Physical Assessment and Vital Signs

• Physical assessment (PA) involves evaluating objective anatomical findings through four distinct activities.

Physical Examination

• Inspection involves looking at the body.
• Palpation involves feeling the body with fingers or hands.
• Auscultation involves listening to sounds.
• Percussion involves producing sounds, usually by tapping on specific areas of the body.

General Survey

• Appearance includes overall hygiene, grooming, attire, skin color, presence of lesions, height, and weight.
• Behavior encompasses facial expressions, level of consciousness, orientation, speech, and demeanor.
• Mobility includes posture, range of motion, use of mobility aids, and gait.

Vital Signs

• Vital signs offer vital information, encompassing blood pressure, heart rate, respiratory rate, and temperature.
• Many practice settings monitor oxygen saturation as well.
• Pharmacists need to proficiently interpret patient vital signs.
• Pharmacists should be able to measure vital signs themselves.

Blood Pressure

• Accurate BP measurement is crucial for managing hypertension and addressing BP-related medication side effects.
• Pharmacists play a key role in managing hypertension through patient monitoring and BP interpretation.
• Pharmacists help mitigate risks and maximize the benefits of drug therapy.
• Pharmacists are well-positioned to detect BP-related drug therapy problems.
• Heart failure (HF) patients often use multiple drugs affecting BP like beta-blockers, ACE inhibitors, & diuretics.
• HF patients tend to have lower BP, but medications may be titrated for maximal benefit.
• Pharmacists could be the first to notice adverse effects during medication titration through follow-up.
• Korotkoff sounds are tapping sounds caused by turbulent blood flow in a partially occluded artery.
• Systolic blood pressure (SBP) is the pressure when at least two Korotkoff sounds are audible.
• Diastolic blood pressure (DBP) is the pressure when the beats are no longer audible.

Heart Rate

• Arterial pulse assessment determines heart rate, pulse strength, and regularity.
• Radial artery is commonly used but other large arteries like femoral or carotid can be used.
• Locate the radial artery on the wrist below the thumb, between flexor carpi radialis and abductor pollicis longus tendons.
• Gently press the artery with the fingertips, not the thumb.
• Determine heartbeats per minute (BPM) by counting pulses in 15 seconds and multiplying by 4.
• Pulse strength is described as normal, weak, or bounding (stronger).
• Pulse can be regular (evenly spaced) or irregular (unequally spaced).
• With irregular pulse, determine if the sequence has a repeating pattern or not.
• Fit individuals might have a resting HR below 50-60 bpm due to cardiovascular adaptations from exercise.
• Bradycardia (HR < 60 bpm) in patients on beta-blockers may warrant dose reduction.
• For those reporting heart palpitations or are tachycardic (>100 bpm), check the pulse for irregularity.
• An irregular pulse suggests arrhythmias like atrial fibrillation (AF).
• ECG rules out AF or arrhythmias with irregular pulse.
• In infections, tachycardia is a sign of sepsis if other symptoms are present.

Respiratory Rate

• Respiratory Rate involves visually monitoring the rise and fall of the patient's chest.
• Count the breaths for 30 seconds and multiply by 2, or count for a minute if irregular.
• It's better not to inform the patient.
• Note normal (depth and rate) versus abnormal patterns (periodic apnea, etc.)
• Observe the usage of accessory muscles which could be muscles in the neck contract with each breath which may indicate respiratory distress.
• Elevated RR indicates respiratory distress, such as in AECOPD, asthma exacerbation, or pneumonia.
• Low RR is worrisome, as the patient may not get adequate gas exchange.
• The result may be hypoxia or respiratory acidosis.
• RR is important in monitoring for opioid toxicity.

Temeprature

• Body temperature screens for illness and monitors drug therapy response.
• Measured temperature varies depending on the measurement site and device.
• A fever is generally accepted to be an oral body temperature of 38°C or higher.

Height and Body Weight

• Patient height and weight are useful for screening and monitoring parameters.
• Patient height and weight also serve as components of the body mass index (BMI).

Skin Inspection

• Skin color is an important aspect of evaluation.
• Palpate the skin for turgor, moistness, temperature, texture, mobility, and edema.
• Assess skin turgor by quickly releasing a fold of skin.
• Skin inspection involves describing color, shape, size, structure, and distribution of dermatological lesions.
• Macule is a small ( 1 cm), solid lesion that may be below, even with, or above the skin.
• Papule is a small ( 1 cm), circumscribed, elevated, and solid lesion.
• Pustule is a circumscribed, elevated lesion of varying size containing pus.

Neurological

• Pharmacists should interpret the neurological exam if relevant to their practice.
• 3+ and 4+ designations referring to reflexes which are more exaggerated than normal.
• Neurological assessments are useful when assessing for serotonin syndrome.
• Pharmacists should look for abnormal movements, gait, and spasticity like post-stroke patients.
• Tardive dyskinesia should be recognizable in patients using antipsychotics.
• Neuropathic pain is commonly characterized by spontaneous, burning, and shooting pains accompanied by paresthesia which is described as “pins and needles."
• Sensory evaluation includes light touch, pressure, temperature, vibration, and proprioception. Use ice or a cold tuning fork to test the patient's perception of temperature.
• Use a cotton swab to test light touch.
• Apply a vibrating tuning fork to test vibration sensation.
• Use a pinprick to test for sensory deficit or abnormal sensations.

Level of Consciousness and Orientation

• A pharmacist should be familiar with the Glasgow Coma Scale (GCS).
• Ensure patients are oriented to person, place, and time.

HEENT (Head, Eye, Ears, Nose, Throat)

• HEENT is evaluated through inspection and palpation; percussion and auscultation are rarely indicated.
• Visual acuity, hearing, facial and ophthalmic reflexes are tested when clinically indicated.
• Inspect the neck for symmetry, masses, enlargement of the parotid and submaxillary glands, and lymph nodes.
• Note dry, flaky scalp with redness indicating possible dandruff, psoriasis, or dermatitis.
• Dry mucous membranes in the mouth may be from dehydration.
• Poor dentition is a general risk factor for systemic illnesses and poor health in general.
• White patches in the mouth indicate oral candidiasis ("thrush").
• Bulges or swelling in the throat indicate goiter, a sign of hypo- or hyperthyroidism.
• Xanthomas, deposits of cholesterol on skin, indicate high cholesterol.
• Tender/swollen cervical lymph nodes can be felt in those with pharyngitis.

Eye

• Pupil size can change from medications.
• Opioid toxicity causes pinpoint pupils (miosis).
• Sympathomimetic drugs dilate pupils (mydriasis), aiding in unknown toxidrome identification.
• Pupil dilation results from the patient having serotonin syndrome.
• Yellowish discoloration of the eye may be jaundice.
• Exophthalmos (eye protrusion) is commonly associated with hyperthyroidism.

Respiratory System

• Barrel chest is an abnormality caused by lung overinflation, seen in COPD patients.
• Lungs should be auscultated from the anterior and posterior, having the patient breathe through their mouth.
• Spirometry results for those with respiratory issues reveal the degree of airflow limitation.
• COPD patients need spirometry testing during diagnosis and exacerbations.
• Pharmacists must know post-bronchodilator forced expiratory volume.
• Some patients use a peak flowmeter in asthma, showing if one has decreased or diminished volume.

Cardiovascular System

• Pharmacists should note S1 (lub) and S2 (dub) heart sounds.
• Extra sounds can suggest heart problems.
• Cardiac murmurs include whooshing/swishing sounds from rapid turbulent blood flow.
• Murmurs’ grading ranges from I to VI (faint to loud).
• Bruits are abnormal sounds in blood vessels due to turbulent blood flow.
• S3: Third heart sound; from ventricular distention during filling; linked to heart failure.
• S4: Fourth heart sound; is from increased left ventricular pressure & loss of elasticity; is linked to hypertension.
• Gallop rhythm is an abnormal rhythm with three or four sounds.

Volume Status

• Volume (euvolemic, hypovolemic, or hypervolemic) status is key for pharmacists.
• Those with hypovolemia are prone to kidney injury & medication accumulation.
• These patients are also at high toxicity risk from nephrotoxic drugs.
• With diuretics, proper fluid status is crucial for proper dosing and minimal toxicity.
• Assess edema by pressing the tips of one or two fingers into the skin.
• Track the time for the indentation to disappear after finger release.
• The plus scale (1+, 2+, 3+, 4+) helps you quantify the edema, with 4+ denoting the most long-lasting indentations.
• Jugular vein distention should be assessed in volume status assessment.
• Jugular vein distention can be a sign of an underlying volume issue.

Abdomen

• Abdominal exam involves inspection, palpation, percussion, and auscultation.
• Tenderness indicates pain or discomfort upon touching the affected area.
• Liver function should be considered because most drugs are metabolized by the liver.
• The categories are A, B, and C, with A being milder dysfunction, and C being severe liver disease.
• Physical findings reveal any ascites, causing very large abdomens due to fluid accumulation.

Extremities

• Upper & lower extremities are assessed.
• Note tenderness, deformity, swelling, or erythema.
• Evaluate joint range of motion and bilateral muscle strength.
• Check tendon function.
• Finally, check Capillary.

Documentation

• Perform the physical assessment and document accordingly.
• Clinical pharmacists need skills gathering objective and subjective information.
• Clinical pharmacists need skills evaluating a patients physical care to ensure outcomes.