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Clinical pharmacology

Surat Tanprawate, MD, MSc (Lond.), FRCP(T)


Division of Neurology, Department of Medicine
Faculty of Medicine, Chiangmai University
www.surattanprawate.com

Medical data record

Physical examination :
the method you should
know

Recommended book and


video

The clinical data approach


and recording

Identification data: age, sex, address, career

Chief complaint

Present illeness

Past history+Family history+History of drug use


and drug allergy

Physical examination

The clinical data approach


and recording

Problem lists

Investigation

Provisional diagnosis

Differential diagnosis

Final diagnosis

Progression note -> S.O.A.P format (inpatient)

F/U -> clinical f/u, score test, lab f/u

Chief complaint

Chief complaint comprises of


= Onset + duration + symptoms or group of
symptoms (syndrome)

First step of clinical thinking is symptomatology


()

Chief complaint :
symptomatology -1

General: Weight, appetite, fever, sleep, mood.

Eyes: Blindness, discharge, conjunctivitis,


proptosis, ptosis.

Ears: Deafness, discharge(otorhea), pain, tinitus,


fullness, dizziness.

Nose: Blockage, discharge(rhinorhea), postnasal


drip, bleeding(epistaxis), headache, cheek
swelling.

Chief complaint :
symptomatology -2

Gastrointestinal systems: abdominal pain, nausea,


vomiting, flatulence, heartburn, dysphagia, jaundice,
mass, hematemesis, melena., diarrhea, constipation,
abdominal pain, mass, hematochezia, bowel habit
change.

Cardiovascular system: Exercise intolerance, nocturnal


dyspnea, chest pain, tightness, palpitation, syncope,
cough, edema.

Respiratory system: Cough, sputum, hemoptysis,


breathlessness, hoarseness, stridor, wheezing, chest pain.

Chief complaint :
symptomatology -3

Nervous system:

cortical : alteration of consciousness, seizure

cranial nerve: diplopia, visual loss, dysphagia, deafness

motor system: weakness, abnormal movement, ataxia

sensory system: numbness, pain, headache

autonomic dysfunction: syncope, bowel and bladder


dysfunction

Dont do physical examination as a blind men.


Surat Tanprawate, Chiangmai 2015.

A resident physician in the Granada Relocation Center, examining a patient's throat.


Parker, Tom, Photographer (NARA record: 4682167) - U.S. National Archives and Records Administration

Scope and content: The full caption for this photograph reads: Granada Relocation Center, Amache, Colorado.
Doctor Gerald A. Duffy, resident physician, examining the throat of one of the first arrivals.

Physical examination

Type

General or screening physical examination

Focused or specific physical examination

exam in the detail that guided by the history or


screening exam

Physical examination

tools

Physical examination

manuvers

musculoskeletal

Inspection ()

Inspection ()

Palpation ()

Palpation ()

Percussion ()

Motion ()

Auscultation ()

Measure ()

Vital sign

Temperature (T), respiratory rate(RR), pulse rate or


heart rate (HR or PR), blood pressure (BP)

Vital signs are objective guideposts that provide


data to determine a persons state of health. Vital
signs include temperature, pulse, respiration
(collectively called TPR), and blood pressure
(BP). Another indicator of a patients health status
is pulse oximetry.

Temperature

Temp

From Bonewit-West K: Clinical procedures for medical


assistants, ed 8, St Louis, 2011, Saunders.

Pulse

Pulse-what to check

Pulse rate

tachycardia (>100)

bradycardia (<60)

Pulse rhythm, and volume

dysrhythmia (arrhythmia) - irregular between the heart beat

pulse deficit (measure apical-radial pulse)

pulse volume - bounding pulse (extremely strong)

Respiration

Pulse
oximetry

First look !

Look healthy , unwell or illness

Mental status ,speech

Expression and emotion

Build, posture and gait

Nutrition (obesity, cachexia, edema)

Skin color(anemia, jaundice, cyanosis) and lesions

Deformity

General and screening


examination

HEENT

Thorax

Heart

Lungs

Abdomen

Skin + hair + nail

Neurological
examination

HEENT - Head

Head: Lesion at scalp and face, aloplegia(hair


loss), hydrocephalus

HEENT - Eyes

sclerae

conjunctivae
icteric sclerae

normal

pale

red conjunctivae in conjunctivitis

HEENT - Ears

External structure: pinna

External auditory meatus

Tympanic membrane

HEENT - Head and Neck

Face and sinus

Lymph nodes : palpation of cervical lymph node


(lymphadenopathy?)

Thyroid : palpate to thyroid gland (look for thyroid


enlargement (goitre)

Trachea: midline?

simple goitre in iodine deficiency

diffuse toxic goitre in Graves disease

Throat

Oropharynx

Lungs and thorax exam

Inspection/observation

general comfort and breathing pattern

use of accessory muscle for breathing

color of patient (esp. around the lips, nail beds)

position of the patient (tri-pod position?)

chest deformity: barrel chest

Emphysimatous
pt. in tri-pod
position

Percussion

Auscultation

Breath sound

Abnormal breath sound

branchial breath sound

crackles

wheeze

stridor

egophony

Heart and cardiovascular


system

Jugular vein, carotid artery

Heart: size, PMI

Heart sound: S1 S2, murmur

Rate (tachycardia, bradycardia)

Rhythm: regular or irregular

Abdomen

Inspection

contour (distension/scaphoid), symmetry, scar,


dilated vessels, pulsation (aneurysm), visible
peristalsis (bowel obstruction)

Auscultation

bowel sound (3-10/mins), normal or active bowel


sound, bruit

Abdomen and GI tract

Palpation: Tenderness, rebound tenderness,


guarding, rigidity(peritonitis), mass, hepatomegaly,
splenomegaly, kidney, full bladder(urinary
retention)

Percussion: Loss of liver dullness


(pneumoperitonium), Fluid thrill/ shifting dullness
(ascites)

obese abdomen

hepatomegaly

ascites

enlarge gall bladder

umbilical hernia

umbilical hernia with Valsava maneuver

Shifting dullness

Fluid thrill

Abdomen and GI tract

ANUS ( PER RECTAL EXAMINATION = PR)

SPHINCTOR TONE

HEMORRHOID

MASS

FECES

- BLOOD, MELANA
- PARASITE etc.

Thrombosed external
hemorrhoid

Prolapse internal
hemorrhoid

Extremities and
musculoskeletal system

Limbs: colour, deformity, range of motion

Joint: swelling, fluid, colour

spine : alignment, deformity

Neurological assessment

Consciousness - wakefulness, orientation to time, place, person

Cranial nerve

CN 1: smell

CN 2: visual acuity, visual fields, pupillary response

CN 3, 4, 6: extraocular movement

CN 5: sensory of face, motor of jaw

CN 7: muscle of facial expression

CN 8: hearing

CN 9, 10: gag reflex , swallow

CN 11: sternocleidomastoid, trapezius

CN 12: tongue movement

Neurological assessment

Motor system: muscle strength, abnormal movement

Reflexes: muscle stretch reflex (DTR), pathologic


reflex (Babinskis sign)

Coordination : finger-to-nose test, heel to chin,


diadochokinesis, gait ataxia

Rombergs test

Sensation: pinprick, light touch, joint position sense

Neurological assessment:
see the video

Thank you for your kind


attention
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