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1 Andrew/Andrea Duncan 72 y.o. STANDARDIZED PATIENT CHECKLIST Your Name Resident Name GLOBAL RATING 1. Andrew/Andrea Duncan was satisfied with this resident physician encounter. YES NO COMMENTS: HISTORY Please record whether the learner elicited the following information. If the learner DID elicit the statement, select YES. If the learner DID NOT elicit the statement, select NO. If you are unsure, select UNSURE. Use the following guide to answer: 2. The resident asked me about my general well-being: "How are you doing? 3. The resident asked me to tell them about my back pain. 4. The resident asked me to describe the site or location of the pain. Where on your back does it hurt? ( In my lower back, right in the middle where my spine is. ) 5. The resident asked me to describe the quality of the pain. What does it feel like? ( My back feels dull and achy my legs feel prickly, crampy and tired, but only after I walk. ) 6. The resident asked me to describe the severity of the pain on a scale of ( About a 5. )
2 7. The resident asked me to describe the radiation of the pain. Does it go anywhere? ( Yes after I walk for five minutes, I can feel the pain shoot from my buttocks on down to my feet. ) 8. The resident asked me how long I have had the pain. ( The back pain has been going on for about four months the leg pain came on in the last month. ) 9. The resident asked me how long the pain lasts. ( My back hurts almost all the time. My legs get better pretty quickly after I sit down. ) 10. The resident asked me if anything makes the pain better or worse. ( Bending over, squatting, or curling up in bed seems to make it a little better. Walking definitely makes it worse. ) 11. The resident asked me if I had urinated or defecated on myself by accident, had numbness in my genitals, or had noticed leg weakness. ( Once in a while I ll lose some urine if I laugh or sneeze, otherwise, no. ) PHYSICAL EXAMINATION 12. The resident asked me to stand up for part of the exam. NOT 13. The resident asked me to bend forward while I was standing. NOT 14. The resident asked me to bend backwards while I was standing. NOT 15. The resident asked me to bend from side to side while I was standing. NOT 16. The resident asked me to keep my hips and feet still while turning my upper body left and right while I was standing. NOT 17. The resident touched the body parts of my lower back (while I was standing or sitting). NOT
3 18. The resident touched the muscles around my lower back and buttocks (while I was standing or sitting). NOT 19. The resident touched the skin on my legs and the tops of my feet and asked me if there were any areas of numbness (while I was standing or sitting). NOT 20. The resident asked me to sit for part of the exam. NOT 21. The resident pushed down on my knee or thigh while I was sitting and asked me to push upwards against him/her. NOT 22. While I was sitting, the resident asked me to kick my lower leg out while s/he pushed against it. NOT 23. While I was sitting, the resident asked me to point my toes upwards (towards the sky or my nose). NOT 24. While I was sitting, the resident asked me to point my toes downwards (like a ballet dancer on tiptoe). NOT 25. While I was sitting, the resident tapped on my knees with a reflex hammer or side of their stethoscope. NOT 26. While I was sitting, the resident tapped on the back of my heel with a reflex hammer or the side of their stethoscope. NOT 27. The resident asked me to lie down for part of the exam. NOT
4 28. The resident asked me to straighten my leg and lift it upwards (either while I was seated or lying down), and asked if I had pain. NOT 29. While lying on my back, the resident asked me to bend one knee and cross my ankle over my other knee and asked if I had pain. NOT 30. The resident asked me to walk normally. NOT 31. The resident asked me to walk on my heels. NOT 32. The resident asked me to walk on my toes. NOT
5 PATIENT-PHYSICIAN INTERACTION How was the resident you saw at: 33. Allowing you to answer questions without interrupting? 34. Behaving warmly, but professionally throughout the entire encounter? 35. Examining you in a way that felt professional and comfortable?
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