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
