General Survey/Vital Signs/Assessment

Constitutional Symptoms

all the systems of the general assessment

broadly affect pt’s physical state:

fatigue

weakness

fever

chills

night sweats

energy level

pain

weight+height+any changes within last 6 months

Energy Level (ROS)

abnormal→underlying health conditions

useful in elderly→indicator for systemic illness

Fatigue (ROS)

non-specific sense of weariness/loss of energy

many causes→life circumstances play large part

Weakness (ROS)

noticeable loss of muscle power

Malaise (ROS)

general feeling of being unwell

pt unable to verbalize more in detail

DX: cancer
infection
autoimmune disorder

Fever (ROS)

abnormal elevation of body temperature

ask:

• if/how measured temperature+max temperature over duration of fever
  document: max temp (method)

• chills/sweats:
  increased temp
  -shivering
  -shaking chills
  -goosebumps
  
  decreased temp
  -sweats
  -hot

• travel+exposure+contact with sick people

• mx use (some mx increase/decrease temp)

Height+Weight (ROS)

ask:
any recent change+what length of time

what pt attributes weight change to

review:
psychosocial
social hx
mx

weight gain:
caloric intake exceeds caloric expenditure
-over time
-results in increased body fat

rapid change to weight in few days→changes in body fluid (not tissue)

review pt mx

weight loss:
5%+ usual body weight over 6-month period

notice sx+signs of malnutrition

many causes

review pt mx

ROS Red Flags

sudden weight gain→DM type 1

sudden weight loss→cancer

unilateral weakness→stroke

General Survey

based on:
observer:
observation
intuition
experience

pt:
mood
build
behavior

collected on:
first impressions+throughout interview
physical exam/PE

goal: describing a pt’s distinguishing features so clearly that colleagues can identify the pt in a crowd of strangers

General Survey Components

apparent state of health

level of consciousness

apparent state of discomfort/distress

skin color+obvious lesions

dress

grooming

personal hygiene

facial expression

odors of body+breath

posture

gait

motor activity

Apparent State of Health

general judgement base on observations throughout the encounter

acutely/chronically ill vs fit and robust

Level of Consciousness

is pt awake/alert/responsive to you+the environment

alert:
eyes opened
looks at examiner→responds fully and appropriately
arousal intact

lethargy:
appears drowsy
opens eyes
looks at examiner→responds then falls asleep

obtunded:
opens eyes
looks at examiner→responds slowly+confused
alertness+interest decreased

stupor:
arises from sleep only after painful stimuli
verbal responses slow
minimal awareness of self/environment

coma:
unarousable
eyes closed
no response to inner need/stimuli

Apparent State of Discomfort/Distress

cardiac/respiratory distress:
clutching chest
pallor
diaphoresis
labored breathing

pain:
wincing/grimacing
diaphoresis
splinting of painful areas

anxiety/depression:
fidgety movements
poor eye contact
psychomotor slowing

Skin Color+Obvious Lesions

changes in skin color

scars

plaques

nevi

pallor (pale skin/Raynaud’s dx)

cyanosis (blue skin)

jaundice (yellow skin)

rashes

bruises

musculoskeletal congenital deformity (cleft lip)

Dress/Grooming/Personal Hygiene

dress:
clothing appropriate to temperature/weather
clean+appropriate to setting

shoes

jewelery/piercings

hair/face/nails/cosmetics

hygiene/grooming:
appropriate to age/lifestyle/occupation/socioeconomic group

Facial Expression

observe facial expressions:
rest
during conversations about sensitive topics
during PE

eye contact:
natural/sustained/unblinking
or
averted quickly
or
absent

Odors of the Body and Breath

observe:
in room
up close during PE

alcohol
acetone→diabetic ketoacidosis (fruity odor)
pulmonary/throat/mouth infections
urine
stool
wound/skin lesions

Posture/Gait+Motor Activity

preferred position of posture:
sitting up→heart failure
leaning forward+braced arms→COPD/respiratory difficulty
lying supine+still→acute abdominal pathology

gait:
smooth
or
limp
instability
loss of balance

motor activity:
tremors
or
other involuntary movements
paralysis

Height+Weight

part of general survey

recorded with vital signs

use calibrated equipment for accuracy

fundamental in nutrition screening+tx interventions
-accurate mx usage
-body fluid gain/loss+fluid requirements

height:
inches
measured in stocking feet
look for extremes+symmetry

weight:
kilograms (2.2lb=1kg)
shoes off

changes: muscle mass
fluid balance

PE: emaciated
slender
plump/obese

location of weight distribution:
centralized fat→obesity
truncal fat+thin limbs→Cushing’s syndrome/metabolic syndrome

BMI

more accurate than body fat

weight (lbs)+height (in):
(weight (lbs) X 700/height (in))/height (in)

weight (kg)+height (meters²):
weight (kg)/height (m²)

abnormal readings:
very muscular+healthy→high BMI
very low muscle mass+reduced nutrition→normal BMI

BMI over 35 kg/m²→measure pt waist circumference just below hip bones→excess body fat+risk for DM+HTN+CV dx
men: over 40 kg/m²
women: over 35 kg/m²

BMI classifications:
underweight: under 18.5
normal: 18.5-24.9
overweight: 25.0-29.9
obesity 1: 30-34.9
obesity 2: 35.0-39.9
obesity 3/extreme obesity: over 40

Vital Signs List

blood pressure (record arm+position of pt)

heart rate+rhythm

respiratory rate+rhythm

temperature (record route)

Blood Pressure

tensions exerted by blood against arterial walls

affecting factors:
ventricular contraction
arteriolar+capillary resistance
elasticity of arterial walls

HTN:
increases risk of MI
stroke
HF
renal failure

korotkoff sounds:
5 phases of sound
occur due to disruption of blood flow in artery

Blood Pressure Procedure

before:

• no caffeine/exercise/tobacco 30 minutes prior

• sit 5 minutes in chair+feet on floor in quiet warm/comfortable room

• arm at heart level+free of clothing/fistulas for dialysis/lymphedema

select appropriate cuff size

determine BP by palpation:

1. lower border of cuff→2.5 cm above antecubital crease

2. put on cuff+position arm with slight flexion

3. palpate radial pulse

4. inflate cuff until pulse disappears+remember number

5. deflate cuff+wait 15-30 seconds

6. add 30mmHg to number→maximum cuff pressure for subsequent inflations

determining BP by auscultation:

1. arm at heart level

2. after 15-30 seconds place BELL of stethoscope over brachial artery

3. inflate cuff to previous pressure+deflate slowly (2-3 mmHg/second)

4. hear 2+ consecutive beats (when heartbeat is first heard)→systolic pressure

5. continue to lower pressure until sounds are muffled+disappear (when heartbeat is last heard)→diastolic pressure

6. listen to pressure decrease 10-20 mmHg more

7. deflate cuff

8. wait 1 minute+repeat

9. average both results=official values

Cuff Size

width of bladder: 40% of upper arm circumference (12-14 cm)

length: 80% of upper arm circumference

lower border of cuff→2.5 cm above antecubital crease

too small→high BP

too large:
small arm→low BP
large arm→high BP

Auscultatory Gap

interval of pressure where korotkoff sounds fade away and reappear at lower pressure point

caused by arterial stiffness+arteriosclerosis

improper interpretation→BP monitoring errors

Blood Pressure Readings+HTN Dx

blood pressure:

• read to nearest 2 mmHg

• wait 1+ minutes→repeat

• average readings=official values

HTN dx:

• mean of 2+ BP readings taken on 2+ office visits

• verified on contralateral arm

• take further readings on arm with higher BP

Pulse Pressure

difference between systolic and diastolic BP

millimeters of mercury (mmHg)

represents force heat generates when it contracts

normal: 40 mmHg (120 systolic-80 diastolic=40 pulse pressure)

• systolic BP-diastolic BP

Orthostatic Blood Pressure/Tilt Test

pt sits+rests for 10 minutes

take BP in supine position

pt stands+waits 3 minutes

DX:
dizziness
lightheadedness
tachycardia

Out Of Office BP Measurement Methods

home blood pressure monitoring (HBPM):

automatic device

requires pt education+accurate technique

repeated measurements:
-2 morning
-2 evening
-for 1 week

helps aid in white coat HTN/masked HTN

ambulatory blood pressure monitoring (ABPM):

clinical+research “gold standard”

automated

24hr average BP (averages day+night systolic and diastolic BPs)

more expensive+may not be covered by insurance

Heart Rate+Rhythm

measured with radial pulse

normal: 60-100 bpm

normal rhythm+rate: count rate 30 seconds x 2→BPM

abnormal rhythm+rate: count for whole minute

irregular rhythm:
listen with stethoscope at apex

determine if:
-regular
-irregular
-regularly irregular

tachycardia: over 100 bpm
E: cardiac dysrhythmia (afib/aflutter/SVT)
dehydration
hypovolemia
hyperthyroidism
fever
exercise
pain
ilicit mx use (cocaine/meth)
excess caffeine

bradycardia: under 60 bpm
E:
cardiac→heart block
mx→beta blockers
athletic conditioning (ex: marathon runners)

Respiratory Rate+Rhythm

observe:
rate: fast vs slow
rhythm: regular vs irregular
depth: shallow vs deep breaths
effort: normal vs working hard to breathe

count 1 minute (visualization/auscultation over trachea)

normal: 14-20 breaths per minute

Abnormal Respiration Patterns

tachypnea: fast
over 20 breaths per minute

bradypnea: slow
under 14 breaths per minute

cheyne-stokes: periods of breathing alternating with apnea

ataxic/biot’s: irregularly irregular
no pattern

hyperventilation/hyperpnea: rapid+deep breaths

kussmaul’s: fast+shallow→slow/deep+gasping

Temperature+Methods

fahrenheit (°F) or celsius (°C):
°C→°F=(C x 1.8)+32
°F→°C=(F - 32)/1.8

ROA:
oral:
between 96.4-99.1°F
altered by hot/cold fluids/smoking

rectal:
unstable pts
pediatric pts
higher than PO by 0.7-0.9°F

axillary:
less accurate
lower than PO by 1.8°F

TM: make sure clear of cerumen

temporal artery: less accurate

Abnormal Temperature Measurements

pyrexia/fever: over 100.4°F
I: infection
trauma
malignancy
blood dx (acute hemolytic anemia)
mx reactions
CNS lesions
autoimmune dx

hyperpyrexia: over 106°F

hypothermia: under 95°F (rectal)
I: reduced movement (paralysis)
vasoconstriction (sepsis/excess alcohol)
starvation
hypothyroidism
hypoglycemia

Pain Assessment

pain: “an unpleasant sensory and emotional experience”

take full hx of pt pain (often takes a tailored approach to each pt)

assessment dx→numeric rating scale

Acute vs Chronic Pain

acute pain:
normal/predicted response to adverse chemical/thermal/mechanical stimulus

less than 3-6 months

chronic pain:
last more than 1 month past acute dx/injury
or
recurring at intervals of months/years

not associated with cancer/mx conditions that persist for more than 3-6 months

Nociceptive (Somatic) Pain vs Neuropathic Pain

nociceptive/somatic pain:
sensory nervous system intact
“dull/pressing/pulling/throbbing/boring/spasmodic/colicky”

neuropathic pain:
lesion/dx damaging somatosensory system
“electric shock-like/stabbing/burning/’pins and needles’”

Order of Physical Exam Documentation

general survey

blood pressure

pulse-radial

respiratory rate

temperature

height

weight

BMI

HTN Screening+Sodium Recommendations

USPSTF recommendation: 40+ y/o or high BP risk→annual screening

average risk age: 18-39 y/o
every 3-5 years

daily sodium intake: under 1,500 mg
maximum sodium intake: 2,300 mg