

NO

PTS

Inspection and Palpation of head

Normocephalic, atraumatic, with normal hair distribution for gender and age. No nits, lice, or flaking of the scalp noted

Palpation of ear

Pinna, tragus and mastoid non-tender to palpation.

Palpation of sinuses

Sinuses are non-tender to palpation bilaterally.

Let patient know that they were going to inspect and palpate their head, and asked the patient to let them know if there was any tenderness during examination Displaced sections of hair to inspect scalp and palpated scalp using both hands, covering all areas of patients scalp. Palpated pinna, tragus, and mastoid of ears bilaterally Asked patient if there was any pain. Applied moderate pressure with thumbs to frontal sinuses, using other fingers to gently brace on the sides of the head Repeated over maxillary sinuses Asked patient if there was any pain Let patient know that they were going to inspect and palpate the eye, and asked the patient to let them know if there was any tenderness during examination Displaces eye lids to inspect the sclera (bilaterally) Let patient know that they were going to touch their neck and asked the patient to let them know if there was any tenderness during

!
/1

!
/1

! ! ! ! !

! ! !

/1 /1

/1

! !

/.5 /.5

Inspection of the eyes

No heterotropia. Sclera and conjunctiva are non-injected and nonicteric. External structures of the eye without edema, ptosis, or erythema No nuchal rigidity. Trachea is midline and freely movable, neck is supple and without

!
/1

/1

Palpation of neck and trachea

Updated 10/14/13

!
/.5

CLPR Physical Exam Rubric

masses.

Palpation of lymph nodes

No lymphadenopathy in pre- and post-auricular, tonsillar, submandibular, submental, anterior and posterior cervical, occipital, and supraclavicular chains.

examination Palpated down back of neck with both hands. Used two fingers to feel above suprasternal notch and visually determine that the trachea was midline. Palpated up anterior neck with thumb on one side and two fingers on the other side checking for masses and at least one gentle movement from side to side to check that trachea was freely moveable. Let patient know that they were going to palpate lymph nodes and asked the patient to let them know if there was any tenderness during examination Palpated bi-lateral pre-auricular, posterior auricular, tonsillar, submandibular, submental, anterior and posterior cervical chains, supraclavicular, and occipital lymph nodes/chains and adequate coverage of areas Used adequate pressure Let patient know that they were going to palpate their thyroid and asked the patient to let them know if there was any tenderness during examination Stood behind patient. Find first two rings of the trachea and flatten out index and 3rd fingers on either side feeling for the thyroid. Asked patient to swallow while the examiner's other hand rolled over the thyroid cartilage. Alternatively used the anterior approach where each side of the thyroid is palpated at a time, asked patient to swallow. Pushed thyroid lateral and felt with other hand; repeated on other side. Held Snellen chart at indicated distance for patient. Had patient cover one eye with hand and read the smallest line possible

!
/1

/.5

!
/.5

/1

/.5

!
/.5

Palpation of thyroid

Thyroid is nonpalpable, OR thyroid is palpable, but nonenlarged and nonnodular.

/1

! ! !

! ! !

/.5

Visual acuity testing

Visual acuity 20/20 OS, OD, and OU with/without correction

/.5

/1

Updated 10/14/13

CLPR Physical Exam Rubric

Visual fields

Visual fields by confrontation testing are intact and adequate bilaterally.

Extraocular movements, nystagmus, convergence, accomodation

EOMI without nystagmus, convergence is symmetrical.

Assess Eye
Updated 10/14/13

No strabismus present

Repeated on opposite eye reading the same line backwards, then read lowest line with both eyes open Stood 3 feet in front of patient, at eye level, asked pt to close right eye while student closed left eye. Asked patient to look at students nose. Held fists up with palms facing student, on either side of one quadrant of view, i.e. just lateral to the head and just lateral to the nose, just above eye level. Hands held slightly closer to student than patient. Held up 1 or 2 fingers simultaneously and asked patient how many fingers they can see. Repeated until all four quadrants were tested. Using penlight or fingers, asked patient to follow the object with their eyes while keeping their head straight. Drew an H pattern slowly in the air in front of patient to test all eye movements. Distance: Held fingers or penlight at about 15 to 18 inches from patient and moved approximately 12 inches laterally from midline and 8 inches superiorly or inferiorly from eye level. Checked for nystagmus by rapidly moving the fingers or light horizontally and holding for 3 seconds while watching the patients eyes, and repeated in opposite direction Checked convergence by bringing object from near sight towards patients glabella and watching for eyes to equally converge; checked accommodation by either a) looking for pupillary constriction upon nearing the glabella, or b) asking patient to look at the wall behind the clinician and then look at the fingers or penlight near the face, looking for pupillary constriction Asked patient to look straight ahead

!
/.5

!
/.5

/1

!
/.5

!
/.5

!
/.5

/.5

/.5

/.5

CLPR Physical Exam Rubric

Alignment

and at distant object Shone penlight directly toward center of face, so that light is reflected onto both cornea Observed that light reflected in same position on cornea in left and right eyes Asked patient to focus on distant object Placed palm directly in front of one eye, and watched opposite eye for movement, as well as watched covered eye for movement upon removing the cover. Repeat opposite eye. Shone light briefly in one pupil and watched same pupil constrict Shone light again briefly in same pupil and watched for constriction of other pupil (Repeat bilaterally) Asked patient to look straight ahead and/or maintain/focus on distant object Holding ophthalmoscope with right hand when examining patients right eye (and left when examining the left) and using other hand to gently elevate the eyelid, approached patients eye at eye level and about 20 degrees from center Scanned all areas of the retina, moving from inferior nasal to superior nasal to superior temporal to inferior temporal, and lastly asked patient to look at the light to inspect the macula. (Repeat bilaterally) Stood about 2 feet behind patient, and occluded patients ear by pressing in tragus with fingers and making continuous circular motions to mask sound. Alternatively you may ask patient to occlude own ear. Exhaled fully, then whispered softly a series of three numbers, and asked patient to repeat them (Repeat

!
/1

! !

!
/.5

/.5

Cover-uncover test

No heterophoria present

/1.5

Pupillary response

Pupils are equal, round and reactive to light and accommodation

! !

! !

/1

/1

!
/.5

Fundoscopy

Fundoscopy reveals no papilledema, cupping of the optic disc, AV nicking, soft or hard exudates.

/1.5

Gross hearing

Gross hearing intact bilaterally

/1

!
/1

Updated 10/14/13

CLPR Physical Exam Rubric

Weber test

Weber test negative

Rinne test

Rinne test normal with AC>BC

Otoscopy

EACs patent and without erythema, flaking, or cerumen. TMs intact bilaterally without hyperemia, injection, retraction, bulging or exudates.

Transilluminati on of sinuses

sinuses transilluminate well bilaterally

Inspection of the nose

Updated 10/14/13

Nasal mucosa is without hyperemia,

bilaterally) Struck a 512 Hz tuning fork and placed vibrating fork on top of patients head, centrally. Asked patient where do you hear the sound? (Then clarifying if same in both ears or more in one ear, if necessary) Struck a 512 Hz tuning fork and placed vibrating fork on the mastoid process, asked patient if sound can be heard (or felt) and then asked patient to let them know when they can no longer hear it. Then placed the tuning fork in front of the auditory meatus, and asked if patient could hear it now. Repeat bilaterally Held otoscope with clean specula with handle pointing obliquely upward as if instrument were a pencil, with right hand for right ear, left hand for left ear. Used fifth digit to stabilize on patients cheek, and used opposite hand to pull pinna up and backward Advanced tip steadily to visualize EAC and TM, and repeated on opposite ear Asked patient to close eyes and explained that they would be placing a light onto the face to examine the sinuses Placed penlight inferior to medial aspect of eyebrow and angled upwards, looking for transillumination of frontal sinus, then repeated on opposite side Asked patient to tilt head back and open mouth; placed the penlight on the maxillary sinus and pointed light downward toward roof of mouth, and inspected light coming through the palate, repeating on opposite side Asked patient to tilt face up toward ceiling and gently pulled tip of nose

!
/.5

!
/.5

/1

!
/.5

!
/1

!
/.5

!
/.5

!
/1

/.5

/.5

CLPR Physical Exam Rubric

polyps, exudates, or crusts. Septum is midline and intact. Inferior and middle turbinates are nonboggy

Inspection of gums, teeth, and oral mucosa

Oral mucosa is pink, moist and without lesions. Teeth and gums are in good repair. Tongue protrudes midline.

Inspection of uvula, palate, posterior oropharynx and tonsils

Uvula is midline, soft palate rises, tonsils +___ bilaterally. Posterior oropharynx is non-injected, without exudates.

Palpation of Tongue

Tongue and floor of mouth are without induration or lesions.

Palpation of floor of mouth

backward with non-dominant hand Held otoscope with clean tip (at same angle as with ear inspection) with dominant hand and stabilized with fifth digit on patients cheek Slowly inserted tip into nose to visualize and repeated on opposite nostril (may ask patient to hold breath while visualizing) Held light source with one hand and tongue depressor with other hand (can wet tongue depressor to prevent gagging) Utilized tongue depressor to move tongue around and visualize oral mucosa, teeth and gums (can also ask patient to move tongue as needed) Thoroughly visualized all tissue surfaces, including floor of mouth Used tongue depressor to keep tongue low in mouth, and holding light source with other hand, asked patient to say ah Inspected for movement of palate, position of uvula, and posterior oropharynx Noted tonsillar size and graded them verbally (Gloved hands) Asked patient to stick tongue out, and student held tongue with small piece of gauze Palpated length of tongue on one side with opposite hand (repeat bilaterally) Held patients cheeks with thumb and third finger of one hand, and index finger placed under the chin, and asks patient to open the mouth. Opposite hand index finger (gloved) palpated the floor of the mouth Index finger of hand holding cheeks palpated under the chin simultaneously with palpation of floor of mouth

!
/.5

!
/1

!
/.5

!
/1

/.5

!
/.5

! ! !

!
/1

! !

/.5

/.5

!
/.5

!
/1

/.5

!
/.5

Updated 10/14/13

CLPR Physical Exam Rubric

Professionalism, Patient Communication & Reporting (5 pts) Demonstrated sensitivity to potential and actual discomfort associated with the examination. Physical contact demonstrated professional approach to touching and a respectful attitude toward the patient overall. Used appropriate/professional language while speaking with the patient & Instructions to the patient were easily understood Reported pertinent negatives accurately (must have approximately !80% correct language for credit) Reported positive findings accurately (i.e. aware of positive/negative findings as actually observable in the patient and described in appropriate medical terms) (must have approximately !80% correct language for credit) Total Final Total Score /50 Notes: ! ! ! ! ! ! ! ! ! !
/0.5 /0.5 /0.5 /0.5

/3

/5

Updated 10/14/13

CLPR Physical Exam Rubric