Healthcare Team & Physical Assessment

• Student pharmacists will understand the basics and objective of physical assessment.
• Student pharmacists will understand the difference between subjective and objective data.
• Student pharmacists will identify the difference between normal and abnormal physical findings relative to the various organs and disease states.
• Student pharmacist will identify and understand the general assessment techniques.
• Student pharmacists will identify the basic steps in the conduction of a physical examination.
• Students will identify the items of the general patient survey.

Healthcare Team & Physical Assessment

• A complete health assessment has three major components.
• The three components include an interview and health history.
• Includes a general survey and vital signs check.
• Includes a physical exam, which includes diagnostic evaluation, and interpretation of findings and diagnosis, treatment, and follow-up.
• Pharmacists can use their physical examination knowledge, principles, methods, and data when providing pharmaceutical care.
• Physical assessments can measure drug/disease outcomes, instead of diagnosis, such as lower limb edema and diuretic response, and heart rate with a B-blocker response.
• This is done during hospital rounds to help patient quick referral in community settings.

Objectives of Physical Examination

• Obtaining valid patient information about their health status.
• Identify the 'normal' state first, then analyze the variations by addressing complaints/symptoms.
• Screen the patient's general well-being/deteriorating status, and monitor current health issues.
• Establish a baseline to start health evaluation & assessment; all documented in the patient's medical record.

Subjective vs Objective Data

• Subjective data is obtained from patient interviews or health history.
• Subjective data results in both alert for physical assessment and stimulate further questioning, allowing attention to the patient's perspective.
• Objective data is a physical assessment, lab or diagnostics.
• Objective data findings amplify, verify, and clarify subjective info.
• The purpose of a physical exam is for general screening or a symptom analysis, or follow-up.

Assessment Techniques

• Four universally accepted assessment techniques are used during a physical exam.
• The four techniques are inspection, palpation, percussion, and auscultation
• Sight + hearing + touch +smell = a whole picture.

Inspection

• It is the first step in an examination.
• Involves using senses, hearing, and smell to validate anything seen, in relation to sounds or odors originating from the patient.
• Uses all subjective and objective information to assist in decision-making regarding diagnoses and treatments.
• In a pharmacy setting, observation is used to note the way the patient: walks, talks, grooms, and behaves toward others.
• Includes observing the patient's body for symmetry, looking for lesions on the trunk/limbs and noting their color, size, shape, etc.

What to Inspect

• Level of consciousness
• Signs of distress
• Apparent state of health
• Skin color and obvious lesions
• Body build
• Posture, motor activity, and gait
• Dress, grooming, personal hygiene
• Odors (body or breath)
• Facial expression

Palpation

• It is the second step in an examination.
• Involves touching or feeling with the hands and is used to add to the info from inspection.
• Palpation is used to assess individual structures on the surface and within body cavities and pulsations.
• Examples may include the size ,shape, and consistency of normal anatomic structures on the abdomen.
• Palpation can uncover the presence of abnormalities, such as enlarged organs and palpable masses.

How to Palpate

• Use fingertip to distal interphalangeal joints to palpate, or 'general" touch.
• Back of the hand/dorsum is used for rough temperature measures.
• Use hands to grasp or hold anything; assess position, size, & consistency of a structure.
• Palmar surface of the hand is used for vibration.
• Use light, medium, & deep palpation for any and all areas being assessed.

Degrees of Palpation

• Start with light palpation, increasing the strength as assessment is required and patient's tolerance allows.

Light Palpation

• This helps locate lesions on the surface or within muscles, as it is gentle and superficial
• This technique serves to relax the patient & prepare them for a medium and deep palpation.
• Pressing the pads of the fingers lightly into the patient's skin & moving the fingers in a circular motion.

Medium Palpation

• Assesses mid-level lesions of the peritoneum, masses, tenderness, pulsations, & pain in most structures of the body.
• Use the palmar surface of fingers and press 1-2cm into patients body, using a circular motion.

Deep Palpation

• Assesses organs deep inside body cavities
• Palpate areas of tenderness or discomfort last.
• Deep palpation can be performed with one or two hands, while the top hand presses the bottom hand down 2-4 cm in a circular pattern.

Five Steps to Palpating the Abdomen

• Wash and warm your hands.
• Palpate painful areas last.
• Perform Light palpation first with one hand.
• Palpate all four quadrants using the degree of palpation.
• Perform Deep palpation with one or two hands.

Percussion

• It is the third step in a physical examination.
• Involves striking the body's surface lightly to determine the position, size, and density of the underlying structures, and to detect fluid or air.
• Striking the surface creates a sound wave that travels 5 to 7 cm.
• How percussion sounds are returned depends on the features of the underlying structures.
• The most common method is indirect percussion, where The passive finger remains gently & firmly against the body's surface, with rest of fingers raised.
• The finger will strike sharply with a strong wrist action between the DIP and PIP joints, and then the hand is quickly flexed back on the forearm, to generate a snapping motion.
• This can also be done with a fist for certain assessments.

Percussion Notes

• The four percussion notes are: pitch, amplitude, duration, and quality

Pitch

• The number of vibrations or cycles per second (cps).
• Rapid vibrations produce a higher pitched tone, slower vibrations produce a lower pitched tone.

Amplitude (Intensity)

• Determines the loudness of the sound, the greater the intensity, the louder the sound.

Duration

• The length of time that the note is heard

Quality (Timbre, Harmonics, or Overtone)

• A subjective concept used to describe the variance secondary to a sound's distinctive overtones.
• A structure with air (lungs) produces a louder, lower, longer sound.
• A denser, more solid structure (thigh/ muscle), produces a softer, higher, shorter sound.
• The density of a thick tissue or mass absorbs/blunts the tone.

Percussion Sounds

• Flat: high pitch, soft, short duration.
• Dull: medium pitch, medium, moderate duration.
• Resonance: low pitch, loud, long duration.
• Hyper-resonance: very low pitch, very loud, long duration.
• Tympany: high pitch, loud, long duration.

Auscultation

• It is the last technique an examination, (except bowel auscultation before palpation & percussion).
• It involves listening to the body sounds created in lungs, heart, blood vessels, & abdominal viscera.
• Auscultated sounds are described by frequency, intensity, duration, quality, & timing.
• Examiners listen for heart sounds, blood pressure; note Korotkoff sounds, airflow through the lungs, & bowel sounds.
• A diaphragm amplifies high-pitched sounds such as breath sounds, bowel sounds & regular heart sounds (S1 and S2).
• A bell amplifies low-pitched sounds & amplifies heart murmurs, arterial (bruits) or venous (hums) turbulence, & organ friction rubs.
• The bell is recommended in measuring BP, although proper placement can be difficult, and so diaphragms are also commonly used.

Preparing for the Examination

• Gather the equipment.
• Prepare the setting (separate area to ensure confidentiality & privacy), with adjusted temp & lighting.
• Ensure patient safety.
• Standard precautions to prevent the spread of infection according to CDC guidelines, by avoiding touching areas around the patient, washing hands, etc.
• Gain consent before any assessment.

The Examination

• Sequence and position the examination for the patients to use, the common positions are sitting, standing, high Fowler’s, semi-Fowler’s, supine, and side-lying.
• Each step should be explained as the examination proceeds, giving advance warning if a maneuver will produce discomfort
• Summarize information and share with the patient, and thank them for their time.

General Assessment & Vital Signs

• What do check for in the general survey?

Survey Checklist

• Age
• Skin color
• Facial features
• Level of consciousness
• Signs of acute distress
• Nutrition
• Body structure
• Dress and grooming
• Behaviour
• Mobility

Survey Details

• For age, note if patient looks older than their stated age.
• Skin color: is assessed through cyanotic (lip/oral cavity), Pallor, Jaundice (nail bed & conjunctiva), and skin tone consistent with genetic background.
• Cyanosis is bluish discoloration resulting from an insufficient blood oxygen.
• Pallor is abnormal skin paleness from reduced blood flow/hemoglobin.
• Jaundice is a yellowing of skin from excess bilirubin.

Facial Movements

• Movements should be symmetrical, & facial expressions should match what is being said.
• One side of the face is paralyzed (stroke, physical trauma, or Bell's palsy).
• A flat/ mask-like expression = no facial emotion - indicates Parkinson's/depression.
• Inappropriate affect means the facial expression does not match, which is a sign of psychiatric illness.

Consciousness

• Patient should be alert & oriented to time, place, and person (written as: alert and oriented X 3).
• Disorientation occurs with organic brain disorders (e.g., delirium, dementia), stroke, & trauma.
• Lethargic patients drift off to sleep easily, look drowsy, & respond to questions slowly.
• Stuporous patients respond to persistent/vigorous shaking and answers questions with a mumble.
• Comatose patients do not respond to any stimuli/pain.

Medical conditions altering consciousness

• Confusion describes disorientation that makes it difficult to participate in an examination.
• This results from sleep deprivation, fever, alcohol intoxication or postictal state etc.
• Delirium: Characterized by by cognition and agitation, hallucinations, as well as by instability of heart rate and blood pressure.
• Can stem from drug withdrawals, drug use , organ failure, and severe infection.
• Lethargy is severe drowsiness, & apathy which requires verbal stimulation to initiate a response and can be caused by severe conditions such as infections or organ failure.
• Obtundation is a reduction in alertness with slow responses that occurs with poisoning, stroke, or organ failure.

Signs of Acute Distress

• Assessing breathing, facial grimacing, or holding body parts can show signs of shortness of breath and/or pain.

Nutrition

• Patient's weight should be appropriate for his or her height and build.
• Truncal obesity means fat is primarily on face, neck and trunk regions of the body which can be caused by Cushing's syndrome or by taking corticosteroids.
• If patient's waist is wider than the hips, they are at an increased risk of developing obesity-related diseases such as DM, HTN, CAD.
• A cachectic appearance, patient looks very thin and has sunken eyes which is associated with chronic wasting diseases (e.g., cancer, starvation, dehydration).

Body Structure Deformities

• Sides of the patient's body should stand comfortably erect and move appropriately for the patient's age.
• A tripod position, leaning forward with arms braced, occurs with chronic obstructive pulmonary disease.
• Physical deformities are kyphosis, a hunched back associated with osteoporosis, and lordosis, an inward curvature in the lower back, seen in late-term pregnant women.

Dress and Grooming

• Patient's clothing should be climate-appropriate, clean, and fit appropriately.
• Patients should appear clean and be groomed appropriately for his or her age/gender.

Behavior

• Patients should be cooperative and interact pleasantly and appropriately with others.
• Speech should be understandable, and clear.

Mobility

• Patients should have smooth/even gait, balanced with feet approximately shoulder-width apart.

Impaired Mobility

• A shuffling gait, hesitant to start walking with short steps, may indicate Parkinson's disease.
• Ataxia is a staggering, unsteady gait can be caused by alcohol or drug ingestion.