Vital Signs and General Appearance

Components of the Exam

General Survey, Vital Signs, Assessment of pain

Fatigue

Non specific symptom

Weakness

Denotes a demonstrable loss of muscle power

Feeling cold, goosebumps and shivering

Rising temperature

Hot and Sweating

Falling Temperature

Feeling hot/sweaty accompanies

Menopause

Nightsweats occur in

Tuberculosis and Malignancy

Temperature in Immunocomprimsed patients with sepsis

Fever may be absent, low grade or hypothermic

Weight changes

Changes in body tissues or fluid

Weight gain causes

Caloric intake exceeds caloric expenditure and abnormal accumulation od body fluids

Edema

Extravascular fluid retention

Where is edema seen?

Heart failure, nephrotic syndrome, liver failure and venous stasis

2 Categories of obesity

Preclinical and Clinical Obesity

Preclinical Obesity

High BMI or waist-to-heigh ratio without active weight-related complication

Clinical Obesity

Excess body fat accopanied by clear organ dysfunction or obesity related health conditions

Clinically significant weight loss

loss of 5% or more of body weight over 6 months

Mechanisms of Weight Loss

Decreased food intake, defective GI absorption/inflammation and increased metabolic requirements

Common eating disorders

Anorexis Nervosa and Bulimia Nervosa

Anorexia Nervosa clinical features

Afraid of gaining weight, starving but in denial. brought in by family, depressed mood, self-induced vomiting and purging

Gynecological complications of Anorexia Nervosa

Amenorrhea

Endocrine complications of Anorexia Nervosa

Hypercortisolemia, hypoglycemia, osteroporosis, euthyroid hypothryoxinemia

Cardiovascular complications of Anorexia Nervosa

Bradycardia, hypotension, arrhythmias, cardiomyopathy

Metabolic complications of Anorexia Nervosa

Hypokalemia, hypochloremic metabolic alkalosis, increased blood urea

Signs/Symptoms of Malnutrition

Weakness, easy fatigability, cold intolerance, flaky dermatitis and ankle swelling

Steps to promote optional nutrition

Measure BMI/waist circumference, assess dietary intake, pt motivation, and counseling

Additional risk factors for heart disease

Hypertension, High LDL, Low HDL, High triglyerides, family hx

BMI 25-29.9

Overweight

BMI over 30

Obese (Class 1)

BMI 35-39.9

Severe Obesity (Class 2)

BMI 40-49.9

Morbid Obesity (Class 3)

BMI over 50

Super Obesity

Excess Sodium can lead to

Hypertension

Daily Dietary Intake of Sodium

2300 mg

Adult weekly exercise

150 minutes of moderate-intensity cardiorespiratory effort

Apparent State of Health

try to make a general judgement based on observations throughout the encounter. Is the patient acutely or chronically ill, frail or fit and robust?

Level of Consciouness

Is the patient awake, alert and responsive to you and others in the environment?

Signs of Distress

Does the patient show any evidence of cardiac or respiratory distress? Pain? Anxiety or depression?

Skin Color and Obvious Lesions

Inspect for any changes in skin color, scars, plaques or nevi

Facial Expression

Observe the facial expression at rest, during conversation, social interactions and during the exam, Is eye contact natural/ Sustained? Absent?

What will you see in facial expressions of pts with hyperthyroidism

A stare

What will you see in facial expressions of pts with Parkinsons

Immobile Facies

What will you see in facial expressions of pts with Depression

Flat/Sad Affect

What will you see in facial expressions of pts with Anxiety

Decreased eye contact

Odors of the body and breath

Can provide important diagnostic clues like fruit breath of diabetes or scent of alcohol

What is important about smelling alcohol on a pts breath?

Never assume it is the reason for change in mental status

How often should height/weight be taken?

Yearly

How do you measure a infants height?

Length, measure height at 2-3 y/o

If BMI is above or equal to 35 what should you do?

Measure waist circumference just above the hips

Ausculatory Office Blood Pressure

Common, inexpensive

What is Ausculatory Office Blood Pressure subject to?

anxiety, observer technique, and cuff calibration

What does Ausculatory Office Blood Pressure require?

measurement over several visits. Single measurement with sensitivity and specificity of 75%

Automated oscillometric office blood pressure

Requires optimal patient positioning, cuff size and placement & device calibration. Takes multiple measurements over short period. Comparable sensitivity and specificity to manual measurements.

Home Blood pressure monitoring

Accurate automated device applied by patient, easy to use, less expensive than ambulatory monitoring. More predictive of cardiovascular risk than office measurements.

Home Blood pressure monitoring requirements

patient education for accurate technique and repeated measurements

What does Home Blood pressure monitoring detect

white coat hypertension and masked hypertension

Ambulatory blood pressure monitoring

Automated; "gold standard," provides 24-hour average blood pressures and averages of awake and asleep numbers

What does Ambulatory blood pressure monitoring show

whether nocturnal BP dips or stays elevated

Ambulatory blood pressure monitoring disadvantages

More expensive. May not be covered by insurance

Hypertension

Office manual or automated blood pressure based on the average of two reading on two seperate occasions >/= 130/80

White Coat Hypertension

Blood pressure >/= 140/90 in medical settings with mean awake ambulatory readings < 135/85

Masked Hypertension

office blood pressure <140/90 but an elevated daytime blood pressure of >135/85 on home or ambulatory testing

What is masked hypertension associated with?

increased risk of cardiovascular disease and end-organ damage

Nocturnal Hypertension

A nocturnal fall of <10% of daytime values

How is nocturnal hypertension diagnosed?

24-hour ambulatory blood pressure

Width of the inflatable bladder of the cuff

40% of upper arm width

The length of the bladder

80% of the upper arm circumference

Normal Blood Pressure

Less than 120 / 80

Elevated Blood Pressure

120-129 / less than 80

Stage 1 Hypertension

130-139 / 80-89

Stage 2 Hypertension

140 or higher / 90 or higher

Severe hypertension/Hypertensive Emergency Blood Pressure

Higher than 180 / Higher than 120

What should patients avoid prior to taking BP

smoking/caffiene/exercise for 30 mins

What should the pt do for 5 minutes prior to BP

Sit quietly in chair with feet on the floor

How should the arm be prepared for BP

Free of clothing, fistulas for dialysis, scars from brachial artery cut down, and lymphedema

How far should the lower border of the cuff be from the antecubital crease

2.5 cm above

What part of the stethoscope do you use to take a blood pressure?

the bell

Lose Cuff=

High readings

Tight Cuff =

Low Readings

What is a normal blood pressure difference between arms?

5-10 mm Hg

What do you do is low blood pressure is indicated?

Orthostatic hypotension

How to take an orthostatic blood pressure

mesure supine position after lying for 3-10 mins and then standing up

Orthostatic hypotension

a drop in systolic blood pressure of at least 20 mm Hg or in diastolic blood pressure of at last 10 mm Hg within 3 minutes of standing

The Obese or Very Thin Patient

For the obese arm, use a cuff 16 cm in width or consider a thigh cuff. For the very thin arm, consider using a pediatric cuff

Arrhythmias

Irregular rhythms produce variations in pressure and therefore unreliable measurements

Coarctation of the aorta

narrowing of the thoracic artery, usually distal to origin of the left subclavian artery

Coarctation of the aorta presentation

systolic hypertension greater in the arms than legs

What age should you start taking blood pressure on pediatric patients?

3 years old

What artery is commonly used to assess HR

Radial

Central/Apical Pulse

Apex of the heart

Pediaric HR less than 1 year

128-130

Pediaric HR 1 year

116-119

Pediaric HR 2-3 years

106-108

Pediaric HR 4-5 years

94-97

Pediaric HR 6-11 years

77-88

Pediaric HR 12-19

72-80

Tachycardia

HR over 100

Bradycardia

HR below 60

Normal Respirations

20, eupnea

Slow Respirations

bradypnea

Rapid Respirations

Tachypnea