สรุปวิธีการลงบันทึกการตรวจร่างกาย Physical Examination จากการฝึกปฏิบัติ

จะต้องประกอบไปด้วยรายละเอียดดังต่อไปนี้

Vital Signs       

                        T…      P…      R…      BP…

                        Wt…   Ht…

General Appearance

-         Thai male ( female) , Age

-         Looking well

-         Normal Growth and body build

-         Cooperative

Skin / Mucous Membrane

-         Not pale, no abnormal pigmentation

-         No surgical scar or keloid

-         Normal hair and nail

Head

-         Normal shape and size

-         Normal face

-         Symmetrical

-         No bony overgrowth

Eyes

-         Normal eye movement

-         No ptosis, no Squint

-         Conjunctivitis not pale

-         No icteric sclerae

-         Pupil round and equal diameter_mm. Rt = Lt , RTL Both eyes

Fundus examination

-         Normal optic disc

-         No vascular abnormalities

-         No A-V nipping, hemorrhage or exudates

Ear

-         Normal hearing

-         No abnormal looking

Otoscopy

-         Ear canals are normal looking ( injected)

-         No discharge

-         Tympanic membranes intact

Nose

-         Symmetrical

-         No septal deviation(deviated to Rt,Lt)

-         No visble blockage, inflammation in the nostrils

Oral cavity

-         No stomatitis

-         No chelosis

-         No dental caries or gingivitis

-         Tongue not deviated

-         Pharynx not injected

-         Tonsils not enlarged, not injected

Neck

-         Trachea in midline

-         Thyroid gland not enlarged

-         Jugular veins not engorged

-         Cervical LN not palpable

Breasts

-         Normal development ( Tanner stage I-V)

-         No mass or abnormal discharge

Chest

-         Symmetrical chest wall

-         Normal breathing movement

-         Expansion full, Rt =Lt

-         Percussion resonance,Rt=Lt

-         Normal breath sound,no adventitious sunds( Crepitation,Rhonchi, Wheezing)

-         Vocal resonance,Rt=Lt

CVS

-         PMI at 5 th Lt ICS,MCL

-         No cyanosis(central, peripheral)

-         No clubbing fingers

-         No heave or thrill

-         Peripheral pulses are equal ( radial, Brachial, popliteal, posterior tibia, dorsalis pedis)

-         No carotid bruit

-         Normal S1 S2, no murmur ( Systolic injection murmur = SIM, Pansystolic murmur = PSM, Diastolic Rumbing murmur = DRM, Diastolic Blowing murmur = DBM ) […murmur grade../VI at…]

Abdomen

-         No distension, no dilated veins

-         Normal movement

-         No scar

-         Bowel sounds normal ( Increased, Decreased, Absent)

-         Soft, not tender, no mass

-         Liver and spleen can’t be palpated ( Liver enlarged_cm.below RCM Smooth surface, sharp edge, span_cm)

-         No liver stigmata ( Parotid gland enlargement, spider nevi, testicular atrophy, Palmar erythema, gynecomastia)

-         Fluid thrill negative

-         Shifting dullness negative

PR

-         Normal anus, no skin tag

-         Normal sphincter tone

-         Empty rectum

-         No tenderness, no mass

-         Prostage gland normal size

-         Normal fecies

Genitalia

Male

-         Normal pubic hair

-         Normal penis and testicular appearance

-         Testes descended

Female

-         Normal pubic hair

-         No labia swelling, no mass, inflammation

-         Normal cristoris

-         No scar ( episiotomy scar at Rt/Lt)

Extremities

-         No deformities, no petechiae, no rash

-         No edema ( pitting edema 1+)

CNS

-         Fully conscious ( drawsy, coma)

-         Good orientation to time,place,person

-         Normal speech, gait

-         Cranial nerves:normal

-         Motor grade V all extremities

-         Sensory grossly intact

-         Reflex 2+ all

-         Babinski’s sign:       neg       neg

-         Clonus:                   neg       neg

-         Cerebellar’s sign(finger to nose, heel to knee, diadocokynesia)

-         No stiff neck, Kernig’s sign :neg