Physical Diagnosis 1- General Survey and Vital Signs (quiz 1)

general survey

Helps you make a decision as to whther the patient is sick or not.

How they walk, how they dress, tone of voice, facial coloration, etc.

Initial impression of the patient before starting the physical exam

What are some things you would want to make note of during the general appearance?

-General Appearance

Apparent state of health, Level of consciousness, Signs of distress, Skin color and obvious lesions/rashes, Dress, grooming and personal hygiene, Facial expressions, Body odors, Posture, gait and motor skills

What are signs of distress?

Signs of Distress

o Cardiac distress

o Is the patient clutching his or her chest? o Respiratory distress

o Is the patient having any kind of labored breathing or unable to catch his or her

breath?

depression

o Pain

o Is the patient guarding an area of the body? Is the patient wincing from pain? o

Anxiety or depression

o Is the patient restless or fidgety? Is the patient pacing back and forth?  anxiety

o Is the patient flat with minimal facial expressions? Is the patient teary eyed 

What do you look for regarding skin?

Skin Color, Lesions and Rashes oJaundice oCyanosis oPallor oBruises oRashes

What do you look for regarding dress grooming and personal hygiene?

Dressed appropritately

Observe hair, nails, jewelry, cosmetics, odditities in dress. depression or dementia may appear unkempt and disheveled

what do you look for in facial expressions

eye contact

Is there good eye contact or lack of it?

o Decreased eye contact can indicate depression or fear while some patients with

Parkinsonism will have an immobile or “masked” face and therefore have minimal eye contact or facial expressions

What do we look for in body/breath odors?

Body odors can indicate personal hygiene issues but odors from the

breath can be indicative of more pathologic issues

o In complications from diabetes patients can sometimes present with

very sweet or fruity breath

fatigue how is it different from weakness

Nonspecific symptom of WEARINESS, LOSS OF ENERGY

Weakness is different than fatigue, and refers to loss of muscle power and is often

associated with neurological etiologies

what do we look for regarding posture, gait, and motor activity?

Posture, Gait and Motor Activity

o Kyphosis/Scoliosis o Tremors o Paralysis o Involuntary movements o Restlessness o Ataxia o Limping o Drop foot

Each of these abnormalities in posture, gait and motor activity can indicate an underlying pathology and help you identify the problem

What are some examples of things that can cause infectious fatigue?

Hepatitis, EBV, TB

What are some examples of things that can cause endocrine fatigue?

hypothyroid, adrenal insufficiency, DM, panhypopituitarism

What are some examples of things that can cause cardiovascular fatigue?

heart failure

What are some examples of things that can cause respiratory fatigue?

COPD, emphysema

What are some examples of things that can cause renal fatigue?

electrolyte imbalance, anemia

What are some examples of things that can cause GI fatigue?

nutritional deficit, medications

What is weakness often suggestive of?

Who is it a generalized complaint among?

neuropathy or myopathy;

the elderly

fever

abnormal elevation in body temperature, that can either be subjective (i.e. I have a warm head), or objective (i.e. patient took an actual measurement

What is considered a fever (i.e. oral or tympanic route)

100.4 degrees farenheit

What does shivering/goosebumps often indicate in terms of a fever?

RISING temp (muscle contractions due to heat)

What does sweating often indicate in terms of a fever?

FALLING temp

What happens to normal body temp during the day

rises

What happens to normal body temp during the night?

falls

What are shaking chills and extreme swings of hot/cold indicative of?

bacteremia/sepsis

What are night sweats often indicative of?

TB (if not that, malignancy or menopause)

When we see rapid changes in body weight over a period of hours to days, there is most likely a problem with what?

body fluids

Which types of medications are most likely to cause weight gain?

mood stabilizers/ antidepressants

What may be some endocrine causes of weight loss?

DM, hyperthyroidism, adrenal insufficiency

What may be some infectious causes of weight loss?

HIV/AIDS, malignancy

What may be some psychiatric causes of weight loss?

anorexia, bulimia

One of the most common symptoms, in which physical exam and psychosocial history are very important

pain

is pain a vital sign?

NO!!!!!

What is considered a normal BMI?

18.5-24.9

What diseases can you be at risk for with obesity?

heart disease, T2DM, cancer, stroke, arthritis (excessive weight on joint=joint degeneration), OSA, infertility, depression

What are the 4 steps to promotion of a healthy diet to reduce risk/lifestyle of obesity?

1. Take OBJECTIVE measurements (i.e. BMI, risks, diseases, etc.)- want to be able to back up with evidence why people should change, since many are sensitive about weight

2. Assess diet

3. Assess patient DESIRE AND WILLINGNESS to commit to change

4. COUNSEL (educate) pt about nutrition and exercise

How do you calculate BMI?

Weight (lbs) x (700/height (in^2))

Weight (kg)/ Height (m^2)

Under what BMI value is considered underweight?

18.5

Between what values are considered an "overweight" BMI?

25-29.9

Between what values would you be considered in the "Obesity I" class?

30-34.9

Between what values would you be considered in the "Obesity II" class?

35-39.9

what values would you be considered in the "Extreme Obesity (Obesity III)" class?

>40

What is the most important initial assessment before you even see the patient?

SpO2 (are they mf breathing..........effectively?)

What way should the "ears" of your stethoscope be facing while taking a BP?

forward

Part of the stethoscope used to hear low-frequency sounds (BP, vessels to assess for bruits, etc.)

How should you rest the piece on the patient?

Bell; Lightly

part of the stethoscope used to hear high-frequency sounds

How should you rest the piece on the patient?

diaphragm; with firm pressure

Why might a home BP be more accurate than an office BP?

1. White coat HTN

2. Home gives an average over a period of time in a more relaxed setting

(NOTE: BP can still fluctuate for several reasons (i.e. stimulants-coffee)

How long should the patient be seated before taking a BP with feet flat on the floor?

5 minutes w/ arm free of clothing

What is considered a normal BP?

What is considered HTN?

Normal= 120/80

HTN= 140/90

What are the types of blood pressure cuffs?

aneroid (manual), electronic, mercury, hybrid

Which type of BP cuff is rarely used anymore?

mercury

Which BP cuffs are most accurate?

electronic

If the BP cuff is too large, how will BP read?

TOO LOW

If the BP cuff is too small, how will the BP read?

TOO HIGH

With a properly sized BP cuff, the width of the cuff will be _______ of upper arm circumference and the length of the cuff will be ______ of the upper arm circumference.

40%; 80%

What should the patient avoid 30 minutes before getting a BP taken? Why?

smoking and caffeine intake; increases HR and vasoconstricts vessels

What artery should you palpate in the antecubital fossa? With what finger do you not want to palpate with? Why?

brachial; thumb; will feel your own pulse

Where should you maintain the brachial artery/arm when taking a BP?

level of the heart

over the brachial artery

Where should you inflate the bladder of the BP cuff?

2.5cm

How far away should the lower border of the cuff be above the AC fossa?

slightly flexed; they are more relaxed

Do you want a patient's arm tensed or slightly flexed when taking a blood pressure? Why?

brachial artery

When you are pumping the cuff to take a BP, what should you be palpating?

30 mmHg

When a pulse is no longer felt in the brachial artery while pumping up the BP cuff, how much above that number should you inflate the cuff?

15-30 sec

How long do you want to wait after you completely deflate the cuff?

How high you need to pump your cuff!

After completing the above steps, what have you now determined?

brachial artery

Where do you want to place the bell of your stethoscope while taking a BP?

2-3 mmHg

How much do you want to deflate your BP cuff every second?

systolic pressure

when you START hearing sounds of at least 2 consecutive beats, this is...

diastolic pressure

As you lower the pressure of the cuff and the LAST SOUND disappears, this is......

2 minutes

About how long should you wait after taking the initial pressure to take the pressure of the other arm?

Beating of the blood that is bouncing off the walls of the brachial artery; turbulent bloodflow (arterial pressure rising above the cuff)

When you are taking a BP, what are you actually measuring? What kind of bloodflow is this considered?

laminar blood flow (cannot hear without a cuff)

What kind of blood flow do you normally see in the body (when you're not taking a BP)?

auscultatory gap;

serious underestimation of SBP or overestimation of DBP;

arterial stiffness/disease;

make sure cuff is inflated high enough

silent interval that may be present between the systolic and diastolic blood pressures; what are the complications of this?; what diseases are often associated with this?; what should you do to prevent these complications?

subclavian steal syndrome

aortic dissection

When there is a pressure difference of 10-15 mmHg in each arm, what possible conditions could we suspect?

Venous congestion (edema/poor pumping)

What can cause less audible sounds while taking a BP? (artificially low SBP and high DBP)

aortic regurgitation

If muffling never disappears while taking a BP, what could this be suggestive of?

No; there is NO arterial blood flow

When the cuff is fully inflated, should you hear ANY blood flow at first? Why?

120/80

What is considered at normal BP?

120-139/80-89

What is considered Pre-HTN BP?

140-159/90-99

What BP is considered stage 1 HTN?

>160/>100

What BP is considered stage 2 HTN?

<140/<90

What BP would we expect for someone with renal disease or DM?

<140/<90

What is the optimal BP for someone <60 who is older?

<150/<90

What is the optimal BP for someone >60 ?

The arteries thicken, increasing force needed to pump blood, and thus BP.

Why does BP go up as you get older?

orthostatic vital signs

HR and BP taken with both the patient laying in supine position followed by standing

10 minutes

How long should you let the patient rest before starting orthostatic vitals?

3 minutes

While doing orthostatics, after you take HR and BP of the patient while lying down, how long do you wait until taking the standing vitals?

SBP: remains/ or slightly drops

DBP: rises

Durting orthostatics, as the patient rises, what should happen to the SBP? DBP?

Drop in SBP >/= 20 mmHg or drop in DBP >/= 10 mmHg

What is orthostatic hypotension defined as?

Pooling of blood in the LE's leading to a decreased venous return and cardiac output

What is the cause of orthostatic hypotension?

50-90 BPM

(Tends to be lower in elderly, and could be as high as 130-160 in peds)

What is a normal HR?

rhythm and amplitude of pulse wave

What do you asses in the heart rate?

Count rate for 30 sec and then multiply by 2

if unusually fast or slow

How do you take a manual HR?

When would you need to do a full minute?

radial

What artery should you palpate with the index/middle finger?

respiratory rate

measures breathing activity by observing rate/rhythm/depth/effort

1. Keep fingers on pulse and count breaths for 1 min.

2. Place stethoscope over trachea and count breaths for 1 min

What are the two ways in which you could measure respiratory rate?

14-20 respirations per min

What is normal adult breathing?

bradypnea

diabetic coma, drugs, increased ICP

slow breathing

What could be some causes?

sighing breathing

hyperventilation syndrome

pattern of breathing in which someone will breathe normal......... sigh.........breathe normal........sigh

What could be a cause?

tachypnea

Pulmonary fibrosis, pleuritic CP, elevated diaphragm

rapid and SHALLOW breathing

What could be some common causes?

Cheyne-Stokes breathing

heart failure, uremia, drug toxicity, brain damage, near death

deep breathing and then apnea

When is it common?