General Survey, Vital Signs and Pain PDF

**A1 N631** **Unit 1 - General Survey, Vital Signs and Pain** - Working with a medical interpreter - Using the patient's preferred language improves understanding, safety, trust, and health outcomes. - Miscommunication increases the risk of **misdiagnosis, incorrect...

**A1 N631** **Unit 1 - General Survey, Vital Signs and Pain** - Working with a medical interpreter - Using the patient's preferred language improves understanding, safety, trust, and health outcomes. - Miscommunication increases the risk of **misdiagnosis, incorrect treatment, or medication errors**. - **Language barriers are linked to higher hospital readmissions and worse health outcomes.** - **Professional interpreters** significantly reduce the risk of **adverse events** compared to using **family members or untrained staff**. - **Legal Requirement (U.S.)** -- Under **Title VI of the Civil Rights Act**, healthcare facilities receiving federal funding **must provide language assistance to LEP patients**. - **Ethical Obligation** -- The **American Medical Association (AMA) and Joint Commission** stress the importance of **clear, patient-centered communication**. - **Protects Against Liability** -- Miscommunication leading to harm can result in **malpractice lawsuits**. - Professional interpreters and translated materials are essential for quality patient care. - Interviewing techniques - active or attentive listening, guided questioning, empathetic responses, summarization, transitions, partnering, validation, empowering the patient, reassurance and nonverbal communication - Collecting health histories - - Collecting subjective data: PQRST - **P - Provocation/Palliation:** *\"What were you doing when the symptoms started?\" \"What makes it better or worse?\"* - **Q -- Quality:** *\"Can you describe what the pain or sensation feels like?\"* (e.g., sharp, dull, burning, throbbing) - **R - Region/Radiation:** *\"Where is the symptom located?\" \"Does it spread anywhere else?\"* - **S -- Severity:** *\"On a scale of 0 to 10, how bad is the pain?\" \"Is it affecting your daily activities?\"* - **T -- Timing:** *\"When did it start?\" \"Is it constant or does it come and go?\" \"Does it happen at a specific time of day?\"* - **U - Understanding (Patient's Perception):** *\"What do you think is causing this?\" "How is this affecting your life?"* - Techniques of physical examination - **Inspection:** close observation of the details of the patient's appearance, behavior, and movement such as facial expression, mood, body habitus and conditioning, skin conditions such as petechiae or ecchymoses, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait. - **Palpation:** tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints. - **Percussion:** use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger. - **Auscultation:** use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart, this involves sounds from closure of the four valves, extra sounds from blood flow into the atria and ventricles, and murmurs. Auscultation also permits detection of bruits or turbulence over arterial vessels. - Patient positioning  - Components of general survey = the initial observation of a patient during a health assessment. It provides valuable information about the patient's overall health status before conducting a focused physical examination. - **Physical Appearance** - Level of Consciousness (LOC): Alert, drowsy, confused, lethargic, or unresponsive. - Facial Expression: Relaxed, anxious, distressed, grimacing (pain). - Skin Color: Pallor, cyanosis, jaundice, erythema, or normal. - Signs of Acute or Chronic Illness: Cachexia, frailty, or well-nourished appearance. - Hygiene & Grooming: Personal cleanliness, odor, and appropriate attire for weather. - **Body Structure & Posture** - Body Build & Symmetry: Well-proportioned, asymmetry, or deformities. - Posture: Upright, stooped, slouched, or rigid. - Nutritional Status: Normal weight, underweight, or obese. - Mobility Aids or Prosthetics: Wheelchair, cane, walker. - **Mobility** - Gait: Smooth, coordinated, limping, shuffling, or unsteady. - Range of Motion (ROM): Full, limited, or painful movement. - Coordination & Balance: Any signs of ataxia or weakness. - **Behavior** - Mood & Affect: Appropriate, flat, anxious, or depressed. - Speech: Clear, slurred, rapid, slow, or monotone. - Eye Contact: Maintained, poor, or avoiding. - Interpersonal Interactions: Cooperative, withdrawn, agitated. - Clinically significant weight changes - Concerning weight gain thresholds - Unintentional gain of \>5% of body weight over 6--12 months - Rapid gain (\>2-3 pounds per week) without clear cause - BMI increase into overweight (BMI \>25) or obesity (BMI \>30) category - Edema, difficulty breathing, or rapid abdominal distension - Concerning weight lost threshold Category Concerning level Details --------------------------------------------------------------------------------- -------------------- ----------------------------------------------------- **≥ 5% of body weight lost in 6 months** Concerning May indicate an underlying medical issue **≥ 10% of body weight lost in 6-12 months** Serious Concerning Requires urgent medical evaluation **Unintentional weight loss with symptoms (fatigue, pain, night sweats, etc.)** Red flag Possible cancer, infection, or systemic disease **Weight loss \>2 lbs per week without clear cause** Severe Consider metabolic, endocrine, or malignancy workup - VS - Temperature: 37 C/98.6F - Celsius: 36.1°C to 37.2°C - Fahrenheit: 97°F to 99°F - HR and pulse: 60 to 100bpm - BP: \ - Carotids and jugulars - assess for bruits through palpation of carotid arteries. [Palpate only 1 carotid artery at a time.] Presence of bruits could indicate thyroid or carotid artery disease/stenosis. Assess for differences in blood pressure in both arms. **Eyes** - Techniques of examination - Acuity: Snellen, Allen, Tumbling Es - Snellen -- pt is [20 ft] away from chart. Keep glasses on if they're used other than for reading. Cover one eye with a card. If patient cannot read the largest letter, they can be positioned closer to the chart -- note the intervening distance. Identify the smallest line of print where the patient can identify [more than half the letters.] Record the visual acuity designated at the side of this line, along with use of glasses, if any. - Field: Finger wiggle test - Position yourself about an arm's length away from the patient. Close one eye and have the patient cover the opposite eye while staring at your open eye. So, for example, when the patient covers the left eye, to test the visual field of the patient's right eye, you should cover your right eye to mirror the patient's field of view. Place your hands about 2 ft apart out of the patient's view, roughly lateral to the patient's ears - Color: plates test - Contrast sensitivity -- focus, unfocus and focus on object. Does it still look the same color - Assess position and alignment of the eyes (protrusion, deviation) - Inspect eyebrows (fullness, distribution, scaliness) - Inspect eyelids and eyelashes (width, edema, color, lesions, eyelid closure) - Assess the lacrimal apparatus (lumps, swelling, tearing, dryness) - Inspect the conjunctivae and sclerae (vascular pattern, color, nodules, swelling) - Inspect the cornea, iris, and lens (opacity, anterior chamber depth) - Inspect the pupils (size, shape, symmetry) - normal size between 3-5mm - Note if any miosis (constriction), mydriasis (dilation), anisocoria (unequal) -- can mean stroke or brain bleed - Test pupillary/corneal reaction to light - Near reaction (includes convergence and accommodation of eye) - Check extraocular muscle movements - Perform fundoscopic exam - Test for pupillary reaction to light (direct and consensual light reactions). - Inspect the light reflection in the corneas - Test the extraocular muscle movements -  - Perform ophthalmoscopic (funduscopic) examination including optic disc and cup, retina, and retinal vessels. **Ears and Nose** - Key components of an ear examination - Inspect the auricle and surrounding tissue (deformities, lumps, pits, or skin lesions) - Move the auricle and palpate the auricle, tragus and mastoid (tenderness) - Examine ear canals and tympanic membranes with an otoscope - Inspect the ear canal (cerumen, discharge, foreign bodies, redness of the skin, or swelling) - Inspect the tympanic membrane and malleus (color, contour, perforations, mobility) - Test auditory acuity or gross hearing with the whispered voice test - If hearing loss or difficulty is present, determine sensorineural versus conductive hearing loss with tuning fork tests (Abnormal Weber & Rinne test) - Sensorial - Common causes - damage to the **inner ear (cochlea) or auditory nerve (CN VIII)** - Hearing pattern - **distorted or unclear sounds**, difficulty understanding speech, especially in noisy environments - Conductive = - Common causes - obstruction or damage in the **outer or middle ear** - Hearing pattern - **muffled or reduced sound intensity**, but clarity may be preserved - Key components of a nose examination - Inspecting inside the nares with an otoscope - Inspect the nasal septum. Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient's finger can reach) is a common source of epistaxis (nosebleed). Inspect for any abnormalities such as ulcers or polyps - Ask if they have a Hx of nose bleeds or if they have hemophilia before inserting anything in their nose - Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses **Throat and Oral Cavity** - Key components of a mouth and throat examination - Inspect the lips (color, moisture, lumps, ulcers, cracking, or scaliness) - Inspect the oral mucosa (discoloration, ulcers, white patches, nodules) - Palpate the oral mucosa (if indicated for any lesions, thickening) - Inspect the gingiva (erythema, discoloration, ulceration, swelling) - Inspect the gum margins and interdental papillae (swelling, ulceration) - Inspect the teeth (missing, discolored, misshapen, or abnormally positioned) - Inspect the roof (hard palate) and floor of the mouth (erythema, discoloration, nodules, ulcerations, or deformities) - Test the hypoglossal nerve, or CN XII (symmetry of tongue protrusion) - Inspect the tongue (color, texture, lesions) - Palpate the tongue (if indicated for any lesions, thickening) - Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx (color, symmetry, exudate, swelling, ulceration, or tonsillar enlargement) - Test the vagus nerve, or CN X (symmetry of uvula) **Unit 2 -- Neurologic System** - **SNS** is responsible for the release of catecholamines in your body **during times of stress**, specifically [norepinephrine, epinephrine, and acetylcholine]: ↑ HR and BP ↑ and opens airways in the lungs ↑ alertness, sight, hearing & other senses Releases blood sugar and fats into circ. Vasoconstriction in the vessels and vasodilation in major organs and muscles ↓ intestinal motility - Physical assessment of neurological system - Mental status - Appearance - Behavior - Speech and language - Mood - Memory - Orientation - **Alertness - speak to the patient in a *normal* tone of voice.** The alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact). - **Lethargy - speak to the patient in a *loud* voice.** For example, call the patient's name or ask, "How are you?" The lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep. - Obtundation - apply *tactile stimulus* by gently shaking the patient as if awakening a sleeper. The obtunded patient opens the eyes and looks at you but responds to you slowly and is somewhat confused. Alertness and interest in the environment are decreased. - **Stupor -** **apply a *painful stimulus* (pinch a tendon, rub the sternum, or roll a pencil across a nail bed).** The stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment. - **Coma - apply *repeated painful stimuli* to the trunk and extremities.** A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli. - Cranial nerves = **"Oh, Oh, Oh, To Tough And Feel Very Green Vegetables, AH"** i. **Olfactory** - check nasal patency and then sense of smell for each nostril. ii. **Optic** - Snellen Eye Chart. Have the patient stand 20 feet away from chart and then ask them to read the smallest line of text that they can see with both eyes, then each eye separately. iii. O**culomotor** iv. **Trochlear** v. **Abducens** vi. **Trigeminal** - Place hands over temporomandibular joint (TMJ) and then ask patient to clench the jaw, noting the strength of contraction. Afterwards, ask patient to close eyes and use cotton ball to check sensation in 3 different areas of the face. vii. **Facial** - Raise eyebrows, close eyes shut, puff the cheek, show the teeth, smile viii. **Acoustic** - Whisper Test ix. **Glossopharyngeal** x. **Vagus** xi. **Spinal accessory** - look for atrophy in trapezius muscles, shrug shoulders, ask patient to turn head back and forth against hand xii. **Hypoglossal -** stick out tongue and ask to move back and forth - Motor system - Strength - 0 = no muscular contraction detected - 1 = barely detectable flicker or trace of contraction - 2 = active movement of the body part with gravity eliminated - 3 -- active movement against gravity - 4 = active movement against gravity with some resistance - 5 = active movement against full resistance without evidence fatigue - Coordination - Rapid alternating movements - Flipping hand back and forth on thigh - Finger to thumb movements - Foot tapping practitioner\'s hand - Point-to-point movements - Finger-Nose Test - Touch examiners finger, then raise arm - Heel-Shin Test - Standing in specific ways - Heel-to-Toe Test - Hopping in place with - Romberg Test = assesses balance and proprioception. The patient stands with their feet together and arms at their sides or crossed in front of them. The test is performed in two parts: first with the eyes open, then with the eyes closed. The examiner observes the patient\'s balance and body movement - Gait - **Spastic hemiparesis** = seen in cerebral palsy or stroke patients as the affected hemiparetic side swings out then inward - **Steppage gait AKA foot drop** = inability to flex the ankle due to nerve impingement in the lower back or stroke - **Cerebellar ataxia =** usually seen in cerebellar disease. Patient has difficulty maintaining balance, maintaining a wide stance. Tendency to lunge or jerk sideways to catch themselves - **Scissors gait** = seen in spinal cord disease resulting in spasticity in the hip adductors, resulting in the legs crossing one another during each step - **Parkinsonian gait =** classic shuffling presentation due to lack of dopamine in the nervous system, resulting in stiff movement with intermittent spasticity - **Sensory ataxia** = form of ataxia caused by the impairment of the somatosensory nerves, leading to the interruption of sensory feedback signals. Seen often in diabetic pts - Abnormal body postures - Hemiplegia = one sided paralysis, flaccid early in course - Decorate = **flexed posturing**  - Suggests **cerebral hemisphere damage**, but **brainstem reflexes may still be preserved**, making the prognosis relatively better - Remember the letters **[COR]** in the word de**cor**ticate for the word "**[core]**". The patient will bring their **ARMS** **to the core of the body (middle)** - Decerebrate = adduction and **[e]**xtension of the arms and pronation of the hands and the fingers will be flexed along with extended legs and plantar flexion of the feet. - Indicates **lower brainstem involvement** (midbrain or pons), which **controls vital functions like breathing and consciousness**. - Remember the **E**'s in the word d**e**c**e**r**e**brat**e** for the word **[EXTENDED]**. The arms are going to be **[e]**xtended rather than flexed. - Sensory system - to evaluate the sensory system, you will test several kinds of sensation: - Pain and temperature (spinothalamic tracts) - Position and vibration - Light touch - Discriminative sensations, which rely on some of the above sensations but also involve processing by the sensory cortex - Reflexes **Brainstem Reflex** **Normal Response** **Brain Death (Absent Response)** ------------------------------------------------ --------------------------------------- ----------------------------------- **Pupillary Reflex** Pupils constrict to light Fixed, dilated pupils **Oculocephalic Reflex (Doll's Eyes Test)** Eyes move opposite head turn No eye movement **Oculovestibular Reflex (Cold Caloric Test)** Eyes deviate toward cold water in ear No eye movement **Corneal Reflex** Blink when cornea is touched No blink response **Cough/Gag Reflex** Cough/gag when suctioned No cough or gag **Spontaneous Breathing (Apnea Test)** Respiratory effort when CO₂ rises No respiratory effort - Special assessment techniques - Meningeal signs - **Nuchal rigidity**-Have patient flex head downward and assess for resistance (abnormal) - **Brudzinski's Sign** - **Kernig's Sign** - Jolt Accentuation of Headache (nice to know) - Cushing's triad: ↓ HR, widening systolic and diastolic and irregular respiration - Ischemic vs hemorrhagic stroke  - Headache - Assessment - **P**ulsatile/throbbing - **O**ne-day duration - **U**nilateral - **N**ausea/vomiting - **D**isabling - Life-threatening causes (emergency conditions) - **Subarachnoid hemorrhage (SAH)** = bleeding into the space around the brain, often due to a ruptured cerebral aneurysm. **"Thunderclap headache"** (sudden, worst headache of life) - **Meningitis & encephalitis** = infection/inflammation of the meninges or brain tissue. Severe headache with **fever and stiff neck**. - **Intracranial hemorrhage (ICH) & stroke =** bleeding in the brain (ICH) or blockage of blood flow (ischemic stroke). **Neurological deficits** (weakness, numbness, speech impairment) - **Increased intracranial pressure (ICP)** = excess pressure inside the skull, often due to a mass (tumor, hemorrhage, hydrocephalus). **Worsening headache when lying down, coughing, or bending forward**. **Papilledema** (swelling of optic disc) - Severe but non-life-threatening causes - **Migraine** = recurrent headaches triggered by stress, hormones, certain foods, or sensory stimuli. **Unilateral, pulsating headache** lasting hours to days. **Aura** (visual changes, tingling, speech disturbances in some cases). - **Cluster headache** = severe headache attacks occurring in clusters over weeks/months. **Unilateral, stabbing pain** around the eye. - **Tension headache** = muscle tension-related headache, often due to stress. **Bilateral, band-like pressure** (not throbbing). - **Trigeminal neuralgia** = nerve irritation of the trigeminal nerve, causing facial pain. **Brief, shock-like pain in face (triggered by touch, chewing, talking).** - Secondary headaches due to other conditions - **HTN** - severe headache with very high blood pressure (risk of stroke, encephalopathy) - **Temporal arteritis -** severe headache in elderly patients, with jaw pain and vision changes (requires urgent steroids to prevent blindness). - **Cervicogenic headache** - headache due to neck dysfunction or injury. - Seizures - SIADH vs DI - Autoimmune disorders Guillain-Barré Syndrome (GBS): Symptoms & TreatmentMultiple Sclerosis (MS): What It Is, Symptoms & Treatment - Spinal cord injury