Clinical Skills Practical Exam

SAMPLE

Signs and Symptoms

Allergies

Medications

Past medical history

Last oral intake

Events leading up to it

OPQRST

Onset: how did the signs and symptoms begin?

Provocation/ palliation: does anything make symptoms worse?

Quality: How does this sensation feel like? Describe your pain for me?

Radiation: Where does it hurt and where is the pain?

Severity: How bad is the pain/ discomfort from a scale of 0-10?

Time: How long have the symptoms been present?

what do you use for heart sounds

BELL SIDE!!! (diastole)

What do you use for lung souds?

BIGGER SIDE- Diaphragm (systolic)

RR

12-20 bpm 15 seconds x 4 or (or by 2 if you did 30 seconds)

Pulse/ HR

60-100 BPM is a normal range 15 second period and multiply by 4 (or by 2 if you did 30 seconds, etc.).

Blood pressure - things to keep in mind

the brachial artery (look for vein), bell of stethoscope

Place the stethoscope in with the earpieces pointing correctly and inflate the cuff up to approx 160-180 mmHg

SYSTOLIC BP (top number) should be a range of < than 120

DIASTOLIC BP (bottom number) <80,

TELL THE PATIENT THE READING U GET

Height

Report in inches

: Have your patient take their shoes off and face away from the scale.

Weight

Report in lbs

Heart Sounds

Listen to the patient's heart sounds (aortic, pulmonic, tricuspid, mitral)

direct skin contact with the bell using light pressure in the correct locations)

). Report +S1 and S2 to the patient

Lung sounds

side to side

direct skin contact with the diaphragm w moderate pressure

report as clear and equal bilaterally (if abnormal say crackles in (ex right upper lobe)

Temperature

if its the one in the room (oral thermometer)

put on the cover

instruct patient to upen their mouth and lift up their tongue

report finding to the patient

EKG

• cleanse w alcohol pad

• 3 or 4 locations

O2 Adminstration

(flow rate or device),

nasal cannula : 1-6 L/min)

non-breather flow rate (12-16 L/min)

urine analysis

Dab the urine strip tile down on a paper towel, then place it right side up on the paper towel for the tiles to react

Blood glucose

alcohol swab, gauze, band-aid, lancet, test strip, and glucometer). 

Explain the procedure to the patient and ask which finger they prefer.

Clean the finger with the alcohol swab and allow it to air-dry. I

nsert your test strip into the glucometer, then press the capped lancet onto the finger (it will not “click” with the cap on).

SOAP

Subjective- Information reported by the patient, such as symptoms, history, and concerns. 

Objective- Measurable data, such as vital signs, physical exam findings, and test results. 

Assessment-The healthcare provider's interpretation of the patient's condition, including possible diagnoses and differential diagnoses.

Plan - The proposed treatment, follow-up care, and any other actions to be taken. 

Subjective

The patient is 55 year old woman who started feeling dizzy, nauseous, sweaty, and tired about 30 minutes ago while walking uphill in the park. She said the symptoms came on suddenly have been persisten since onset. Movement makes her feel worse, but she feels a little better when she sits down. She rates her discomfort a 6/10. She has a history of atrial fibrillation and takes Furosemide 40 mg once a day. She has no known allergies and had a light snack of fruits and crackers earlier in the day.

Objective

Her vital signs are stable: temperaure 97 degrees F, pulse 70, respiratory rate 14, and blood pressure 115/60. Her oxygen level is 98% on room air, and her pain level is 6/10. She is alert and oriented to a person, place, time, and situation. Her heart and lung sounds are normal. Her blood sugar is 90 mg/dl. A urinalysis showed yellow, but cloudy urine, a ph of 5, and a specific gravity of 1,020. There was no blood, protein, or glucose in the urine, but the urobillinogen was slightly low. These results suggest possible mild dehydration.

Assessment

The patient’s symptoms are most likely related to mild dehydration or low blood pressure caused by exertion and her daily use of the diuretic furosemide. Her stable vitals and normal blood sugar help rule out more serious issues for now but her history of atrial fibrillation is still important to keep in mind. The urinalysis supports that she might be slightly dehydrated, but there are no signs of infection or kidney problems.

Plan

She should be encouraged to rest and drink fluids to rehydrate. If her symptoms don’t improve or worsen, she may need IV fluids. A heart monitor or ECG may be helpful to check for any abnormal rhythms due to her history of atrial fibrillation. Her medication should be reviewed to make sure she isn’t becoming too dehydrated from the diuretic. She should avoid intense activity like walking uphill until she feels better. Follow up with her cardiologist is recommended to manage her atrial fibrillation and adjust medications if needed.