medical history + examination

anamnestic investigation order

the first “tool” available to doctor to get diagnosis

• general information

• family history

• general history, physiological functions + habits

• past medical history

• recent medical history

symptom

• feeling noticed by a patient, reflecting the presence of an unusual state or of a disease

  • subjective, observed by the patient

sign

objective evidence obseved by the physician during a physical examination

• cyanosis, rush, edema

keys to taking a history

• introduce yourself with eye contact and keep an appropriate distance

• establish trust and clear + concise communication

• level appropriate language + be honest

• write stuff down

examples of personal history

• childbirth + delivery methods

  • cesarian section, forceps, etc.

• breastfeeding

• menarche, period, pregnancies, menopause

• education

• marital status

• occupation/retirement

• living arrangements

examples of physiological functions + habits

• appetite, nutrition, alcohol intake, smoking

• amount of water/day (glasses)

• digestion

• intestinal function

• urinary function (nycturia, dysuria, etc.)

• sleep (quality, number of pillows)

keys to performing a physical

• introduce yourself + select an appropriate setting

• wash your hands (before + after)

• drape appropriately + prioritize dignity

physical examination

• inspection

• palpation

• percussion

• auscultation

physiology of pulse + heart rate

• during systolic contraction of heart, a high amplitude blood wave gets ejected through aortic valve + out towards the periphery

• this wave distends the arteries sustaining the systolic wave of blood throughout body

  • creates spike followed by downward slope in pulse

• this waveform is propagated throughout the arterial system + can be felt and seen easily in periphery

• higher pressure = greater palpated intensity

central pulse

• in heart and carotid

  • preferred pulse points used during adult resuscitation

peripheral pulse

• in upper extremities

  • brachial + radial (brachial = often evaluation site during cardiopulmonary infant resuscitation

• in lower extremities

  • femoral, popliteal, dorsalis pedis, posterior tibialis

pulse intensity scale

• 0-4

• 0: nonpalpable pulse

• 1: barely detectable pulse

• 2: slightly diminished

• 3: normal pulse, easily palpable (full)

• 4: “bounding” (stronger than normal)

characteristics of heart rate

• 60-100 bpm

• 15 seconds = minimum amount of acceptable time (x4 for bpm)

  • also, heart auscultation while palpating a peripheral pulse to ascertain if every pulse gets transmitted as a palpable beat

systolic blood pressure

maximum pressure in aorta when the heart contracts + ejects blood into the aorta from the left ventricle

• 120mmHG

diastolic blood pressure

minimum pressure in aorta when the heart is relaxing before ejecting blood into the aorta from the left ventricle

• 80 mmHg

measurement of blood pressure

• under normal resting conditions, flowing blood through brachial artery travels in a smooth flow + not heard by stethoscope

• once sphygmomanometer = inflated, the brachial artery is compressed + flow becomes turbulent = heard by stethoscope

phase 1 of Korotkoff sounds

clear tapping sounds heard for at least 2 consecutive beats

• systolic blood pressure

phase 2 of Korotkoff sounds

the softening of the tapping sounds + addition of a swishing sound

phase 3 of Korotkoff sounds

the return of tapping sounds like phase 1, but with more sharpness + intensity

phase 4 of Korotkoff sounds

the abrupt muffling of sounds, exhibiting a soft and blowing quality

phase 5 of Korotkoff sounds

the complete disappearance of all sounds

• diastolic blood pressure

normal blood pressure

less than 120/80 mmHg

elevated blood pressure

systolic between 120-129 and diastolic less than 80

stage 1 blood pressure (hypertension)

systolic between 130-139 or diastolic between 80-89

stage 2 blood pressure (hypertension)

systolic at least 140 or diastolic at least 90 mmHg

hypertensive crisis

• systolic over 180 and/or diastolic over 120

  • patients needing prompt changes in medication if there’s no other indications of problems, or immediate hospitalization if there are signs of organ damage