Pharmacists' scope of practice is rapidly evolving to include more sophisticated patient assessment, including physical examination. This page includes important links, cheat sheets, and references useful for pharmacists wishing to practice to their full scope.

Videos & Pictures

• TED Talk: A Doctor's Touch A video about the importance of physical examination to the physician-patient relationship, which is equally applicable to the pharmacist-patient relationship.

Findings on exam

Gen / Derm

• Skin mottling
  • MoA: Hypoperfusion of the skin.
  • DDx: Shock (hypovolemic, cardiogenic, obstructive or vasodilatory).
• Blue man syndrome from amiodarone

ENT

• Eyes: Corneal deposits from amiodarone

CVS

• JVP: Cannon A waves [1], [2] (due to AVNRT, with subsequent resolution following carotid sinus massage)
  • MoA: Right atrium contracts against a closed tricuspid valve.
  • DDx: 1o AVB with marked prolonged PR interval, arrhythmias (3o AVB, SVT/APC, VT/PVC), severe TS.
• JVP: Monomorphic venous pulsation (Lancisi's sign) [1] , [2]
  • MoA: Blood flows retrograde into right atrium via regurgitant tricuspid valve during ventricular systole, obliterating the x descent of the typical jugular venous pulsation.
  • DDx: Severe TR (functional changes 2o to volume/pressure overload vs endocarditis, rheumatic fever, congenital, etc)
• JVP: Kussmaul's sign
  • MoA: The right ventricle is unable to accommodate the increased venous return on inspiration, leading to a rise (or no change) in the JVP rather than the typical lowering.
  • DDx: Severe LV/RV dysfunction, RV infarct, PE, TS, constrictive pericarditis, restrictive cardiomyopathy.

Neuro

• Motor & tone: Acute dystonia from metoclopramide use
  • MoA: Dopamine D2 receptor blockade in the nigrostrial pathway leads to increased, sustained muscle tone. 
  • Drug DDx: Antipsychotics (1st gen > 2nd gen), metoclopramide, especially parenteral administration & higher doses.
• Motor & tone: Clonus

Endo

• Myxedema (severe hypothyroidism)

Books

1. Oxford Handbook of Clinical Examination and Practical Skills The most pertinent and succinct how-to guide for physical examination.
2. The Rational Clinical Examination A collection of systematic reviews evaluating the physical examination diagnosis of common and important condition.
3. Mechanisms of Clinical Signs Brief mechanistic explanation and differential diagnosis for key physical examination findings.
4. Bates' Guide to Physical Examination and History-Taking

Articles

• Does this patient have a pleural effusion? JAMA 2009;301:309-17. 
• Fundamentals of lung auscultation NEJM 2014;370:744-51.
• Towards the standardisation of lung sound nomenclature Eur Respir J 2016;47:724-32.

Apps

• Diagnose A collection of key physical exam findings that change the likelihood of a diagnosis (based mainly on the JAMA Rational Clinical Examination series)