Bate's Chapter 4 - Beginning the Physical Exam

Question 1

Fatigue

Answer 1

nonspecific symptom with many causes.
- common symptom of anxiety/depressiion
- do good psychosocial hx w/pt to help figure out causes of fatigue
- learn about pt’s sleep patterns
- find out about pt’s diet
- all of these things can ensure proper dx

Question 2

Weakness

Answer 2

denotes demonstrable loss of muscle power, and is typically localized.
- sometimes can be suggestion of general muscle weakness and in rare cases neuropathy

Question 3

Fever

Answer 3

abnormal elevation in body temperature
- look at if fever is related to chronic or acute symptoms to help figure out illness
- feeling chilly and cold or sweaty??
- focus on timing of illness to figure out if fever is associated w/infectious processes

Question 4

Weight Loss and Gain

Answer 4

look closely at pt’s diet and time in which they are consuming food
- evaluate pt’s food intake and ensure that gain or loss isn’t associated with things like edema or malnutrition

Question 5

Four Steps to Promote Optimal Weight & Nutrition

Answer 5

1. Measure BMI and waist circumference; adults w/BMI >25 kg/m^2 are at an increased risk for heart disease and obesity-related diseases. Measuring the waist-to-hip ratio (waist circumference divided by hip circumference) may be better risk predictor for individuals older than 75. Ratios of >0.95 in men and >0.85 in women are considered elevated
2. Assess dietary intake
3. Assess the pt’s motivation to change
4. Provide counseling about nutrition and exercise

Question 6

Strategies that Promote Weight Loss

Answer 6

• most effective diets combine realistic weight loss goals with exercise and environmental reinforcements
• encourage patients to walk 30 to 60 minutes 5 or more days a week, or a total of 150 minutes per week. Pedometers help patients match distance in steps with calories burned
• consider certain diets to decrease overall calories consumed
• encourage proven behavioral habits such as portion-controlled meals, meal planning, food diaries, and activity records
• follow professional guidelines for pharmacologic therapies in patients have high weights and morbidities who do not respond to conventional treatment

Question 7

10 Tips to a Great Plate

Answer 7

1. balance calories
2. eat less
3. avoid oversized portions
4. eat nutrient-dense food more often
5. make half the plate fruits and veggies
6. make half of grain intake whole grains
7. switch to fat-free or low-fat milk
8. eat foods high in solid fats, salt, and added sugars less often
9. use nutrition labels to lchoose lower sodium versions of foods like soup, bread and frozen meals
10. drink water or unsweetened beverages instead of sweeten soda, energy drinks or sports drinks

Question 8

Excess Sodium means…

Answer 8

Higher risk of hypertension and cardiovascular disease

Question 9

General Survey

Answer 9

review of pt’s appearance, height and weight, begins at beginning of physical exam w/pt
- after physical exam, should be able to describe the distinguishing features of the pt so clearly that a colleague could spot the pt in a crowd
- general survey should include: height, weight, blood pressure, posture, mood, alertness, facial coloration, dentition and condition of tongue and gingiva, color of nail beds, muscle bulk, etc.

Question 10

General Appearance Things to Note in Exam

Answer 10

1. Apparent state of health: is pt frail? Robust? Fit?
2. Level of Consciousness: is pt awake and alert? Response?
3. Signs of Distress: does pt show symptoms of cardiac or respiratory distress? Any pain? Anxiety or depression?
4. Skin Color and Obvious Lesions: inspect skin for any changes in color, scars, etc.
5. Dress/Personal Hygiene: how is pt dressed? Is clothing suitable for weather? Clean? Well put? Makeup? Jewelry? Rips in clothes?
6. Facial Expression: is pt avoiding eye contact? Does pt appear calm? Scared? Absent?
7. Odors of Body and Breath: do they smell like alcohol? Does pt smell fruity?
8. Posture, Gait & Motor Activity: what is pt’s posture? How do they move?
9. Height and Weight: determine BMI. Is pt very tall? Short? Overweight? Underweight?
10. Waist Circumference: how is their waist? Large waists indicate increased risk for Htn, DM, and cardiovascular issues

Question 11

BMI Calculation

Answer 11

(weight in pounds x 700)/height (inches) = BMI

Question 12

Vital Signs

Answer 12

Include:
1. blood pressure
2. heart rate
3. respiratory rate
4. temperature
*provide critical information that often influences tempo and direction of evaluation depending on presenting symptoms

Question 13

Heart Rate

Answer 13

calculated by palpating radial pulse with your fingers and counting for one minute
- can also be calculated by listening for apical pulse with stethoscope

Question 14

Respiratory Rate

Answer 14

calculated by counting how often pt is breathing, usually taken during heart rate as well so pt does not change breathing habits

Question 15

Temperature

Answer 15

taken in various sites depending on equipment available and indicates if pt has a fever or a very low temp

Question 16

Ambulatory Blood Pressure Monitoring

Answer 16

blood pressure monitoring at home via attached cuff to arm over 24-48 hours has been found the most accurate way to confirm if elevated pressures in office are accurate or not and accurately confirm dx of hypertension

Question 17

Auscultatory Office Blood Pressure with aneroid or mercury blood pressure cuff

Answer 17

• common, inexpensive
• subject to pt anxiety (white coat syndrome), observer technique, cuff recalibration every 6 months
• requires measurement over several visits
• ambulatory or home monitoring needed to detect masked hypertension
• single measurements with sensitivity an specificity of 75% compared to ambulatory monitoring

Question 18

Automated Oscillometric Office Blood Pressure

Answer 18

• requires optimal pt position, cuff size and placement, and device calibration
• takes multiple measurements over short period
• requires confirmatory measurements to reduce misdiagnosis
• comparable sensitivity and specificity to manual measurements

Question 19

Home Blood Pressure Monitoring

Answer 19

• accurate automated device applied by pt, easy to use, less expensive than ambulatory monitoring
• acceptable alternative if ambulatory monitoring not feasible; more predictive of cardiovascular risk than office measurements
• requires pt education for accurate technique, repeated measurements (two morning, two evening readings daily for 1 week), nighttime readings not recorded
• detects white coat hypertension (present in 20%)
• detects masked hypertension (present in 10%)
• sensitivity 85%, specificity 63% compared to ambulatory monitoring

Question 20

Ambulatory Blood Pressure Monitoring

Answer 20

• automated; clinical and research “gold standard”
• provides 24-hour average blood pressures and averages of daytime (awake), nighttime (asleep), systolic (top number), and diastolic (bottom number) blood pressures
• shows whether nocturnal pressure “dips” (normal) or stays elevated (cardiovascular disease factor)
• more expensive, may not be covered by insurance

Question 21

Definition of Hypertension Clinically

Answer 21

• office manual or automated blood pressure based on the average of two readings on two separate occasions: >140/90
• home automated blood pressure: >135/85
• ambulatory automated blood pressure:
  a. 24 hr average of >130/80
  b. daytime (awake) average: >135/85
  c. nighttime (asleep) average: >120/70

Question 22

Three Types of Hypertension

Answer 22

1. White Coat Hypertension
2. Masked Hypertension
3. Nocturnal Hypertension

Question 23

White Coat Hypertension (Syndrome)

Answer 23

blood pressure over 140/90 in medical settings and mean away ambulatory readings 135/85
- does not require treatment
- only seen in medical settings
- carries normal to slightly increased cardiovascular risk
- contributed to conditioned anxiety response

Question 24

Masked Hypertension

Answer 24

defined as office blood pressure <140/90 but an elevated daytime blood pressure of >135/85 on home or ambulatory testing
- more serious
- increased risk of cardiovascular disease and end-organ damage

Question 25

Nocturnal Hypertension

Answer 25

blood pressure should dip below daytime records. when it falls less than 10% of daytime averages or rises in comparison to daytime averages, that is nocturnal hypertension
- often associated w/poor cardiovascular outcomes
- only can be spotted w/24-hour ambulatory blood pressure monitoring

Question 26

Steps to Ensure Accurate Blood Pressure Measurement

Answer 26

1. Pt should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement
2. Examining room should be quiet and comfortably warm
3. Pt should sit quietly for 5 minutes in chair w/feet on floor, rather than on exam table
4. Arm selected should be free of clothing, fistulas for dialysis, scars from brachial after cutdowns, or lymphedema from axillary node dissection or radiation therapy
5. Palpate brachial artery to confirm a viable pulse and position the arm so that th brachial artery, at the antecubital crease, is at heart level roughly level with the fourth interspace at its junction w/the sternum
6. If pt is seated, rest the arm on a table a little above the pt’s waist, if standing, try to support pt’s arm at the midcoast level

Question 27

Auscultatory Gap

Answer 27

a silent interval that may be present between the systolic and diastolic pressuresS

Question 28

Systolic Blood Pressure

Answer 28

top number of reading and first beats you will hear.
- note the level when you hear the sounds of at least two consecutive beats (this is systolic pressure)

Question 29

Diastolic Blood Pressure

Answer 29

bottom number of reading and you will find as you deflate the cuff
- The disappearance point, which is only a few mm Hg below the muffling point, provides the best diastolic blood pressure (this is when you no longer hear heartbeats)

Question 30

Take a Blood Pressure

Answer 30

1. position cuff on arm: lower part of cuff should be about 2.5 cm above the antecubital crease
2. estimate systolic pressure & add 30 mm Hg: hold fingers on radial pulse and inflate cuff rapidly until pulse disappears, then add 30 mm Hg to know how much to inflate the cuff to
3. Position the Stethoscope: position stethoscope over the brachial artery. listen for Korotkoff sounds
4. Identify Systolic Blood Pressure: when you hear the sounds of at least two consecutive beats
5. Identify Diastolic Pressure: deflate cuff until you no longer hear heartbeats, take pressure at disappearing point right after it gets muffled
6. Average Two or More Readings: read both systolic and diastolic levels to nearest 2 mm Hg. Wait 2 minutes and repeat. Average out and retake more if two BPs are too different

Question 31

Arrhythmias

Answer 31

irregular rhythms of heartbeat produce variations in pressure and unreliable measurements
- determine average of several observations of BP and note that they are approximate
- suggest ambulatory monitoring for 2-24 hours to ensure accurate BP readings

Question 32

Weak or Inaudible Korotkoff Sounds

Answer 32

often due to technical problems w/equipment but if equipment is all sound, could be a sign of vascular disease or shock

Question 33

BP Higher in Arms than in Legs

Answer 33

With hypertensive pts, always assess femoral BP as well to assess for a “femoral delay” that can occur where BP taking on legs is not high while arms are
- this is normal, BP taken in the legs should be less than the arms

Question 34

Coarctation of the Aorta

Answer 34

arises from narrowing of thoracic aorta, usually distal to origin of the left subclavian artery, and classically presents w/systolic hypertension greater in the arms than the legs
- when leg bp is greater than in the arms, it is this condition

Question 35

Pulmonary Artery Temperature

Answer 35

the research gold standard for core body temperature is blood temperature in the pulmonary artery
- however, this is invasive and clinicians must rely on noninvasive methods to get temperatures

Question 36

Oral Temperatures

Answer 36

often one of the most common ways to obtain temperature
- often lower than core body temperature
- lower than rectal temps by 0.4-0.5 C (0.7-0.9 F)
- higher than axillary temperatures by approximately 1 degree
- taken using electronic or glass thermometers, but electronic are most common due to dangers of mercury in glass one

Question 37

Rectal Temperatures

Answer 37

still commonly used but not as frequently
- lower than natural core body temperature
- done using a rectal thermometer w/a stubby tip for lubrication
- insert 3-4 cm into the anal canal and hold in anus for 3 minutes
- remove after 3 minutes and read digital temperature recording

Question 38

Tympanic Membrane Temperatures

Answer 38

often more variable than rectal and oral temperatures
- not as accurate as other methods
- uses digital reader w/laser that scans tympanic membrane

Question 39

Temporal Artery Temperature

Answer 39

takes advantage of location of temporal artery, which branches off the external carotid artery
- correlates closely w/pulmonary artery temperature but about 0.5 C lower
- similar to oral temp in accuracy and closeness to pulmonary artery temp
- forehead and behind the ear has been found to be most accurate instead of just forehead

Question 40

Pain

Answer 40

“an unpleasant sensory and emotional experience”

Question 41

Chronic Pain

Answer 41

defined in several ways:
- not associated w/cancer or other medical conditions that persists for more than 3-6 months
- pain lasting more than 1 month beyond the course of an acute illness or injury
- pain recurring at intervals of months or years
**affects an estimated of 100 million americans
**leading cause of disability and impaired performance at work

Question 42

Nociceptive (somatic) Pain

Answer 42

linked to tissue damage to the skin, musculoskeletal system, or viscera (visceral pain), but the sensory system is intact, as in arthritis or spinal stenosis.
- mediated by the afferent A-delta and C-fibers of sensory system
- involved afferent nociceptors can be sensitized by inflammatory mediators and modulated by both psychological processes and neurotransmitters like endorphins, histamines, acetylcholine, serotonin, dopamine, and norepinephrine

Question 43

Neuropathic Pain

Answer 43

direct consequence of a lesion or disease affecting the somatosensory system
- neuropathic pain may become independent of the inciting injury, becoming burning, lancinating or shock like in quality over time
- may persist after healing from injury
- many mechanisms postulated as to what causes this pain like strokes and spinal trauma
- these postulated triggers appear to induce changes in pain signal processing through “neuronal plasticity,” leading to pain that persists after healing

Question 44

Central Sensitization

Answer 44

there is alteration of central nervous system, processing of sensation, leading to amplification of pain signals
- lower pain threshold to non painful stimuli and response to pain might be more severe than expected
- mechanisms are subject to ongoing research

Question 45

Psychogenic Pain

Answer 45

involves the many factors that influence the patient’s report of pain
- psychiatric conditions like anxiety or depression
- personality and coping style
- cultural norms
- social support systems

Question 46

Idiopathic Pain

Answer 46

pain without an identifiable etiology

Question 47

Managing Chronic Pain: Measurement Based Care

Answer 47

1. Measure pain intensity and interference: a validated two-item questionnaire is available for primary care asking patients to rate pain in the past month and interference in daily activities on scale of 1 to 10
2. Measure mood: treatable depression, anxiety, and PTSD frequently accompany chronic pain. Use the PHQ-4 for detecting anxiety and depression
3. Measure the effect of pain on sleep: opioid doses correlate w/sleep-disordered breathing and sleep apnea
4. Measure risk of co-occurring substance abuse: estimated at 18-30%
5. Measure opioid dose: calculate opioid dose equivalency using web-based calculators