clinical exam for pharmacist
DESCRIPTION
This is the slide created for teaching pharmacy student.TRANSCRIPT
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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
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Physical examination : the method you should know
Medical data record
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Recommended book and video
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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
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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
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Chief complaint
Chief complaint comprises of
= Onset + duration + symptoms or group of symptoms (syndrome)
First step of clinical thinking is symptomatology ()
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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.
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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.
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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
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Surat Tanprawate, Chiangmai 2015.
Dont do physical examination as a blind men.
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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.
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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
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Physical examination tools
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Physical examination manuvers
Inspection () Palpation () Percussion () Auscultation ()
musculoskeletal
Inspection () Palpation () Motion () Measure ()
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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.
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Temperature
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Temp
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From Bonewit-West K: Clinical procedures for medical assistants, ed 8, St Louis, 2011, Saunders.
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Pulse
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Pulse-what to check Pulse rate
tachycardia (>100)
bradycardia (
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Respiration Pulse rate
tachycardia (>100)
bradycardia (
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Pulse oximetry
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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
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General and screening examination
HEENT
Thorax
Heart
Lungs
Abdomen
Skin + hair + nail
Neurological examination
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HEENT - Head
Head: Lesion at scalp and face, aloplegia(hair loss), hydrocephalus
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HEENT - Eyes sclerae
conjunctivaeicteric sclerae
normal pale red conjunctivae in conjunctivitis
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HEENT - Ears External structure: pinna
External auditory meatus
Tympanic membrane
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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?
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simple goitre in iodine deficiency diffuse toxic goitre in Graves disease
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Throat Oropharynx
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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
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Emphysimatous pt. in tri-pod
position
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Percussion
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Auscultation Breath sound
Abnormal breath sound
branchial breath sound
crackles
wheeze
stridor
egophony
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Heart and cardiovascular system
Jugular vein, carotid artery
Heart: size, PMI
Heart sound: S1 S2, murmur
Rate (tachycardia, bradycardia)
Rhythm: regular or irregular
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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
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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)
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obese abdomen hepatomegaly
ascites enlarge gall bladder
umbilical hernia umbilical hernia with Valsava maneuver
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Shifting dullness
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Fluid thrill
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Abdomen and GI tract ANUS ( PER RECTAL EXAMINATION = PR)
SPHINCTOR TONE
HEMORRHOID
MASS
FECES - BLOOD, MELANA
- PARASITE etc.
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Thrombosed external hemorrhoid
Prolapse internal hemorrhoid
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Extremities and musculoskeletal system
Limbs: colour, deformity, range of motion
Joint: swelling, fluid, colour
spine : alignment, deformity
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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
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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
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Neurological assessment: see the video
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Thank you for your kind attention