health history and physical diagnosis

levels of consciousness

alert

lethargic

obtunded

stupor

comatose

 Alert

awake and aroused easily, oriented X3 (time, place, person)

◦X4 (+ situation)

◦AAO (awake, alert, and oriented x4)

 Lethargic

responds to a loud voice, drowsy , thinking slow but responds appropriately to questions (a little slower than alert)

 Obtunded

responds to tactile stimuli (touch), sleeps most of the time, confused when aroused, decreased interest in the environment. 

Stupor (Semi-comatose)

responds to vigorous shaking and or painful stimuli, nonverbal except for possible moaning, returns to sleep when stimuli ceases.

comatose

does not respond to any stimuli

make sure they are not on sedation medication to determine this state

Signs of Distress

 Cardiorespiratory Insufficiency- Labored breathing, wheezing or cough

 Pain- Wincing, sweating, protecting a painful body part

 Anxiety- Anxious face, fidgety movements

Clarify what kind of stress

Skin color

Pallor, jaundice, cyanosis (not getting enough oxygen)

obvious lesions

Erythema

Rashes or lesions

Bruises

Scars

Dress, Grooming, Hygiene

◦Is hygiene and grooming appropriate for the setting, temperature and weather?

◦Is hygiene and grooming appropriate for the patient’s age, lifestyle, and occupation?

Facial Expressions

◦During conversation and during physical examination

◦Flat affect (how they carry themselves), sad

◦Eye contact – unblinking, sustained, averted (autism, cultural), absent?

◦Immobile facies of parkinsonism – “facial masking”

◦Fixed stare of hyperthyroidism

 Odors of Body and Breath

Acetone – Ketones in DKA

Alcohol smell (Never assume alcohol intoxication is the only cause of an altered mental state)

Signs of infection, liver disease (rotten egg small), or uremia (ammonia smell)

 Posture, Gait and Motor activity

Is patient restless, is there involuntary movements or loss of balance

Vital signs

•Height, Weight, BMI

•Temperature

•Respiratory Rate

•Arterial Pulse  Rate

•Blood Pressure 

•Pulse Oximetry

•Pain Scale

Height and Weight

 Helps monitor nutritional status (major weight loss can be a problem, ask if weight loss is intentional or not)

 Important for calculating dosages (Pediatrics & Adults)

 Helps assess body fluid gain or loss (Which type of patient? Heart failure – retain fluid and can put strain on your heart)

 Important for calculating fluid requirements

 *Always ask whether weight loss/gain was intentional or not

BMI calculation

(weight in lbs and divide by height in inch ²) X 703

less than 18.5 = underweight

18.5-24.9 = normal

25-29.9 = overweight

30-34.9 = obese 1

35-39.9 = obese 2

over 40 = morbidly obese (extreme)

Blood Pressure Technique beginning considerations

 Choose Appropriate Size Cuff (too small = too high reading, too big = too low)

 Measure Bilateral Sitting, Standing and Supine BP

 Avoid smoking, caffeine, exercise prior to measuring

 Keep brachial artery at heart level

 Arm should be free of clothing

 Check for AV fistula or lymphedema before measuring a BP (don’t take BP on that arm)

Blood Pressure Technique performing it

 Lower boarder of cuff should be 2.5 cm above arm crease/antecubital fossa

 First estimate systolic pressure by palpation

◦Note the pressure when the pulse is no longer palpated

 Inflate cuff 30 mm Hg above palpated systolic pressure

 Place Diaphragm or Bell over brachial artery

 Then slowly deflate the pressure in the cuff,  2-3 mm Hg per second

 Identify sounds of the first 2 consecutive beats (Korotkoff sounds); this reading indicates the systolic pressure

 Continue to lower cuff pressure until sounds  disappears, this reading indicates the diastolic pressure.

 Confirm disappearance by letting pressure drop  another 10-15 mmHg before stopping the measurement and releasing all the cuff pressure.

Blood Pressure Technique tips

 Blood pressure should be taken in both arms at least once.

 BP in left arm tends to be slightly higher than right arm

 There may be a difference in pressure measurements of 5 -10 mm Hg between  arms in the same patient - Normal

 Pressure differences of more than 10-15 mm Hg suggests arterial compression

◦Consider stenosis or obstruction of  brachiocephalic or subclavian artery or  aortic dissection with greater pressure differences.

Auscultatory Gap

 An Auscultatory gap is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure caused by stiff blood vessels.

 The improper interpretation of this gap may lead to blood pressure monitoring errors: i.e., an underestimation of systolic blood pressure and/or an overestimation of diastolic blood pressure.

 Auscultatory Gap may be seen:

◦When there is decreased blood flow to the extremities

◦Causes:

◦Aortic Stenosis and uncontrolled hypertension

◦Atherosclerosis of blood vessels

 correct for an auscultatory gap

he radial pulse should be monitored by palpation.

 Typically, the blood pressure obtained via palpation is around 10 mmHg lower than the pressure obtained via auscultation.

normal BP

<120 / <80

elevated BP

120-129/ <80

stage 1 HTN

130-139 / 80-89

Stage 2 HTN

> or equal to 140/ > or equal to 90

Low Blood Pressure or Hypotension

Blood pressure that is below the patient’s baseline

Shock

evidence of inadequate tissue perfusion such as change in mental status, chest pain, shortness of breath, decreased urine output, cool clammy extremities etc.

symptomatic hypotension

Relative Hypotension

 Some patients may live with a blood pressure below 120/80 at baseline.

 A drop in pressure to below the baseline levels is relative hypotension and the patient may or may not have symptoms of weakness or dizziness.

Hypertension

Hypertension is The “Silent Killer”

 Damages blood vessels leading to MI, Stroke, Kidney Failure, etc.

 Increases afterload on the heart leading to heart failure

 Pressures over 200/120 considered accelerated hypertension

 Malignant Hypertension

patient has end organ damage such as intracranial bleeding, MI or heart failure

Baroreceptor Reflex

 Stretch receptors located in carotid sinus and the arch of aorta

 Monitors blood pressure

 In volume depletion this reflex increases heart  rate and contractility

 Initially may prevent significant drop in BP

Cardiac output = heart rate X stroke volume

Orthostatic Blood Pressure /Postural Hypotension

 Measure blood pressure in supine position after patient has been resting in this position for 3-10 minutes

 Stand patient up, then repeat BP within 3 minutes of standing.

 -Fall in Systolic of 20 mm Hg or drop in diastolic BP of 10 mmHg, especially with  lightheadedness, indicates orthostatic BP.

  -Increase in the heart rate of 30 bpm.

 Causes – drugs, moderate to severe blood loss, prolonged bed rest and disease of the autonomic nervous system

 Home Blood Pressure Monitoring

Patient checks their blood pressure with their own cuff at different intervals and records reading for self-monitoring

More practical but less accurate ( due to not calibrating correctly)

 Ambulatory Blood Pressure Monitoring (ABPM)

Used to obtain BP outside of the office at preset intervals and usually programmed to obtain readings over a period of 24 hours. Patient follows their normal routine during this time

More accurate but less practical

Measuring the Arterial Pulse

 Grasp both hands to palpate radial pulse

 If regular beats, count for 30 sec then multiply by 2, or 15 sec multiply by 4

 If irregular beats or excessively fast/slow, count for a full minute

Confirm rate by auscultating the heart at the apex while palpating the radial pulse

 Determine Rate, Rhythm and Amplitude of pulse

Sinus Tachycardia

 Usually, a normal physiological response to some underlying condition.

 If the Rate is over 140 consider cardiac arrhythmia.

 Elevated heart rate is associated with a decrease in cardiac output and blood pressure.

Common Causes Tachycardia

exercise

 Anxiety

 Infection

 Thyrotoxicosis / Hyperthyroidism

fever

 Dehydration

 Hemorrhage

  Heart disease

  Hypoxemia – low levels of O2

  Anemia

  Drugs, inc. alcohol

Relative Tachycardia

 Patients on Beta blockers / calcium  channel blockers and digoxin may have  resting heart rates between 50-60 bpm.

 Heart rates in the 80-90’s could be considered tachycardic in these patients

Sinus Bradycardia

 Rate less than 60 bpm

 Common Causes

◦Athletes/Increased Vagal Tone

◦Hypothyroidism

◦Hypothermia (cold)

◦Sinus node disease

◦Drugs / Beta blockers / Calcium blockers

Irregularly Irregular Pulse

 Pulse which has no pattern 

 Typical of Atrial Fibrillation

Atrial Fibrillation (A-FIB)

 Sinoatrial node (SA) is the normal pacemaker

 A-fib is a condition where there are multiple pacemakers in the atrium

 Atria quiver instead of contracting

 AV node bombarded with impulses

 Ventricular rate is irregular because the AV node lets the  impulses though randomly

(can cause a clot in the heart)

pulse deficit

in Atrial fibrillation 

difference between the peripheral pulse and the apical pulse. 

 Pulse deficit occurs when there are fewer peripheral pulses than there are heartbeats

Amplitude of Pulse

 4+ Bounding

 3+  Brisk, Normal

 2+ Slightly diminished

 1+ Diminished, weaker than expected

 0  Absent

Small Weak Pulses

 Due to decreased Stroke Volume ( amount of blood being pushed out)

 Common causes include

◦Heart Failure

◦Hypovolemia

◦Severe Aortic Stenosis

 Or due to increased Vascular Resistance

 Common Causes include

◦Exposure to cold

◦Severe heart failure

◦Peripheral Vascular Disease

Large Bounding Pulses

 Usually due to:

◦Increased stroke volume, decreased vascular resistance or both

◦Increased stroke volume due to slow HR

◦Decreased compliance of the aortic walls (aging and atherosclerosis)

Paradoxical Pulse

 Common Causes 

◦Fever

◦Anemia 

◦Hyperthyroidism 

◦Calcified blood vessels

◦Aortic regurgitation

◦Patent ductus arteriosus

Paradoxical Pulse

 AKA Pulsus Paradoxus

 Brath in and slight drop of 4-5 mm Hg in systolic pressure =normal

 Respiratory Rate and Rhythm

Note the rate, rhythm, depth, and effort of breathing.  Never ask the patient to breathe normally. 

technique for taking respiratory rate

After taking the pulse, subtly direct your eyes to the patient’s upper anterior thorax and evaluate respirations.

Many practitioners continue to palpate the pulse while counting respirations to distract the patient. 

Count the number of respirations over 30 seconds and multiply by 2.

If irregular rate or rhythm, count for a full minute

normal respiratory rate

•12-20/minute in a quiet, regular pattern (this may vary).

Tachypnea

respiratory rate over 20

Bradypnea

respiratory rate below 12

 Rapid Shallow Breathing

◦Seen with Respiratory Failure

◦Restrictive Lung Disease

◦Pleuritic Chest Pain

 Rapid Deep Breathing

Anxiety, Infection, Exercise, DKA

 Slow Breathing

Diabetic coma, Drugs, Brain hemorrhage

 Cheyne-Stokes Breathing

Cyclical episodes of apnea and hyperventilation. Seen in elderly, after strokes, trauma and sometimes with CHF

 Kussmaul Breathing

Deep, rapid labored breathing, usu. at a consistent pace, as the body tries to dispel excess CO2

 Ataxic Breathing

Characterized by unpredictable irregular breathing with irregular pauses and periods of apnea. Seen in brain tumors, brain injury or increased intracranial pressure.

 Obstructive Breathing

Seen with asthma, emphysema, bronchitis

 Paradoxical Breathing

Abnormal breathing pattern where the chest wall moves in during inspiration and out during expiration.  Often, the chest wall and the abdominal wall move in opposite directions with each breath. Can be seen in chest trauma

 Asymmetrical Rise and Fall of Chest Wall

◦    Consider a Pneumothorax

ways to take temp

•Oral (PO)

•Rectal (PR)

•Tympanic (ear)

•Axillary

•Temporal Artery (head)

normal temp range

97.8 – 99◦F (36.5- 37.2◦C)

fever

Oral temperature of 100.4◦F/ 38◦C or greater

Causes include:

•infection, malignancies, infarctions, drugs and immune disorders

•First 48H post-op: atelectasis, not infection

Immune-suppressed and elderly patients may not mount a fever (but can still have an infection)

oral temp

•Insert the thermometer under the tongue, on either side of the frenulum linguae, as far back as possible

•Digital thermometer usually reads in approx. 10 seconds

rectal temp

•Patient should be lying down on their side

•Lubricate the thermometer

•Insert probe in about 3-4 cm into the anal canal

•Direct the probe toward the umbilicus

•Digital thermometer reads in approx. 10 seconds

tympanic membrane

•TM shares the same blood supply as the hypothalamus where temperature regulation occurs in the brain

•Auditory canal should be free of cerumen

•Position probe so infrared ray is aimed at the TM

•Usually provides a reading in 2-3 seconds

temporal artery

•Place probe against the center of the forehead

•Brush the device across the forehead, down the cheek and behind the earlobe

•This method more accurate than just scanning the forehead

Pulse oximetry

Device that measures the oxygen saturation of arterial blood in the patient by utilizing a sensor attached typically to a finger, toe, or ear

•Determines the percentage of oxyhemoglobin in blood pulsating through a network of capillaries

•Typically sounds an alarm if the blood saturation becomes less than optimal

Normal 95 – 100 %

Acute pain

normal, predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus. Lasts less than 3-6 months.

Chronic pain

pain not associated with cancer or other medical conditions, that persists for more than 3-6 months, pain lasting more than 1 month beyond the course of an acute illness or injury, or pain recurring at intervals of months or years.

Assessing Severity of Pain

Numeric Rating: 0-10

The Wong-Baker FACES Pain Rating Scale

The General Appearance Write-Up Includes

Age

ethnic background (only if relevant)

Level of consciousness

Physical description

When adding weight note if the patient told you their weight or if it was measured in office