PharmD , doctor of pharmacy Ward rounds basic clinical skills howto take case of patients

1. Basic Parameters in Patient Profile
Form
Manik Chhabra
Department of Pharmacy Practice
ISF College of Pharmacy, Moga 142001, Punjab
Punjab, INDIA

2. List of medical abbreviations: Latin
abbreviations
bbrev. Meaning Latin (or New Latin) origin
a.c. before meals ante cibum
a.d., ad, AD right ear auris dextra
a.m., am, AM morning ante meridiem
a.s., as, AS left ear auris sinistra
a.u., au, AU both ears together or each ear aures unitas or auris uterque
b.d.s, bds, BDS 2 times a day bis die sumendum
b.i.d., bid, bd
twice a day / twice daily / 2
times daily
bis in die
gtt., gtt drop(s) gutta(e)
h., h hour hora
h.s., hs at bedtime or half strength hora somni
ii two tablets duos doses

3. iii three tablets trēs doses
n.p.o., npo, NPO
nothing by mouth / not by
oral administration
nil per os
o.d., od, OD
once a day
right eye
omne in die
oculus dexter
o.s., os, OS left eye oculus sinister
o.u., ou, OU both eyes oculus uterque
p.c. after food post cibum
p.m., pm, PM afternoon or evening post meridiem
p.o., po, PO
orally / by mouth / oral
administration
per os / nonstandard form per
orem
p.r., pr, PR rectally per rectum
p.r.n., prn, PRN
as needed, (also Pertactin - a
key antigen of ac.Pertussis
vaccine)
pro re nata
q. every quaque

4. q.1.d., q1d every day quaque die
q.1.h., q1h every hour quaque hora
q.2.h., q2h every 2 hours quaque secunda hora
q.4.h., q4h every 4 hours quaque quarta hora
q.6.h., q6h every 6 hours quaque sexta hora
q.8.h., q8h every 8 hours quaque octava hora
q.a.m., qAM, qam every morning quaque ante meridiem
q.d., qd every day / daily quaque die
q.d.s, qds, QDS 4 times a day quater die sumendum
q.h., qh every hour, hourly quaque hora
q.h.s., qhs
every night at
bedtime
quaque hora somni
q.i.d, qid 4 times a day quater in die

5. Medical History
 "Always listen to the patient, they might be telling you the
diagnosis."
William Osler
 The medical history of a patient is the most useful and important
element in making an accurate diagnosis, much more valuable
than either physical examinations or diagnostic tests.
 The medical interview is the process of gathering data that will
lead to an understanding of the disease and the underlying
physiological process.
 To be effective, an interviewer must possess good
communication skills and be alert to nonverbal clues as well as
to the verbal message.
 Often, more information is conveyed by nonverbal actions and
tone of voice than by words.

6. Importance of Medical History
The objective is to obtain an accurate and comprehensive
picture of the patient’s situation, including the nature and
timing of symptoms, emotional factors (including types
of stress), and past medical conditions that may place the
patient at greater risk for certain diseases.
The information obtained in this way, together with the
physical examination, enables the Physician to form
a diagnosis and Clinical Pharmacist (PharmD) to form
a treatment plan.
Clinical Pharmacist with the help of proper medical
history can review the case and plan the therapy in a
better way.

7. Importance of Medical History…
Ultimately, a proper medical history taking is an art
which will help in better patient outcomes.
A complete medical history consists of an account of:
(1) The present illness;
(2) Past medical history;
(3) Family history;
(4) Occupational background;
(5) Psychosocial history; and
(6) A review of body systems.

8. The Present Illness
• An account of the present illness, which includes the
circumstances surrounding the onset of recent health
changes and the chronology of subsequent events that
have led the patient to seek medical care, is essential
to understanding the course of the disease process.
• Medications are listed in the medical history because
they may play a role in the current illness.

9. Past Medical History
• The past medical history is an overall view of the
patient’s health prior to the present illness.
• It should include previous hospitalizations, injuries,
operations, and any significant illness that may not
have required hospitalization.

10. Family History
• Family history consists of information about disorders
from which the direct blood relatives of the patient have
suffered.
AIM
 Accurate knowledge of a patient's family history to
identify a predisposition to developing certain illnesses
 To take clinical decisions and allow effective
management or even prevention of present conditions .

11. Family History…
• Included in a family history are the age and state of health of each
immediate family member as well as the cause of death of any
parents, grandparents, and other close relatives.
• Of particular importance are genetic or environmental diseases that
have known risks.
• If a close relative such as a father died of a heart attack (acute MI)
before age 60, all his children are at greater risk of suffering an early
heart attack.
• This risk increases if other factors such as hypertension or elevated
serum cholesterol are present.
• Similarly, a history of some cancers (e.g., colorectal cancer)
increases the risk that offspring will develop that type of cancer.
• The development of lung cancer in a person provides even greater
impetus for close relatives to avoid smoking.

12. Family History…
Examples of other diseases that may have
hereditary roots are schizophrenia, diabetes
mellitus and other forms of mental illness,
and arthritis.
In fact, any disease that arises in two or more
members of a family suggests a possible
predisposing factor, and the patient should be
considered to be at increased risk for this
condition.

13. Social History (OccupationalSocial History (Occupational
Background)Background) Similarly, patients assume that their doctor knows their social
situation. It may be relevant such as the single mother with a
handicapped child or the child with asthma who lives in a smoky,
damp and overcrowded environment.
 Occupation may be very relevant to the aetiology of the disease
and its management. It also indicates the person's level of
education and hence ability to comprehend certain issues.
 It is a portion of the medical history including the following points
addressing
familial status
Occupational
recreational aspects of the patient's personal life that have the
potential to be clinically significant.

14. The occupational history is important because the
workplace may be a source of toxins, such as chemicals,
asbestos fibres, or cigarette smoke, that place one at
higher risk of cancer or other diseases.
Components can include inquiries about:
Substances
Alcohol
Tobacco
illicit drugs (illegal drugs)
occupation

15. Allergy History
• An allergy is a hypersensitivity disorder of
the immune system. Main aim is to provide
proper health care
Symptoms-
 Red eyes
 Itching
 Runny nose
 Eczema
 Hives, or an asthma

16. Provisional Diagnosis
Provisional diagnosis means they are not 100% sure of
your diagnosis because they need more information.
It is just what they are "guesstimating" as your most likely
diagnosis for the time being based upon what they have.
Differential diagnosis means there is more than one
possibility for what your diagnosis is and they must
differentiate between these to determine what your actual
diagnosis is.

17. ExaminationExamination
• The first part of any examination is to observe. Learn
to observe.
• Look before you lay on hands.
• Examination of the cardiovascular or respiratory
systems does not start with the stethoscope.
• You may get valuable information from the facies,
skin colouration, gait, handshake and personal
hygiene (reflective of physical, psychological and
social background).
• Note the red eye, paleness of skin, dullness of skin
any swelling etc.
• A number of endocrine disorders may be
immediately apparent.

18. Physical examination
Central nervous system (CNS)
 Orientation (OPPT)
 Head
 Consciousness
 Calm
 Aggressive
 Depression

19. Cardiovascular
 Edema
 Pallor
 Koilonychia
 Cyanosis
 Clubbing
 Icterus
 Lymphatic node enlargement

20. 1. Edema (Cardiovascular Exam)
Increased fluid in the interstitial tissue spaces.
• Fluid may also accumulate in body cavities:
1. Hydrothorax
2. Hydropericardium
3. Hydroperitoneum is also called Ascites
• Massive generalized edema is called Anasarca

21. Fluid Homeostasis
Homeostasis is maintained by the opposing effects of:
•Vascular Hydrostatic Pressure
•Plasma Colloid Osmotic Pressure

22. Normal
Pulmonary Edema

23. Edema of the BrainEdema of the Brain
Trauma, Abscess, Neoplasm, Infection
(Encephalitis due to say… West Nile
Virus), etc

24. Edema MorphologyEdema Morphology
Subcutaneous EdemaSubcutaneous Edema
 Edema of the subcutaneous tissue is most easily detectedEdema of the subcutaneous tissue is most easily detected GrosslyGrossly
(not microscopically)(not microscopically)
 Push your finger into itPush your finger into it
 Depression remainsDepression remains
 Dependent Edema is a prominent feature of Congestive Heart
Failure

25. 2. Pallor
Pallor is a pale color of the skin which can be caused by illness,
emotional shock or stress, stimulant use, or anemia, and is the result of
a reduced amount of oxyhaemoglobin in skin or mucous membrane.
.

26. Pallor…
• Pallor is more evident on the face and palms. It can
develop suddenly or gradually, depending on the
cause.
• It is not usually clinically significant unless it is
accompanied by a general pallor (pale lips, tongue,
palms, mouth and other regions with mucous
membranes).
• It is distinguished from similar presentations such as
hypopigmentation (lack or loss of skin pigment) or
simply a fair complexion

27. Causes of pallor
• Migraine attack or headache
• Excess estradiol and/or
estrone
• Vitamin D deficiency
• Osteoporosis
• Emotional response, due to
fear, embarrassment, grief
• Anemia, due to blood loss,
poor nutrition, or underlying
disease such as sickle cell
anemia
• Shock, a medical emergency
caused by illness or injury
• Frostbite
• Common cold
• Cancer
• Hypoglycemia
• Leukemia
• Panic attack

28. Koilonychia
• Koilonychia also known as spoon nails
• It is is a nail disease that can be a sign of
hypochromic anemia, especially iron-
deficiency anemia.
• koilonychia is the opposite of nail clubbing.
• Koilonychia is associated with Plummer-
Vinson syndrome and iron deficiency anemia.

29. Koilonychia nail

30. Cyanosis
• Cyanosis is defined as a bluish discoloration,
especially of the skin and mucous membranes,
due to excessive concentration of
deoxyhemoglobin in the blood caused by
deoxygenation.

31. Cyanosis is divided into two main types
• Central (around the core, lips, and tongue)
• Peripheral (only the extremities or fingers).

32. Central cyanosis
• Central cyanosis is often
due to a circulatory or
ventilatory problem that
leads to poor blood
oxygenation in the
lungs. It develops when
arterial oxygen
saturation drops to
≤85% or ≤75%.
• Central cyanosis may be
due to the following
causes:
• 1. Central nervous
system (impairing
normal ventilation):
• 2. Respiratory system:
• 3. Cardiovascular
diseases:

33. Peripheral cyanosis
• Peripheral cyanosis is the blue tint in fingers due to
inadequate circulation.
• The blood reaching the extremities is not oxygen rich
and when viewed through the skin a combination of
factors can lead to the appearance of a blue color.
• Peripheral cyanosis can be observed in the absence
of heart or lung failures. Small blood vessels may be
restricted and can be treated by increasing the normal
oxygenation level of the blood.

34. Peripheral cyanosis may be due to the following
causes:
• All common causes of central cyanosis
• Reduced cardiac output (e.g. heart failure,
hypovolaemia)
• Cold exposure
• Arterial obstruction (e.g. peripheral vascular
disease, Raynaud phenomenon)
• Venous obstruction (e.g. deep vein
thrombosis)

35. Differential cyanosis
• Differential cyanosis is the bluish coloration of the lower
but not the upper extremity and the head.
• This is seen in patients with a patent ductus arteriosus.
• Patients with a large ductus develop progressive pulmonary
vascular disease, and pressure overload of the right
ventricle occurs.
• As soon as pulmonary pressure exceeds aortic pressure,
shunt reversal (right-to-left shunt) occurs.
• The upper extremity remains pink because the
brachiocephalic trunk, left common carotid trunk and the
left subclavian trunk is given off proximal to the PDA.

36. Diagnosis of Cyanosis
• Inquire about duration (cyanosis since birth suggests
congenital heart disease) and exposures (drugs or
chemicals that result in abnormal hemoglobins).
• Differentiate central from peripheral cyanosis.
• Check for nail clubbing.
• Combination of clubbing and cyanosis suggests
congenital heart disease and occasionally pulmonary
disease.
• If cyanosis is localized to an extremity evaluate for
peripheral vascular obstruction
• Evaluate abnormal hemoglobins by hemoglobin
electrophoresis, spectroscopy, and measurement of
methemoglobin level

37. A baby with a heart condition. Note
purple nailbeds.

38. Clubbing
• A nonspecific sign of pulmonary and cyanotic
cardiovascular disorders
• Clubbing is painless ,usually bilateral increase
in soft tissues around the terminal phalanges of
fingers or toes
• In early normal clubbing ,the normal 160-
degree angle between the nail and nail base is
about 180 degree as clubbing progresses this
angle widens becomes visibly swollen

39. Finger and toe clubbing

40. Icterus or Jaundice
The term jaundice comes from the French word jaune,
meaning yellow.
Jaundice is a yellowish pigmentation of the skin, the
conjunctival membranes over the sclerae (whites of the
eyes)
•Yellow colour of mucous membranes caused by
hyperbilirubinemia (increased levels of bilirubin in the
blood)
• This hyperbilirubinemia subsequently causes increased
levels of bilirubin in the extracellular fluid. Concentration of
bilirubin in blood plasma is normally below 1.2 mg/dL
(<25µmol/L). A concentration higher than approx. 3 mg/dL
(>50µmol/L) leads to jaundice.

41. • Jaundice is often seen in liver disease such as hepatitis or
liver cancer.
• It may also indicate leptospirosis or obstruction of the
biliary tract, for example by gallstones or pancreatic
cancer,
• less commonly be congenital in origin (e.g., biliary
atresia).
• Yellow discoloration of the skin, especially on the
palms and the soles, but not of the sclera and mucous
membranes (i.e. oral cavity) is due to carotenemia—a
harmless condition important to differentiate from
jaundice.

42. Signs and symptoms of Icterus
• The main symptom of jaundice is a yellow
discoloration of the white part of the eyes
(sclera) and of the skin.
• The conjunctiva of the eye are one of the first
tissues to change color as bilirubin levels rise
in jaundice. This is sometimes referred to as
scleral icterus.

43. Signs and symptoms
• The sclera themselves are not "icteric" (stained
with bile pigment) but rather the conjunctival
membranes that overlie them.
• The yellowing of the "white of the eye" is thus
more properly termed conjunctival icterus. The
term "icterus" itself is sometimes incorrectly used
to refer to jaundice that is noted in the sclera of the
eyes .
• It is more common and more correct meaning is
entirely synonymous with jaundice

44. A 4-year-old boy with icteric (jaundiced) sclera
which later proved to be a manifestation of
hemolytic anemia due to G6PD deficiency
following fava bean consumption
Jaundice

45. BIOCHEMICAL
Tests

46. Introduction and roles of various
Biochemical tests in Diagnosis

47. Introduction to Clinical biochemistry
• CLINICAL BIOCHEMISTRY (also known as clinical
chemistry or chemical pathology) is the laboratory
service absolutely essential for medical practice or
branch of laboratory medicine in which chemical and
biochemical methods are applied to the study of
disease.
• The results of the biochemical investigations carried
out in a clinical chemistry laboratory will help the
clinicians to determine the diseases (diagnosis) and
for follow-up of the treatment/recovery from the
illness (prognosis).

48. Introduction to Clinical biochemistryIntroduction to Clinical biochemistry

49. Introduction to Clinical biochemistry
 The use of biochemical tests:The use of biochemical tests:
 Biochemical investigations are involved in everyBiochemical investigations are involved in every
branch of clinical medicine.branch of clinical medicine.
 The results of biochemical tests may be of use in:The results of biochemical tests may be of use in:
 diagnosis and in the monitoring of treatment.diagnosis and in the monitoring of treatment.
 screening for disease or in assesing the prognosis.screening for disease or in assesing the prognosis.
 reseach into the biochemical basis of diseasereseach into the biochemical basis of disease
 clinical trials of new drugsclinical trials of new drugs
 Biochemical investigations hold the key for theBiochemical investigations hold the key for the
diagnosis and prognosis of diabetes mellitus,diagnosis and prognosis of diabetes mellitus,
jaundice, myocardial infarction, gout, pancreatitis,jaundice, myocardial infarction, gout, pancreatitis,
rickets, cancers, acid-base imbalance etc. Successfulrickets, cancers, acid-base imbalance etc. Successful
medical practice is unimaginable without the servicemedical practice is unimaginable without the service
of clinical biochemistry laboratory.of clinical biochemistry laboratory.

50. Test selection for the purposes of discretionary
testing
CategoryCategory ExampleExample
To confirm a diagnosisTo confirm a diagnosis Plasma (free TPlasma (free T44) and (thyroid-) and (thyroid-
stimulating hormone, TSH) instimulating hormone, TSH) in
suspected hyperthyroidismsuspected hyperthyroidism
To aid differential diagnosisTo aid differential diagnosis To distinguish between differentTo distinguish between different
forms of jaundiceforms of jaundice
To refine a diagnosisTo refine a diagnosis Use of ACTH to localize Cushing'sUse of ACTH to localize Cushing's
syndromesyndrome
To asses the severity of diseaseTo asses the severity of disease Plasma (creatinine) or (urea) inPlasma (creatinine) or (urea) in
renal diseaserenal disease
To monitor progressTo monitor progress Plasma (glucose) to follow ofPlasma (glucose) to follow of
patients with diabetes mellituspatients with diabetes mellitus
To detect complications or sideTo detect complications or side
effectseffects
ALT measurements in patientsALT measurements in patients
treated with hepatotoxic drugtreated with hepatotoxic drug
To monitor therapyTo monitor therapy Plasma drug concentration inPlasma drug concentration in
patients treated with antiepilepticpatients treated with antiepileptic
drugsdrugs

51. Examples of tests used in case-finding
programmes.
Programmes to detect diseases inProgrammes to detect diseases in Chemical investigationsChemical investigations
NeonatesNeonates::
PKAPKA (phenylketonuria)(phenylketonuria) Serum [phenylalanine]Serum [phenylalanine]
HypothyroidismHypothyroidism Serum [TSH] and/or [thyroxine]Serum [TSH] and/or [thyroxine]
Adolescents and young adultsAdolescents and young adults::
Substance abuseSubstance abuse Drug screenDrug screen
PregnancyPregnancy::
Diabetes mellitus in the motherDiabetes mellitus in the mother Plasma and urine [glucose]Plasma and urine [glucose]
Open neural tube defect (NTD) in the foetusOpen neural tube defect (NTD) in the foetus Maternal serum [a-fetoprotein]Maternal serum [a-fetoprotein]
Industry:Industry:
Industrial exposure to leadIndustrial exposure to lead Blood [lead]Blood [lead]
Industrial exposure to pesticidesIndustrial exposure to pesticides Plasma cholinesterase activityPlasma cholinesterase activity
MalnutritionMalnutrition Plasma [albumin] and/or [pre-albumin]Plasma [albumin] and/or [pre-albumin]
Thyroid dysfunctionThyroid dysfunction Plasma [TSH] and/or [thyroxine]Plasma [TSH] and/or [thyroxine]

52. Tests used in case-finding programmes

53. DiseaseDisease Unexpected abnormal test resultsUnexpected abnormal test results
HyperparathyroidismHyperparathyroidism Raised plasma calciumRaised plasma calcium
HypothyroidismHypothyroidism Raised plasma TSH and/or a low TRaised plasma TSH and/or a low T44
Diabetes mellitusDiabetes mellitus High random plasma glucoseHigh random plasma glucose
Renal tract diseaseRenal tract disease Raised plasma creatinine or ureaRaised plasma creatinine or urea
Liver diseaseLiver disease Increased plasma ALT, ASTIncreased plasma ALT, AST

54. Programmes to detect diseases inProgrammes to detect diseases in Chemical investigationsChemical investigations
NeonatesNeonates::
PKAPKA (phenylketonuria)(phenylketonuria) Serum [phenylalanine]Serum [phenylalanine]
HypothyroidismHypothyroidism Serum [TSH] and/or [thyroxine]Serum [TSH] and/or [thyroxine]
Adolescents and young adultsAdolescents and young adults::
Substance abuseSubstance abuse Drug screenDrug screen
PregnancyPregnancy::
Diabetes mellitus in the motherDiabetes mellitus in the mother Plasma and urine [glucose]Plasma and urine [glucose]
Open neural tube defect (NTD) in the foetusOpen neural tube defect (NTD) in the foetus Maternal serum [a-fetoprotein]Maternal serum [a-fetoprotein]
Industry:Industry:
Industrial exposure to leadIndustrial exposure to lead Blood [lead]Blood [lead]
Industrial exposure to pesticidesIndustrial exposure to pesticides Plasma cholinesterase activityPlasma cholinesterase activity
MalnutritionMalnutrition Plasma [albumin] and/or [pre-albumin]Plasma [albumin] and/or [pre-albumin]
Thyroid dysfunctionThyroid dysfunction Plasma [TSH] and/or [thyroxine]Plasma [TSH] and/or [thyroxine]

55.  The biochemical investigations (on blood/The biochemical investigations (on blood/
plasma/serum) carried out in the clinicalplasma/serum) carried out in the clinical
biochemistry laboratory may be grouped intobiochemistry laboratory may be grouped into
different typesdifferent types..

1.1. Discretionary or on-off tests :Discretionary or on-off tests : MostMost
common clinical biochemistry tests that arecommon clinical biochemistry tests that are
designed to answer specific questions, e.g.,designed to answer specific questions, e.g.,
does the patient have increased blooddoes the patient have increased blood
urea/glucose concentration? Normally, theseurea/glucose concentration? Normally, these
tests are useful to support the diagnosis.tests are useful to support the diagnosis.
TYPES OFTYPES OF
LABORATORY TESTSLABORATORY TESTS::

56. • 2. Biochemical profiles : These
tests are based on the fact
that more useful information
on the patients disease status
can be obtained by analysing
zor more constituents rather
than one e.g., plasma
electrolytes (Na+, K+, Cl-,
bicarbonate, urea); liver
function tests (serum
bilirubin, ALT, AST).

57. • 3. Dynamic function tests : These
tests are designed to measure the
body's response to external stimulus
e.g., oral glucose tolerance test (to
assess glucose homeostasis) :
bromosulphthfein test (to assess
liver function)