Physical Diagnosis - General Survey & Vital Signs Lecture Notes PDF

Physical Diagnosis General Survey and Vital Signs Dr Joseph M Daleo DPA PA-C Vitals / General Assessment Level of Consciousness Alert – Awake and aroused easily A O X3 ◼ Lethargic – Difficult to arouse, drowsy , thinking slow but appropriate ◼ Obtunded- Sleeps most of the time, Confused when ar...

Physical Diagnosis General Survey and Vital Signs Dr Joseph M Daleo DPA PA-C Vitals / General Assessment Level of Consciousness Alert – Awake and aroused easily A O X3 ◼ Lethargic – Difficult to arouse, drowsy , thinking slow but appropriate ◼ Obtunded- Sleeps most of the time, Confused when aroused , speech mumbled ◼ Stupor – (Semi comatosed)responds to vigorous shaking and or painful stimuli, nonverbal except for possible moaning ◼ Comatose – Can not be aroused with any stimuli ◼ Signs of Distress Cardiorespiratory Insufficiency labored breathing, wheezing or cough ◼ Pain Wincing, sweating, protecting a painful part ◼ Anxiety Anxious face, fidgety movements ◼ Observe for ◼ Skin Color or Obvious Lesions Pallor, jaundice, cyanosis, rashes or bruises ◼ Height and Build Unusually short or tall, slender or lanky, any obvious deformities ◼ Sexual Development Voice, facial hair, breast size Observe for ◼ Weight Emaciated, Slender or Obese, is fat distributed evenly or concentrated in the trunk ◼ Posture, Gait and Motor activity Is patient restless, involuntary movements, loss of balance Observe For ◼ Dress, Grooming, Hygiene Appropriately dressed for temperature. Is hygiene and grooming appropriate. ◼ Odors or Body and Breath Alcohol or Acetone – Ketones in DKA ◼ Facial Expressions During conversation and during physical examination Sample Write Includes ◼ Age ◼ Ethnic Background ◼ Level of consciousness ◼ Physical description Examples of Write Up ◼ Slender Asian female, neatly groomed, looks younger than her stated age of 84 ◼ Well developed well nourished 60 yo African American male in no apparent distress, alert and cooperative. ◼ Cachectic 70 yo white female sitting up in bed in obvious respiratory distress, using accessory muscle to breath and unable to communicate. Sample Write Ups ◼ Frail 90 yo female lying in bed, nonverbal, appears comfortable. ◼ Obese 52 yo white male, alert in moderate respiratory distress, appears pale and anxious. Brought in by E.M.S.. With complaint of chest pain Vital Signs ◼ Arterial Pulse BMI ◼ Respiratory Rate Pulse Ox ◼ Blood Pressure ◼ Temperature Arterial Pulse ◼ Grasp both hands to palpate radial pulse ◼ If regular count for 30 sec then multiply by 2 or 15 sec multiply by 4 ◼ If irregular count for full minute. Confirm rate by auscultating the heart. ◼ Determine Rate, Rhythm and Amplitude of pulse Rate ◼ Sinus Tachycardia Rate over 100 bpm ◼ Typically Rate Between 100-140 ◼ If Rate Over 140 Consider Cardiac Cause Common Causes Tachycardia ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ ◼ Exercise Anxiety Infection Thyrotoxicosis / Hyperthyroidism Hemorrhage Acute MI / Ischemia Hypoxemia – low levels of O2 Anemia Drugs Sinus Tachycardia ◼ Usually a normal physiological response to some underlying condition ◼ If the Rate is over 140 consider cardiac arrhythmia. ◼ Elevated heart rates associated with a decrease in cardiac output and blood pressure. Sinus Bradycardia Rate less than 60 bpm ◼ Common Causes ◼ Increased Vagal Tone ◼ Athletes ◼ Hypothyroidism ◼ Hypothermia ◼ Sinus node disease ◼ Drugs / Beta blockers / Calcium blockers ◼ Relative Tachycardia ◼ Patients on Beta blockers / calcium channel blockers and digoxin may have resting heart rates between 50-60. ◼ Heart rates in the 80-90’s could be considered tachycardic in these patients Relative Hypotension ◼ Some patients may live with significantly elevated blood pressures. ◼ A drop in pressure to so called normal levels may be considered relative hypotension Pulse Rhythm ◼ Regular ◼ Regularly Irregular ◼ Irregularly Irregular Regularly-Irregular Pulse ◼ Has a regular rhythm which is interrupted by some irregularity ◼ Typical of Premature Atrial contraction and premature Ventricular contractions ◼ Causes include caffeine and nicotine Irregularly Irregular Pulse ◼ Pulse which has no pattern ◼ Typical of Atrial Fibrillation Atrial Fibrillation (A-FIB) ◼ SA node is the normal pacemaker ◼ Afib is a condition where there are multiple pacemakers in the atrium ◼ Atria quivers instead of contracting ◼ AV node bombarded with impulses ◼ Ventricular rate is irregular because the AV node lets the impulses though randomly. Atrial Fibrillation ◼ Pulse Deficit is the difference between palpated pulse and the actual heart rate. Pulse deficit occurs when there are fewer pulses than there are heartbeats. ◼ Patients in A-Fib are prone to strokes and heart failure as well as hypotension. Amplitude of Pulse 4+ Bounding ◼ 3+ Full ◼ 2+ Normal ◼ 1+ Diminished ◼ 0 Absent ◼ Small Weak Pulses ◼ Due to decreased stroke volume ◼ Common causes include Heart Failure Hypovolemia Aortic Stenosis Large Bounding Pulses ◼ Usually Due to Increased Stroke Volume ◼ Common Causes Anemia Hyperthyroidism Calcified blood vessels Respiratory Rate ◼ Normal respiratory rate 12-18 but variable ◼ Tachypnea - Rate over 20 ◼ Rates of 30 Very Dangerous ◼ Bradypnea - Rate Below 12 Observer Respirations for Rate, Depth, Regularity and Symmetry ◼ Rapid Shallow Breathing Seen with Respiratory Failure, Restrictive Lung Disease and Pleuritic Chest Pain ◼ Rapid Deep Breathing Anxiety, Infection, Exercise, DKA ◼ Slow Breathing Diabetic coma, Drugs, Raised Intracranial Pressure Observe Respirations For ◼ Cheyne-Stokes Breathing Seen in Elderly, After Strokes, Trauma and sometimes with CHF - cyclical episodes of apnea and hyperventilation ◼ Ataxic Breathing Characterized by unpredictable Irregularity ◼ Obstructive Breathing Seen With Asthma, emphysema, bronchitis Paradoxical Breathing ( Chest Trauma) Instead of moving out when taking a breath, the chest wall or the abdominal wall moves in. Often, the chest wall and the abdominal wall move in opposite directions with each breath ◼ ◼ Asymmetrical Rise and Fall of Chest Wall Pneumothorax Respirations Respiratory Rate and Rhythm: Note the rate, rhythm, depth, and effort of breathing. Never ask the patient to breathe normally. After taking the pulse, subtly direct your eyes to the patient’s chest and evaluate respirations. Count the number of respirations over 30 seconds and multiply by 2. Normal is 14-20 breaths/min Arterial Blood Pressure ◼ Low Blood Pressure i.e. Hypotension Decreased Profusion of Organs Not shock until evidence of inadequate tissue profusion. Such as change in mental status, chest pain, decreased urine output, cool clammy extremities etc. Some patients normally have low BP If you are called to see a patient with low BP ask what is the patients baseline blood pressure and are they symptomatic? Arterial Blood Pressure ◼ Hypertension ◼ 120/80 ◼ The “Silent Killer” ◼ Damages blood vessels leading to MI, Stroke, kidney Failure etc ◼ Increases afterload on the heart leading to heart failure ◼ Pressures over 200/120 considered accelerated hypertension occasionally asymptomatic. ◼ Look for signs of end organ damage consistent with malignant hypertension such as intracranial bleeding, MI or heart failure Measuring Blood Pressure ◼ Palpatory Method ◼ Auscultatory Method ◼ Korotkoff Sounds Blood Pressure Technique ◼ Choose Appropriate Size Cuff , Small, Medium, Large ◼ Do Bilateral Sitting, Standing and Supine ◼ Avoid smoking, caffeine, exercise ◼ Keep brachial artery at heart level ◼ Arm Free of Clothes ◼ Check for AV fistula or lymphedema - avoid that arm Blood Pressure Technique ◼ Lower Boarder of Cuff 2.5 cm above arm crease ◼ First estimate systolic pressure by palpation ◼ Pump cuff 30 mm Hg above palpated pressure ◼ Use Bell over brachial artery Blood Pressure Technique ◼ Inflate cuff then let deflate slowly 2-3 mm Hg second ◼ Hear sounds of 2 consecutive beats this is the systolic pressure ◼ Continue to lower cuff pressure until sounds disappear this is diastolic pressure. ◼ Confirm disappearance by letting pressure drop another 10-15 mmHg Blood Pressure Technique ◼ Blood pressure should be taken in both arms at least once ◼ BP in left arm tends to be slightly higher ◼ Pressure differences of more than 10-15 mmHg suggests arterial compression Auscultatory Gap An Ausclatory gap is a period of diminished or absent Korotkoff souds during the manual measurement of blood pressure. The improper interpretation of this gap may lead to blood pressure monitoring errors: namely, an underestimation of systolic blood pressure and/or an overestimation of diastolic blood pressure. In order to correct for an auscultatory gap the radial pulse should be monitored by palpation. It is therefore recommended to palpate and auscultate when manually recording a patient's blood pressure. Typically, the blood pressure obtained via palpation is around 10 mmHg lower than the pressure obtained via auscultation. In general, the examiner can avoid being confused by an auscultatory gap by always inflating a blood pressure cuff to 20-40 mmHg higher than the pressure required to occlude the brachial pulse Auscultatory Gap ◼ May be seen when there is decreased blood flow to the extremities ◼ Aortic Stenosis and uncontrolled Hypertension ◼ Palpating Systolic Pressure first avoid the Gap Baroreceptor Reflex ◼ Stretch receptors located in carotid sinus and the arch of aorta ◼ Monitors blood pressure ◼ In volume depletion this reflex increases heart rate and contractility ◼ Initially may prevent significant drop in BP Orthostatic Blood Pressure / Postural Hypotension ◼ Measure blood pressure in supine position ◼ Stand patient up wait one minute then repeat BP ◼ Fall in Systolic of 20 mm Hg or drop in diastolic BP of 10 mmHg especially with lightheadedness indicates orthostatic BP Causes of Orthostatic BP ◼ Hypovolemia ◼ Prolonged Bed Rest ◼ Autonomic Dysfunction ◼ Drugs Paradoxical Pulse ◼ AKA Pulsus Paradoxus ◼ Increased intra thoracic pressure during inspiration ◼ Increases blood return to the right heart ◼ Displaces intra-ventricular septum ◼ Results in decrease in LV stroke volume ◼ Drop of 4-5 mm Hg in systolic pressure is normal during inspiration Pulsus Paradoxus ◼ Cardiac Tamponade condition where sac surrounding heart fills with fluid ◼ Increased pressure surrounding heart prevents it from relaxing ◼ The inspiratory increase in RV volume and bulging of intra-ventricular septum has a greater effect on LV filling ◼ A drop of more than 10 mm Hg during inspiration is an important sign of cardiac tamponade ◼ May also be seen with obstructive lung disease Technique ◼ Have patient breathe normally ◼ Inflate cuff so no sounds heard ◼ Gradually deflate cuff until sounds heard durnig expiration only ◼ Note this pressure ◼ Gradually deflate cuff until sounds heard during inspiration ◼ If the difference is greater than 10 mm Hg pulsus paradoxus is present Pulsus Paradoxus Video https://youtu.be/jTsjCZ9QxW8 Asymmetrical Blood Pressure ◼ 5-10 mm Hg difference between the right and left arm is considered normal ◼ Left arm usually has slightly higher pressure ◼ Consider stenosis or obstruction of brachiocephalic or subclavian artery or aortic dissection. Temperature Oral (PO) ◼ Rectal (PR) ◼ Tympanic ◼ Axillary ◼ Fever 100.4F/ 38C or greater ◼ Causes includes infection, malignancies, infarctions, drugs and immune disorders. ◼ Elderly patients may not mount a fever ◼ BMI (body mass index) Calculating the BMIEnglish units: [weight (lbs)/height (in2)] x 703 SI units: weight (kg)/height (m2) BMI Weight Status <18.5 Underweight 18.5-24.9 Normal 25-29.9 Overweight >30 Obese Pulse oximetry Device that measures the oxygen saturation of arterial blood in a subject by utilizing a sensor attached typically to a finger, toe, or ear to determine the percentage of oxyhemoglobin in blood pulsating through a network of capillaries and that typically sounds an alarm if the blood saturation becomes less than optimal Normal 95 – 100 percent Sample write up Write Up: General: Slender white female, neatly groomed, looks her stated age of 84 years and appears in no apparent distress. Vital Signs: T: 98.6 F or 37.1 C oral/rectal/axillary R: 14/min, regular, non-labored P: 72, regular BP: (R) (L) Sitting 110/70 110/70 Standing 105/66 110/66 Supine 110/68 108/66 Height and Weight (recorded or as stated by patient) BMI Clinical Scenario #1 ◼ The nurse calls to report your patient has a heart rate of 170. ◼ What is the most common cause of heart rates over 140? ◼ What is the danger of heart rates over 150? Clinical Scenario #2 ◼ A nurse call you for a patient with a history of high blood pressure complaining of severe abdominal pain who has a heart rate of 92. ◼ Is this patient tachycardic? Clinical Scenario #3 ◼ You are called to see a patient who is slurring his speech and is a having an apparent stroke. ◼ While you are taking his pulse it wouldn't surprise you to find he has which type of cardiac rhythm? Clinical Scenario #4 ◼ The nurse calls to report a patient with atrial fibrillation has a heart rate of 50 you suspect the heart rate is really much higher. How would you confirm this? Clinical Scenario #5 ◼ You are called to see a patient complaining of difficulty breathing on inspection you note the patient is breathing rapidly and shallow and seems to be using his stomach to breathe. ◼ What are the danger of rapid, shallow breathing. ◼ Why is the patient breathing shallow? ◼ What is paradoxical breathing? And what does it signify? Clinical Scenario #6 ◼ The nurse calls you to report her patient has a blood pressure of 210/90 ◼ What questions would you ask the nurse? ◼ What are the dangers of a sudden rise in blood pressure? Clinical Scenario #7 ◼ The nurse calls you for a blood pressure of 85/48 ◼ What questions would you ask the nurse? ◼ When is low blood pressure a danger? Clinical Scenario #8 ◼ The nurse calls you for a patent who has just had a larger bloody bowel movement. ◼ When the patient stands his systolic pressure drops 20 mm Hg while his heart rate increased from 90-110 bpm ◼ What is the significance of these findings? Clinical Scenario #9 ◼ The nurse calls you to tell you her patient has a temperature of 100.1 orally. ◼ Does this patient have a fever? Clinical Scenario #10 ◼ You are called for a patient with a heart rate of 110. this is post operative day 2 for and appendectomy. ◼ What are the most common causes of tachycardia? ◼ What could be causing tachycardia in this patient? Bates Checking Vitals Video https://youtu.be/qs2SuuWheN8