Physical Diagnosis - General Survey & Vital Signs

what are the first two things we look at during the general suvery?

observations of the patient's appearance and the apparent state of health

what are the 5 levels of consciousness

alert

lethargy

obtundation

stupor

coma

what is it called when the patient responds fully and appropriately to stimuli?

patient is alert

your patient appears drowsy but opens their eyes, looks at you, responds and then falls asleep. what is their level of conciousness?

lethargy

you approach a patient who must be shaken awake. once awake, the patient looks at you and slowly responds. they are confused. what is their level of conciousness?

obtundation

what is a patient's level of consciousness when they arouse only with painful stimuli, can only give slow or absent responses and are unresponsive otherwise?

stupor

what is the level of consciousness when a patient remains unarousable to inner or external stimuli?

coma

what two questions do we ask to assess if a patient is in distress?

1. does the patient show evidence of cardiac or respiratory distress?

2. does the patient show they are in pain?

what are some signs of a patient in cardiac or respiratory distress?

chest clutching, pallor, diaphoresis, labored breathing, wheezing or coughing

what are some signs of a patient is in pain?

wincing, diaphoresis, guarding, weird posture

when assessing a patient's dressing, grooming and personal hygine what are 2 questions you should ask yourself?

1. how is the patient dressed?

2. is the clothing suitable for the temperature and weather?

when looking at a patient's shoes, what can holes or slippers suggest?

gout, bunions, edema

run down shoes can contribute to....

foot/ back pain, calluses, falls and infections

when taking note of a patient's personal hygiene and grooming appearance what should you be comparing it to?

to their norm

when taking note of someone's facial expression what else should you be noticing?

eye contact

patient's with what condition prefer to sit upright?

left-sided heart failure

patient's with what condition prefer to sit in the tripod position?

COPD- they cant breathe

what question are we asking when taking note of a patient's posture, gait, and motor activity?

does the patient walk smoothly with balance?

T/F: It doesnt matter if the patient is wearing their shoes when measuring their height and weight

false, remove shoes!!

what can very short stature be indicative of?

turners syndrome, childhood renal failure, achondroplastic, hypopituitary dwarfism

abnormally long limbs in proportion to the trunk can be indicative of..

marfan syndrome

a patient you have been treating for many years comes to your office for a physical. you compare their height to previous years and recognize a sudden height loss. what could be a possible diagnosis?

osteoporosis or vertebral compression fractures

you notice your patient is obese. what should you be observing on the patient?

1. is the fat distributed evenly

----is the fat concentrated over the upper torso

---is the fat settled around the hips

which two syndromes are consistent with truncal fat and relatively thin limbs?

cushing syndrome and metabolic syndrome

who is BMI inaccurate for?

very muscular and older adults

what BMI classifies a patient as underweight?

less than 18.5

what is a normal BMI range?

18.5-24.9

what BMI is considered overweight

25.0-29.9

a BMI of greater than or equal to 30 is considered obese. what are the BMI for the 3 classes of obese?

-Obese class I : 30.0-34.9

-obese class II : 35.0 - 39.9

-obese class III : greater than or equal to 40

weight circumference is indicated for anyone with a bmi of ______

what class of obesity is this? and where do you measure the circumference?

-greater than or equal to 35

- class two

- measure the patient's waist right above their hips

women with a waist circumference of _____ and men with a waist circumference of ____ are at a higher risk for diabetes, hypertension, cardiovascular disease

- women: greater than or equal to 35 inches

- men: greater than or equal to 40 inches

What are the 4 vital signs?

Heart rate, blood pressure, respiratory rate, temperature

your MA takes vital signs for a patient and they come back abnormal. How do you proceed?

retake them yourself during the visit!!

in which situation would a home/ ambulatory confirmation blood pressure be necessary?

if the patient has elevated office readings

what is considered the reference standard for confirming elevated office blood pressure?

automated ambulatory blood pressure monitoring

how long is a patient's blood pressure taken for if they are being monitored with an automated ambulatory pressure cuff?

24-48 hours

What should you NOT do before taking a blood pressure?

smoke/exercise/drink caffeine for 30 minutes

What should you do when taking a blood pressure?

sit in a quiet, comfortable room and position for at least 5 minutes, make sure the arm is free of clothing, AV fistulas, scarring, and has no history of mastectomy

How do you know if a blood pressure cuff is the right size for a patient?

the size of the bladder of the cuff should be about 80% of the arm's circumference

What do you do before you begin to take the blood pressure?

palpate the brachial artery, position and support the arm, center bladder over the brachial artery and about 3 cm about antecubital crease

what is considered normal bp?

less than 120/less than 80

what is considered an elevated bp?

120-129/<80

what is considered high blood pressures/ hypertension stage 1

130-139/ 80-89

what is considered high blood pressure/ hypertension stage 2

>140/ >90

what is considered a hypertensive crisis

>180/120 mmHg

Define white coat hypertension

High blood pressure in the doctor's office, but not at home.

does white coat hypertension require treatment? what are these patients at a risk for?

-no treatment

- higher cardiovascular risk

How do you estimate the systolic BP?

Position cuff and palpate radial artery.

Inflate cuff until you cannot feel radial pulse

add 30 mmHg

you take your patient's blood pressure and it comes back normal. but they tell you they have an elevated daytime blood pressure. what is the diagnosis

masked hypertension

unidentified or untreated adults with masked hypertension are at a high risk of ____

cardiovascular disease

white coat hypertension is present in ____% of patients

20

masked hypertension is present in ____% of patients

10-30

high office BP and high out of office BP =

sustained hypertension

high out of office BP + normal office BP =

masked hypertension

normal out of office bp + high office BP =

white coat syndrome

normal out of office bp + normal Bp =

normal bp :)

what is nocturnal hypertension?

bp dipping between 10-20% in patients at night

what are 3 nocturnal patterns are associated with poor cardiovascular outcomes

1. nocturnal dipping of <10% daytime values

2. nocturnal rising patterns

3. nocturnal dipping of >20% of daytime values

how do you confirm nocturnal hypertension?

24-hour ambulatory bp monitoring

What is an asculatory gap?

When you hear a gap in between the systolic and diastolic pressures and can lead to an underestimation of the systolic and overestimation of the diastolic

what side of the stethoscope do you use for taking the BP?

the bell

How do you take a BP?

1. rest arm at heart level

2. center the bladder of the brachial artery

3. cuff should be ~2.5 cm above the antecubital crease

4. secure cuff

5. slightly flex patient's arm at the elbow

when estimating the systoloc pressure how much mmHg do you add once the radial pulse disappears

30 mmhg

if 2 bp readings differ by more than _____ mmHg you should retake the bp

5 mmHg

What can cause a falsely high BP?

anxiety, too small cuff, arm too low, muscle contraction, smoking <30 minutes prior

What can cause a falsely low BP?

too large cuff, arm too high, pressing the bell too firmly to arm, failure to recognize an auscultatory gap

What are the parameters for orthostatic hypotension?

drop in systolic greater than or equal to 20 mmHg OR drop in diastolic bp of greater than or equal to 10 mmHg between the patient being supine and within 3 minutes of patient standing up.

what are possible causes of orthostatic hypotension?

drugs, moderate-severe blood loss, prolonged bed rest and autonomic nervous system diseaes.

What is the average heart rate?

60-100 bpm

What 3 things should you asses when obtaining pulse?

rate, rhythm, and amplitude

What is tachycardia?

heart rate greater than 100 bpm

What is bradycardia?

heart rate less than 60 bpm

How do you assess capillary refill?

press nail bed and watch it turn from white back to pink within 2-3 seconds

What should you take notice of when observing respirations?

Rate, rhythm, depth, effort of breathing

How do you palpate radial pulse?

1. use the pads of your index and middle fingers

2. compress the radial artery until a maximal pulsation is detected

3. count rate for 30 seconds

4. multiply by 2

what is a patient at risk for with an elevated resting heart rate?

cardiovascualr disease and mortality

How do you assess heart rhythm?

1. palpate the radial pulse

2. determine if the beats occur in a regular or irregular pattern

- is the irregular pattern predictable or erratic?

What should you check if the heart rhythm is irregular?

ECG

How do you observe respiratory rate?

1. observe while takeing heart rate; do not lift fingers from artery

2. count the number of respirations in 1 minute

What is the normal respiratory range?

12-20 breaths/minute

-an occasional sigh is normal

Can body temperate fluctuate?

Yes, there is a fluctuation of 1C over the course of the day

- lowest in the AM

- highest in the PM

What are the 5 methods to obtain bosy temperature?

1. oral

2. rectal

3. axillary

4. tympanic membrane

5. temporal artery

How do you take an oral temperature?

1. place the disposable cover over the probe

2. insert the thermometer under the tongue

3. ask the patient to close both lips

4. watch closely for digital readout (about 10 seconds)

What can alter an oral temperature?

hot or cold liquids

smoking

-delay taking temperature 10-15 min

What is the least reliable temperature mode?

axillary

- lower than oral by 1C

What can affect tympanic membrant temperature?

increased cerumen (earwax) can decrease temp

What are some cuases of hypothermia?

exposure to cold (most common), paralysis, sepsis, excess alcohol, starvation, hypothyroidism, hypoglycemia

Who is most susceptible to hypothermia and least likely to develop a fever?

older adults

what is pain?

a complex, unpleasant sensory/ emotional experience associated with tissue damage

what is chronic pain?

Pain that is NOT associated with cancer or other medical conditions that persists for more than 3 to 6 months

How long must pain last for after an acute illness or injury for it to be considered chronic?

at least 1 month

How many people does chronic noncancer pain affect?

around 100 million Americans

5-33% of patients in primary care settings

What are some methods to assess pain severity?

- verbal pain intensity scale

- visual analogue scale

- 0-10 numeric pain intensity scale

- Wong-Baker FACES pain rating scale

How is using the Wing-Baker FACES pain rating scale more effective than other methods?

it can be used by children, patients with language barriers, and patients with cognitive impairment

Lower use of anelgesics in seen in what communities?

African American and Hispanic patients

What are some contributors to health disparities?

clinician stereotypes, language barriers, unconscious clinician biases ("drug-seeking")

What are the 5 types of pain?

1. nociceptive (somatic)

2. neuropathic

3. central sensitization

4. psychogenic

5. idiopathic

What is nociceptive (somatic) pain?

typical pain; sensory nervous system is intact and can be acute or chronic

What tissue damage is nociceptive pain linked to?

skin, musculoskeletal system, and viscera

What is neuropathic pain?

Pain casued by lesion or disease affecting the somatosensory system. Can be persistant post healing from injury.

- typically feels like burning, lancinating, or shock-like