Final Video History and Physical Grading Rubric

Student Name: Mallory Zabor

Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)
CHIEF COMPLAINT/REASON FOR VISIT 1 1
PAST MEDICAL HISTORY 1 1
 General state of health
 Significant illnesses
 Surgeries
 Other hospitalizations
 Trauma
MEDICATIONS 1 1
 Prescription
 Over the counter
 Herbal/alternative treatments
ALLERGIES 1 1
 Seasonal or contact or food or insect-sting
 Drug
 Reaction
IMMUNIZATIONS 1 0, neglected/forgot
assessment piece
FAMILY MEDICAL HISTORY (Need to give 1 1
3 disease examples from each system for full
credit)
 Cardiovascular
 Pulmonary
 Gastrointestinal
 Renal
 Endocrine
 Musculoskeletal
 Neurological
 Hematological
 Psychiatric

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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)
 Cancer

PSYCHOSOCIAL 1 0.75; could have been more

 Work/school thorough and inquired further
 Home/family/relationships regarding this
 Leisure activities
 Stress factors
 Support system
HEALTH RISK FACTORS 1 0.5; needed to inquire more
 Smoking regarding amount of alcohol when
 Alcohol socially drinking, marijuana
 Other social drugs frequency and use/method, ask for
 Environmental risks further elaboration for diet.
 Diet
 Exercise
 Recent travel
Total for this section: 8 6.25 *
GENERAL 1
 Recent weight change 1
 Malaise
 Fatigue
 Appetite disturbance
 Sleep disturbance
 Fever
 Chills
 Night sweats
SKIN/HAIR/NAILS 1 1
 Lesions
 Itching
 Changes in texture
 Rash
 Abnormal hair growth or loss or other changes in
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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)
hair
 Changes in nails
 Tendency to bleed or bruise
 Change in moles
HEAD 1 1
 Hx of head injury
 Headaches
 Dizziness
EYES 1 1
 Visual changes
 Double vision
 Visual acuity
 Discomfort
 Glasses/contact lenses
 Last eye exam
EARS 1 0.75; forgot vertigo
 Earache
 Tinnitus
 Discharge
 Vertigo
 Hearing loss
NOSE and SINUSES 1 1
 Rhinitis
 Allergies
 Nosebleeds
 Injury
MOUTH and THROAT 1 1
 Sore throat
 Hoarseness
 Sore tongue
 Bleeding gums
 Loose, broken, or decayed teeth
 Difficulty or pain with swallowing

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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)
 Last dental exam

NECK 1 1
 Lumps
 Swollen glands
 Goiter or other thyroid issue
 Pain on movement
BREASTS (First 3 should be asked of males 1 1
and females)
 Lumps
 Pain
 Discharge
 Self-examination practices
 Last mammogram
PULMONARY 1 1
 Cough
 Sputum
 Hemoptysis
 Dyspnea
 Pleural pain
CARDIOVASCULAR 1 1
 Chest Pain
 Shortness of breath
 Palpitations
 History of murmur
 Orthopnea
 Intermittent claudication
 Syncope
 Last EKG

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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)

GASTROINTESTINAL 1 1
 Dysphagia
 Nausea
 Vomiting
 Dyspepsia
 Hematemesis
 History of ulcers
 Abdominal pain
 Changes in stool
 Rectal problems
PERIPHERAL VASCULAR 1 1
 Cold, numbness, pallor in legs
 Extremity hair loss
 Swelling in calves, legs, or feet
 Color change in fingers or toes in cold weather
 Swelling with redness or tenderness in
extremities.
GENITOURINARY 1 1
 Frequency
 Nocturia
 Dysuria
 Incontinence
 Hematuria and/or changes in color
 Renal stones

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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)

FEMALE REPRODUCTIVE 1
 Last pelvic examination
 Last pap smear
 Menstrual history
 Menstrual problems
 Vaginal discharge
 Contraception
 History of pregnancies
1
MALE REPRODUCTIVE
 Scrotal masses
 Pain or discharge
 Hernia
 Prostate infection or enlargement
 Difficulty with erection or ejaculation
 Self-examination practices
NEUROLOGICAL 1 1
 Seizures
 Numbness or tingling
 Weakness
 Pain
MUSCULOSKELETAL 1 1
 Joint pain, redness, stiffness, swelling
 Decreased range of motion
 Back, limb or neck pain
HEMATOLOGIC 1 1
 Anemia
 Easy bruising or bleeding
 Past transfusions; transfusion reactions

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 Health History Points Points and comments (Student) Points Earned and Comments
Possible (Faculty)
 Clotting disorders

ENDOCRINE 1 1
 Excessive thirst or urination
 Heat or cold intolerance
 Wt gain or loss
 Hair, skin, nail changes
SEXUALITY 1 1
 Sexual Identity
 Sexually active or Celibate
 Number of partners
 Hx of STDs
PSYCHIATRIC 1 1
 History of any treatment in the past for
psychiatric disorders
 Mood swings
 Hallucinations
 Delusions
Total for this section: 21 20.75*

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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)
Wash/Sanitize Hands 1 1
GENERAL AND SKIN
Vital signs (BP, P, R) 1 1
Inspect General Appearance 1 1
Inspect and Palpate Integument (anterior and posterior) 1 1
HEAD/FACE, HAIR
 Inspect & palpate scalp, hair 4 4
 Inspect and palpate bone configuration of face and skull
 Assess CN VII - (facial muscles - smiling, frowning, puffing
cheeks)
 Test sensation - forehead, cheeks, jaw (CN V)—should do both
light touch assessment and pain (dull/sharp) tests
EYES
 Check best corrected vision/visual acuity (CN II) (use handheld 5.25; neglected to
eye chart or Snellen chart) 6 closely inspect eyes and
 Inspect external ocular structures (lids, conjunctiva, sclera, displace eyelids to view,
cornea, lacrimal ducts, eye alignment)
assessed without doing
 Observe pupillary response to light and accommodation
 Evaluate EOMs (CN III, IV, and VI)
such
 Examine visual fields
 Inspect the internal ocular structures (lens and retina) with
opthalmoscope
EARS
 Inspect and palpate the external ear and mastoid 5
 Inspect internal ear structures 5
 Assess CN VIII (whisper test or finger rub)
 Weber test
 Rinne test
NOSE
 Inspect external nasal structures 3 3
 Palpate sinuses (frontal and maxillary)
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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)
 Inspect internal nasal structures (septum and turbinates)
MOUTH 3; neglected assessment
 Inspect oral cavity and pharynx 4 of masseter/TMJ (CN V)
 Assess CN IX (elevation of uvula)
 Assess CN XII (tongue movement and strength)
 Evaluate masseter compression and TMJ (CN V)
NECK
 Palpate the lymph nodes (Preauricular, posterior auricular, 12 12
occipital, tonsillar, submandibular, submental, superficial cervical,
posterior cervical, deep cervical chain, supraclavicular)- Say lymph
nodes that you are palpating while performing this part of the
assessment. 0.5 point deduction for each one not palpated (5 points
total)
 Inspect the position of the trachea
 Palpate the carotid pulse
 Auscultate carotids
 Shrug shoulders against resistance (CN XI)
 Turn head against resistance (XI)
 Determine range of motion of cervical spine
THYROID
 Observe the size of the thyroid
Palpate the thyroid with and without swallowing using posterior
assessment method.

CHEST
POSTERIOR CHEST 13 13
 Inspect posterior thorax during inspiration and expiration
 Palpate posterior thorax and assess for symmetry on inspiration
and expiration
 Palpate for tactile fremitus
 Percuss lung fields
 Percuss flanks (check for CV tenderness)
 Auscultate the lung fields (systematically, side to side) (do not
listen through clothing)

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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)

ANTERIOR CHEST
 Inspect the anterior chest during inspiration and expiration
 Palpate anterior thorax including supraclavicular area and assess
for symmetry on inspiration and expiration
 Palpate for tactile fremitus
 Percuss anterior chest
 Auscultate all areas including apices (do not listen through
clothing)
 Estimate A:P diameter (student should verbalize)
 Auscultate lateral thorax
HEART
 Inspect neck veins and precordium 6
 Palpate for PMI, heaves, and thrills when supine 6
 Auscultate the heart (aortic, pulmonic, tricuspid, mitral) using
both the bell and the diaphragm
 Auscultate 3 cardinal positions (sitting forward , supine, left
lateral decubitus) (1 points for each position)
ABDOMEN
NOTE: Students should verbalize all auscultatory areas; Auscultate
before manipulation or palpation (-1 point if not done after
inspection)
15 14, I believe I forgot to
 Inspect the abdomen, including both flanks and groin
palpate (lightly and
 Auscultate bowel sounds in all four quadrants (not over gown)
 Auscultate abdominal aorta, liver, spleen, renal arteries, iliac deeply); was highly
arteries, femoral arteries (1 point each) distracted by continued
 Percuss abdomen re-direction of patient
 Percuss the liver and estimate measurement of liver span to put hands at sides as
 Palpate the abdomen systematically using light and deep doing abdominal
palpation (legs should be bent for deep palpation) assessment however, I
 Palpate abdominal aorta am not making excuse. I
 Palpate the liver
Knew I was forgetting
 Palpate the spleen
something as I moved to
 Palpate the femoral pulses

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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)
next assessment piece
but decided to not delay
remainder of exam at
risk of losing points for
time and further
distraction.
HANDS AND ARMS
 Inspect the nails and check for capillary refill 8 8
 Inspect and palpate joints and musculature of upper extremities
 Palpate radial, ulnar, and brachial pulses bilaterally (1 point
each)
 Assess active ROM of the joints of the fingers and hands
 Assess active ROM of the joints of the arms (including elbow
and shoulder)
 Palpate the epitrochlear lymph nodes
LOWER EXTREMITIES AND SPINE
 Inspect the nails and check for capillary refill 8 8
 Inspect and palpate joints and musculature of lower extremities
 Palpate dorsalis pedis, posterior tibial, and popliteal pulses
bilaterally (1 point each)
 Assess the active ROM of the toes, ankles, knees, and hips
 Inspect and palpate spine
 Observe ROM of spine
NEUROLOGICAL
 Test for motor function against resistance in upper extremities 18 17.5; forgot to do rapid
(fingers, wrists, elbows, shoulders) alternating movements
 Test motor function against resistance in lower extremities
(toes, ankles, knees, and hips)
 Test for vibratory sense
 Test for sensation (both light touch and pain [dull/sharp])
bilaterally upper and lower extremities
 Test cerebellar function (finger to nose, heel to shin, rapid
alternating movements, heel toe walking, knee bend)

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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)
 Assess deep tendon reflexes in upper and lower extremities
(biceps, triceps, brachioradialis, knees, Achilles) (1 point each)
 Test for Babinski
 Test for clonus
 Test proprioception bilaterally (position sense in toe and
finger)
 Test for neurosensory loss to pain (monofilament test)
 Test Rhomberg
 Observe gait (walking normal, on tiptoes, and on heels) (1
point each)
MENTAL STATUS
 Orientation (time, place, personal identity) 5 4; forgot abstract
 Memory (recent, remote) reasoning and
 Calculation calculation
 Abstract reasoning
Learning (assessment of immediate recall of 3 words and then
recall of the same 3 words later on in the mental status exam)
Total for this section: 111 106.75 *
PERFORMANCE SKILLS Possible Points Points Earned and Points Earned and Comments
Comments (Student) (Faculty)
 During the physical examination did the student: 10 points 9; don’t believe I offered
o Coordinate the examination in a systematic manner blanket to cover lower
o Perform techniques smoothly half while doing supine
o Did not examine through gown assessments however, I
o Appropriately draped and positioned patient felt as though my exam
o Give clear directions to the patient resulting in smooth made sense and was out
patient performance of order in some ways but
o Provide explanations to the patient went ahead and
examined extra items
o Deal with patient’s questions and concerns
while I was assessing
o Deal with patient’s nonverbal communicated concerns
those regions to try to
(trembling, signs of pain, etc) have lesser patient
o Maintain time frame without rushing repositioning and have it
o Avoid medical jargon, used lay terms “make sense” for the
patient, as opposed to the
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 Performance of Physical Exam Points Points Earned and Points Earned and Comments
(Each item is worth 2 points unless otherwise specified) Possible Comments (student) (Faculty)
system that we are
following as healthcare
professionals at times.
Total Points for all sections 150 142.75**

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