PDX-1.03 BEGINNING THE PHYSICAL EXAMINATION; GENERAL SURVEY, VITAL SIGNS AND PAIN.pdf

PHYSICAL DIAGNOSIS BEGINNING THE PHYSICAL EXAMINATION; GENERAL SURVEY, VITAL SIGNS AND PAIN MAGNOLIA REYES, MD | AUGUST 14, 2024 OUTLINE o Leave the room or draw...

PHYSICAL DIAGNOSIS BEGINNING THE PHYSICAL EXAMINATION; GENERAL SURVEY, VITAL SIGNS AND PAIN MAGNOLIA REYES, MD | AUGUST 14, 2024 OUTLINE o Leave the room or draw a separating curtain 1. Vitals Signs c. Major arteries while the patient changes to maintain a. Getting Started d. Selected Heart privacy. b. Observation Rates and Rhythms 2. Temperature e. Selected Irregular Gown Usage: a. Fever Rhythms o Ensure the patient does not use the gown as b. Hypothermia f. Techniques for a poncho, cape, or in any unconventional 3. Respiratory Rate and Rhythm Measuring Radial a. R.R measurement Pulse manner, as this can interfere with the b. Abnormalities in 5. Body Mass Index examination. Respiratory Rate 6. Waist to Hip Ratio Pre-Examination Procedures: and Rhythm 7. Important topics for Health 4. Heart rate and Rhythm Promotion and Counseling Rest Period: a. Pulse Rate 8. Blood Pressure o Allow the patient to sit quietly for Measurement a. Techniques in approximately five minutes before measuring b. Abnormalities of Measuring B.P Pulse and Pressure 9. Oxygen Saturation vital signs. waves o This rest period helps ensure that the measurements are not influenced by the exertion of walking to the exam room. Measurement Conditions: Vital Signs: LEGENDS o Ensure all vital signs are measured while the Lecturer Book Presentation patient is seated. B. Observation I. THE VITAL SIGNS Initial Observation: Vital signs include the measurement of: temperature, Purpose: respiratory rate, pulse, blood pressure and, where o Conduct a preliminary assessment of the appropriate, blood oxygen saturation. These numbers provide patient’s overall condition before starting the critical information (hence the name "vital") about a patient's detailed examination. state of health. In particular, they: Steps for Effective Observation: 1. Can identify the existence of an acute medical Positioning: problem. o Observe from a Distance: Take a moment to 2. Are a means of rapidly quantifying the magnitude of observe the patient from an unobtrusive an illness and how well the body is coping with the position. resultant physiologic stress. The more deranged the General Appearance: vitals, the sicker the patient. o Emotional State: Note if the patient appears 3. Are a marker of chronic disease states (e.g. anxious, in pain, or upset. hypertension is defined as chronically elevated blood pressure). o Dress and Hygiene: Assess the patient's clothing and personal hygiene. Look for any signs of poor grooming or inappropriate Most patients will have had their vital signs measured by an RN attire, which may provide clues about their or health care assistant before you have a chance to see overall health or well-being. them. However, these values are of such great importance Assessment Focus: that you should get in the habit of repeating them yourself, particularly if you are going to use these values as the basis for Behavior and Comfort: management decisions. This not only allows you to practice o Observe the patient’s body language and obtaining vital signs but provides an opportunity to verify their facial expressions for signs of discomfort or accuracy. As noted below, there is significant potential for distress. measurement error, so repeat determinations can provide o Consider how their demeanor might impact critical information. the examination process. Initial Impressions: A. Getting Started o Document any immediate concerns or Preparation of the Examination Room: observations that might influence the Environment: examination or indicate specific areas of o Ensure the room is quiet, warm, and well-lit. focus. Patient Preparation: Integration into the Examination: Post-Interview Instructions: Begin Examination: o Provide the patient with a gown (referred to o Remember, your clinical evaluation starts as as "Johnny"). soon as you see the patient. Initial o Ask the patient to remove all clothing except observations can guide your approach and for briefs. inform subsequent questions and o Instruct the patient to wear the gown with the assessments. opening in the rear. TRANS Calubaquib, Corpuz, Francisco, Madriaga, Pablo, Urata 1 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN II. TEMPERATURE Causes of fever include infection, trauma (such as surgery Measurement of Body Temperature: or crush injuries), malignancy, blood disorders (such as Method: acute hemolytic anemia), drug reactions, and immune o Use an oral thermometer to obtain a digital disorders such as collagen vascular disease. reading. o Place the sensor under the patient’s tongue 1. Continuous Fever: for an accurate measurement. Temperature remains above normal throughout a 24- Equipment Availability: hour period with minimal fluctuation (less than 1°C). o Note that not all exam rooms may have Examples: Pneumonia, typhoid fever, urinary tract thermometers available. infection (UTI), infective endocarditis, brucellosis, o Recheck temperature only if the recorded typhus. value appears inconsistent with the patient's 2. Remittent Fever: clinical condition (e.g., patient feels feverish Temperature remains above normal throughout the but temperature is normal, or vice versa). day with fluctuations greater than 2°C within 24 hours. Temperature Scales and Definitions: Examples: Typhoid fever, infective endocarditis. Measurement Units: 3. Pel-Ebstein Fever: o Temperature can be measured in either Alternating cycles of fever and apyrexia. Typically Celsius (°C) or Fahrenheit (°F), depending on involves a 3-day pattern: 3 days of rising temperature, institutional preference. 3 days of high temperature, and 3 days of decline, Fever Thresholds: followed by a period of normal temperature. o Celsius: Fever is typically defined as a Note: This pattern can vary, and the fever cycle may temperature greater than 38-38.5°C. not always follow the exact 3-day pattern. o Fahrenheit: Fever is generally defined as a 4. Intermittent Fever: temperature greater than 101-101.5°F. Temperature spikes are present for some hours of the Types of Temperature Measurements: day with periods of normal temperature in between. Oral Temperature: The pattern can be daily, every other day, or every o Represents the temperature measured at the few days. mouth, which is standard for many clinical Examples: Malaria, pyemia, septicemia. settings. 5. Septic Fever: Rectal Temperature: Very high temperature that does not improve with o Approximate Difference: Rectal antipyretics, indicating a potential septic condition. temperatures are typically about 1°F higher Action: Requires prompt medical evaluation to than oral temperatures. prevent further deterioration. o Core Body Reflection: Rectal temperatures 6. Cyclical Recurrent Fevers (Periodic Fevers): are considered to more accurately reflect Recurring episodes of fever lasting from a few days to core body temperature. a few weeks, separated by symptom-free intervals. Clinical Considerations: Causes: Assess Discrepancies: Always consider the clinical o Infectious: Recurrent infections. context if there is a significant discrepancy between o Non-Infectious: Malignancy, non-infectious the patient’s reported feelings (e.g., feeling hot) and inflammatory diseases (e.g., Still’s disease, the temperature reading. rheumatoid arthritis, Crohn’s disease, Measurement Method: Choose the appropriate Behçet’s syndrome). method based on clinical requirements and the o Familial: Family history might suggest patient’s condition. conditions like Familial Mediterranean Fever or Hyper-Ig D syndrome. Average oral temperature, usually 37°C (98.6°F), fluctuates considerably from the early morning to the late afternoon or evening. Rectal temperatures are higher than oral temperatures by about 0.4 to 0.5°C (0.7 to 0.9°F) but also vary. Axillary temperatures are lower than oral temperatures by approximately 1°C but take 5 to 10 minutes to register and are considered less accurate than other measurements. Tympanic membrane temperatures can be more variable than oral or rectal temperatures. Studies suggest that in adults, oral and temporal artery temperatures correlate more closely with the pulmonary artery temperature, but are about 0.5°C lower. A. Fever Fever or pyrexia refers to an elevated body temperature. Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F). PHYSICAL DIAGNOSIS 2 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN gradually decreasing to normal (e.g., Brucellosis) 6. Recurrent Fever: Fever recurs at irregular intervals, involving the same organ or multiple organ systems. Example: Familial Mediterranean Fever Defervescence: In differentiating malaria from typhoid fever, effective anti-malarial therapy leads to fever defervescence by crisis (within hours) whereas in typhoid fevers resolution occurs by lysis (gradually over days) following effective antibiotics. Types of Fever Based on Pattern: 1. Sustained or Continuous Fever: Fever remains elevated with minimal daily fluctuation (less than 1°C or ~1.5°F) and does not return to normal. Examples: o Typhoid Fever o Drug Fever o Typhus Examine the temperature chart of the patient for 48 hours o Neoplasms to assess the fever pattern for more efficient diagnosis. 2. Remittent Fever: Fever fluctuates more than 1°C or ~1.5°F within 24 B. Hypothermia hours but does not return to normal. Hypothermia refers to an abnormally low temperature, Pattern: Common in many infectious and inflammatory conditions. below 35°C (95°F) rectally. 3. Intermittent Fever: The chief cause of hypothermia is exposure to cold. Other Fever spikes and returns to normal within a 24-hour causes include reduced movement as in paralysis, period. interference with vasoconstriction as from sepsis or excess Patterns: alcohol, starvation, hypothyroidism, and hypoglycemia. o Quotidian (24-hour periodicity): P. falciparum Older adults are especially susceptible to hypothermia (malaria) and also less likely to develop fever. o Double Quotidian (12-hour periodicity): Kala- azar, Gonococcal Arthritis, Juvenile III. RESPIRATORY RATE AND RHYTHM Rheumatoid Arthritis, some drug fevers (e.g., A. Respiratory Rate Measurement Carbamazepine) Respiratory rate is the number of breaths taken per minute. 4. Hectic or Septic Fever: Characterized by significant variation between the Procedure: peak and nadir of temperature. o Count Duration: Record respirations for at least 30 seconds. Counting for 15 seconds may lead to Examples: errors due to the small number of breaths, which o Kawasaki Disease can significantly impact accuracy when o Pyogenic Infections multiplied by 4. 5. Periodic or Cyclic Fever: o Observation Technique: To avoid altering the Fever episodes recur at regular intervals. patient’s breathing pattern: Patterns: ▪ Surreptitious Counting: Observe the rise o Tertian (48-hour periodicity): P. vivax, P. ovale and fall of the patient’s chest or hospital (malaria) gown discreetly, while appearing to take o Quartan (72-hour periodicity): P. malariae their pulse or performing another (malaria) assessment. o Pel-Ebstein Fever: Fever bouts lasting 3 to 10 Normal Range: days followed by asymptomatic periods of o Normal Respiratory Rate: Typically ranges the same length (e.g., Hodgkin’s Disease) between 12 and 20 breaths per minute. o Relapsing Fever (every 10-14 days): Borrelia Clinical Relevance: recurrentis o Routine Examination: In a standard check-up, o Undulant Fever: Gradual rise in temperature respiratory rate may not provide significant that remains high for a few days before information. PHYSICAL DIAGNOSIS 3 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN o Cardio-Pulmonary Illness: In the context of ▪ Radial Pulse: Place the tips of your index respiratory or cardiac conditions, respiratory rate and middle fingers just proximal to the can be a valuable indicator of disease activity patient’s wrist on the thumb side. and overall respiratory function. ▪ Finger Placement: Orient your fingers so Best Practices: that they are aligned with the length of Accuracy: Ensure accurate counting by observing for the radial artery. a full 30 seconds and multiplying as necessary. o Simultaneous Measurement: Discretion: Minimize patient awareness to avoid ▪ Double Check: You may palpate both conscious alteration of their breathing rate. radial arteries simultaneously to enhance Documentation: Record the respiratory rate clearly accuracy and ensure that the pulse is and note any abnormal findings or patterns that may consistent on both sides. warrant further investigation. Steps to Measure Pulse: To measure a person’s respiratory rate discreetly and o Locate the Pulse: Use your index and middle without making them self-conscious, observe their fingers to find the radial pulse on the thumb side of the wrist. breathing while they are at rest or while take their blood o Apply Gentle Pressure: Press lightly until you feel pressure. the pulse. Avoid using excessive pressure, which Observe the rate, rhythm, depth, and effort of breathing. can occlude the pulse. Count the number of respirations in 1 minute either by o Count the Beats: Count the number of beats for visual inspection or by subtly listening over the patient’s 30 seconds and multiply by 2 to get the pulse rate trachea with your stethoscope during examination of the per minute. For accuracy, especially if rhythm head and neck or chest. Normally, adults take 14 to 20 irregularities are suspected, count for a full 60 breaths per minute in a quiet, regular pattern. seconds. Normal Pulse Rate: B. Abnormalities in Rate and Rhythm of Breathing o Adult: Typically ranges from 60 to 100 beats per minute. Clinical Considerations: o Rhythm and Quality: Assess not just the rate, but also the rhythm (regular vs. irregular) and the quality (strong vs. weak) of the pulse. o Documentation: Record the pulse rate, rhythm, and any abnormalities noted during the assessment. Best Practices: Accuracy: Ensure correct finger placement and avoid excessive pressure to get an accurate reading. Consistency: Use the same pulse point for consistency in monitoring over time. Attention to Detail: Note any irregularities or discrepancies between pulse points that may need further investigation. The radial pulse is used commonly to count the heart rate. With the pads of your index and middle finger, compress the radial artery until you detect a maximal pulsation. If the rhythm is regular, count the rate for 15 seconds and multiply by 4. If the rate is unusually fast or slow, count it for 60 seconds. When the rhythm is irregular, evaluate the rate by auscultation at the cardiac apex (the apical pulse). B. Abnormalities of the Arterial Pulse and Pressure Waves IV. Heat Rate and Rhythm A. Pulse Measurement Purpose: o To assess the heart rate and rhythm by palpating a pulse point where a large artery is accessible. Common Pulse Points: o Radial Pulse: Most commonly used for convenience. o Other Points: Carotid, femoral, or apical (listening over the heart). Procedure: o Positioning: PHYSICAL DIAGNOSIS 4 of 10 1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN E. Selected Irregular Rhythms C. Major Arteries A basic knowledge in anatomy is essential when palpating these major arteries. Understanding these locations helps ensure accurate measurement and F. Techniques for Measuring Radial Pulse assessment in clinical practice. The pictures below demonstrate the location of the radial artery (surface anatomy on the left, gross anatomy on the right). D. Selected Heart Rates and Rhythms Visual Inspection: Pulsations: Look for transmitted pulsations to help locate the radial artery. Palpation: The radial artery is usually palpable in most patients, as upper extremity peripheral vascular disease is uncommon. Palpation Technique: 1. Initial Touch: Begin with light pressure to locate the pulse. 2. Increased Pressure: Apply more pressure, if necessary, particularly in patients with significant subcutaneous fat. PHYSICAL DIAGNOSIS 5 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN 3. Avoid Excessive Pressure: Avoid pressing too hard to VI. WAIST TO HIP RATIO prevent occluding the vessel and mistaking your own pulse for that of the patient. WAIST HIP RATIO- effective way to examine regional fat Evaluation Criteria: distribution. 1. Quantity: RATIO= 𝑊𝑎𝑖𝑠𝑡 𝑐𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒 (𝑐𝑚) o Measurement: Count the number of beats for 30 𝐻𝑖𝑝𝑠 𝑐𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒 (𝑐𝑚) seconds and multiply by 2 (or count for 15 seconds and multiply by 4). For abnormal rates, Health risk Men Women measure for a full 60 seconds to minimize errors. High risk >1.0 >0.85 o Normal Range: Typically, between 60 and 100 Moderate 0.90- 1.0.80-.85 beats per minute. Low risk 140 mmHg direction while listening over the brachial artery and watching the pressure gauge. The first sound that you hear DBP: >90 mmHg reflects the flow of blood through the no longer completely It is important to recognize that blood pressure is rarely occluded brachial artery. The value on the manometer at elevated to a level that causes symptoms. That is, while this moment is the SBP. Note that although the needle hypertension in general is common, emergencies resulting from extremely high values and subsequent acute end may oscillate prior to this time, it is the sound of blood flow that indicates the SBP. organ dysfunction are quite rare. Rather, it is the chronically elevated values which lead to 6. Continue listening while you slowly deflate the cuff. The diastolic blood pressure (DBP) is measured when the target organ damage, though in a slow and relatively silent fashion. sound completely disappears. This is the point when the pressure within the vessel is greater than that supplied by At the other end of the spectrum, the minimal SBP required to maintain perfusion varies with the individual. Therefore, PHYSICAL DIAGNOSIS 7 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN interpretation of low values must take into account the hypovolemia. This requires first measuring these values clinical situation. Those with poorly functioning hearts, for when the patient is supine and then repeating them after example, can adjust to a chronically low SBP (e.g. 80-90) they have stood for 2 minutes, which allows for and live without symptoms of hypoperfusion. However, equilibration. others, used to higher baseline values, might become Normally, SBP does not vary by more than 20 points when quite ill if their SBPs were suddenly decreased to these a patient moves from lying to standing. In the settling of same levels significant volume depletion, a greater than 20-point drop may be seen. Steps to Ensure Accurate Blood Pressure Measurement Changes of lesser magnitude occur when moving from 1. Do not place the blood pressure cuff over a patient lying to sitting or sitting to standing. This is frequently clothing or roll a tight-fitting sleeve above their biceps associated with symptoms of cerebral hypoperfusion when determining blood pressure as either can cause (e.g., light headedness). Heart rate should increase by not elevated readings. more than 20 points in a normal physiologic attempt to This would cause BP elevation augment cardiac output by providing chronotropic 2. Make sure the patient has had an opportunity to rest compensation. In the setting of GI bleeding, for example, before measuring their BP. Patients who are not too a drop in blood pressure and/or rise in heart rate after this physically active (i.e. relatively deconditioned) will maneuver is a marker of significant blood loss and has develop an elevation in both their SBP and DBP. Also, see important prognostic implications. what effect raising or lowering the arm, and thus the Orthostatic measurements may also be used to determine position of the brachial artery relative to the heart, has on if postural dizziness, a common complaint with multiple BP. possible explanations, is the result of a fall in blood The patient should rest about 10 to 30 minutes. You also pressure. For example, patients who suffer from diabetes don’t take the BP after the patient walked. frequently have autonomic nervous system dysfunction 3. If the reading is surprisingly high or low, repeat the and cannot generate appropriate arteriolar measurement towards the end of your exam. vasoconstriction when changing positions. This results in Repeat the measurement three times but always deflate. postural vital sign changes and symptoms. 4. Instruct your patients to avoid coffee, smoking or any The patient’s BP should not drop for more than 20 points other unprescribed drug with sympathomimetic activity The 20-point value is a rough guideline. In general, the on the day of the measurement. greater the change, the more likely it is to cause 5. If possible, measure the blood pressure of a patient who symptoms and be of clinical relevance. has an indwelling arterial catheter (these patients can be found in the ICU with the help of a preceptor). Arterial HYPERTENSION: Basis of Severity transducers are an extremely accurate tool for assessing SBP DBP blood pressure and therefore provide a method for Pre-hypertension 120-140 80-90 checking your non-invasive technique. Stage I Hypertension >140-160 >90-100 Stage II Hypertension >160 >100 Ideally, several measures on different occasions should verify the finding. One-time measures > 160/100 also confirms the diagnosis. It's worth mentioning that normal is 110s/70s, and cardiovascular risk rises w/any values above these points. Hypertension (HTN) causes and accelerates the progression of: renal dysfunction, coronary artery disease, systolic & diastolic heart, left ventricular hypertrophy, peripheral arterial disease, stroke, and retinopathy. The risk of HTN induced damage correlates both with height of BP and chronicity of elevation (i.e. longer and higher = worse). The treatment of HTN prior to the development of Target Note: If the brachial artery is below heart level, the blood Organ Damage (aka TOD) is referred to as "primary pressure reading will be higher; if the brachial artery is prevention"; while treatment to prevent &/or slow above heart level, the reading will be lower. progression once disease has already been established is called "secondary prevention." Orthostatic (a.k.a. postural) Hypotension Those without TOD, you have primary prevention (i.e., Orthostatic (a.k.a. postural) measurements of pulse and change of lifestyle). If there is already TOD, you call it blood pressure are part of the assessment for secondary prevention. PHYSICAL DIAGNOSIS 8 of 10  1.03 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN Evaluation of patients w/HTN requires careful history, 7. Most patients have primary hypertension (i.e., the elevation exam, labs, & other studies to search for co-morbid in BP is the primary disorder). Secondary HTN (elevation in BP problems (diabetes, sleep apnea, etc.) and/or occult secondary to another, treatable condition) is rather TOD. Most patients with HTN are asymptomatic, at least uncommon - though worth thinking about in the right situation. until they develop target organ damage, which can take Secondary causes include: pheochromocytoma, excess years to occur. cortisol production, hyperaldosteronism, The majority of patients with HTN (> 60%) will require at hypo/hyperthyroidism, renal artery stenosis, & chronic kidney least 2 meds for treatment. disease. o For a BP between 140-160/80-100, best initial drug 8. Certain conditions favor particular meds - for example: treatment is typically with hydrochlorothiazide, a Diabetes → ACE-I or Angiotensin Receptor Blockers (ARBs); very mild diuretic with potent anti-hypertensive coronary artery disease → B blockers. properties. 9. The use of 3 or more meds for refractory HTN isn't uncommon o For those with starting values of > 160/100, it's best - in particular with very obese patients. to start with two medications simultaneously. 10. Acute interventions to immediately lower BP are largely reserved for those times when there is clear evidence of acute TYPES OF HYPERTENSIONS symptoms from acute TOD (e.g., CHF, coronary ischemia, 1. White coat hypertension (isolated clinic hypertension): increased intra-cranial pressure) secondary to very high defined as blood pressure ≥140/90 in medical settings and mean awake ambulatory readings