Clinical pharmacology

Surat Tanprawate, MD, MSc (Lond.), FRCP(T) Division of Neurology, Department of Medicine

Faculty of Medicine, Chiangmai University

www.surattanprawate.com

Physical examination : the method you should know

Medical data record

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

Surat Tanprawate, Chiangmai 2015.

Dont do physical examination as a blind men.

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 AdministrationScope 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

Inspection () Palpation () Percussion () Auscultation ()

musculoskeletal

Inspection () Palpation () Motion () 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 (

Respiration Pulse rate

tachycardia (>100)

bradycardia (

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

conjunctivaeicteric 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