EXAM1/CH4- General Interview + Examination Skills Flashcards
what is important during the general interview
to be as detailed as possible throughout
-everything the patient mentions is important, don’t assume ANYTHING
what does the general interview do
establish baseline
is the general interview confidential
yes
should you assume the patient is referred based on the reason for referral listed
NO
-don’t always assume the patient knows why they were referred
general interview topics (7)
-reason for referral
-demographic information
-history of present illness (HPI)
-current medications/allergies
-past medical history
-family history
-social history
interview demographics
-age
-sex + ethnicity
-also includes medical history
in the interview, what is age a predictor of
independent predictor of survival in almost every cardiopulmonary condition
in the interview, why is sex + ethnicity important
there are certain diseases that are more prevalent in males vs females, same with sex, ethnicity, etc.
-this is called the “scope of the disease”
scope of the disease
areas where the disease is more prevalent- like gender, ethnicity, etc.
HPI
history of present illness
history of present illness (HPI)
-record + convey information that led to the referral
-chief complaint + manifestations
-symptoms (OPQRSTA)
-objective (medical record) vs. subjective (patient)
HPI- differentiate signs vs. symptoms
signs: things you can see (ex: patient is pale)
symptoms: NOT things you can see, things the patient is reporting to you (ex: pain)
in HPI, do objective (medical record) + subjective (patient) always match
no
what is objective of the HPI
medical record
what is subjective of the HPI
patient
HPI- how do we characterize symptoms
OPQRSTA
OPQRSTA
onset
provocation + palliation
quality
region + radiation
severity
timing
associated signs + symptoms
when characterizing symptoms (OPQRSTA) on the HPI, what is the first thing you must do
identify the chief complaint
-we complete OPQRSTA based on the chief complaint
OPQRSTA- onset
the very first occurrence of the chief complaint
OPQRSTA- provocation
things that make the symptom worse
OPQRSTA- palliation
things that make the symptom better/go away
OPQRSTA- quality
ADJECTIVES, look for adjectives/words that describe the chief complaint
(ex: severe, dull, aching, tingling, burning, stinging, intense)
OPQRSTA- region
anatomical region of the body where symptom occurs
OPQRSTA- radiation
does it occur anywhere else?
OPQRSTA- severity
be careful with how we define severity because it can be subjective
-try to quantify the severity using scale 1-10
-“given your symptom on the scale 1-10 how bad is it right now”
-this isn’t perfect because symptoms fluctuate, so also ask how bad it is when 1-10 when it is at its BEST + WORST
for severity on OPQRSTA, how many values should we get
3
-1-10 how bad is it right now
-1-10 how bad is it at its worst
-1-10 how bad is it at its best
if you don’t get 3 values for severity on OPQRSTA, what do you do
it is okay to use other information to estimate or substitute for severity if we don’t have all 3 values
-in the real world you won’t always have access to the patient
OPQRSTA- timing
what is the most recent event related to the chief complain
-we want to know WHEN it occurred + WHAT occurred
-don’t confuse this with onset
OPQRSTA- associated signs + symptoms
include ANY other information here
-ex: patient says pain is so bad it causes them to vomit
OPQRSTA example- LBP
ONSET- 60 days ago
PROVOCATION/PALLIATION-
Increased pain when bending/lifting
Decreased pain when sitting or using hot/cold pack
QUALITY-
Sharp with movement
Dull ache while sitting
REGION/RADIATION-
Middle region of lumbar spine radiating up into thoracic spine
SEVERITY- Highest = 9/10 Lowest = 4/10
TIMING- worsened while lifting 50 lb bag of bird seed 3 days ago
ASSOCIATED S&S: hunched over due to stiffness and pain
interview medications + allergies- what to include for cucrent medications
-medication name (generic vs brand)
-dosage (be sure to indicate correct units)
-administration route (enteral vs parenteral)
-time (when to take medicine, morning/evening/etc.)
enteral vs parenteral
enteral- orally, through digestive system (pill, feeding tube, etc.)
parenteral- through bloodstream (IV)
interview medications + allergies- what to include for allergies
-allergy name (could be food, medication, environment, etc.)
-reaction (hives, closed airway, rash, etc.)
interview medications + allergies- drug purpose
DO NOT confer new functions but rather attentuate, accentuate, or replace a response
interview medications + allergies- desired effect vs. side effect
-all medications have 2 effects: desired effect + side effect
-desired effect: medication is doing what it is supposed to
-side effect: any other causes the drug has, not all side effects are bad
interview medications + allergies- medical reconciliation
-compare the medications that patients state they are taking against their medical records
-THIS SHOULD HAPPEN EVERY TIME YOU SEE THE PATIENT, ALWAYS DO THIS
-“have you had any changes in your medical history?”
how frequently should medical reconciliation be done
EVERY TIME you see the patient
exercise + drug absorption
-medications can affect the heart rate response at rest or during exercise
-blood redistribution during exercise is significant
-can result in shunting of blood away from important drug absorption + metabolism sites
-blood flow during exercise, is also redistributed to the skin; important for patients with transdermal medications
3 important drug absorption + metabolism sites
-liver
-kidneys
-GI tract
how is liver important in drug absorption/metabolism
main organ responsible for drug metabolism
how are kidneys important in drug absorption/metabolism
main organ for drug elimination
how is GI tract important for drug absorption/metabolism
drug absorption
(this is all the slide said)
when someone is exercising, what happens with blood/drug absorption
when someone exercises, blood is redistributed to the periphery, so if a medication affects internal organs, it might not absorb well
-therefore we must plan our exercise testing or PT exercise around the times they take this medication
important question to ask patient about medication
DID YOU TAKE YOUR MEDICATION TODAY?
interview- medical history
this is everything OUTSIDE OF THE CHIEF COMPLAINT
-past medical problems
-focus on problems that may have potential to influence ability to exercise test or train
medical history- musculoskeletal probelms that may influence ability to exercise test/train
-LBP
-gout
-joint issues
medical history- neurologic probelms that may influence ability to exercise test/train
-cerebrovascular disease
-stroke
-dementia
medical history- respiratory probelms that may influence ability to exercise test/train
-asthma
-obstructive lung disease
interview- family history
-restrict to FIRST-DEGREE relatives (parents, siblings, + offspring)
-identify relevant heritable disorders (certain cancers, adult diabetes, familial hypercholesterolemia, coronary heart disease after age 55 in men + 65 in women)
interview family history- what are some heritable disorders we should look out for
-certain cancers
-adult diabetes
-familial hypercholesterolemia
-coronary heart disease after age 55 in men + 65 in women
interview- social history
-social
-inquire about tobacco, alcohol, illicit drugs
-nutrition patterns + habits
-sleep habits + snoring
-leisure activities
-prior + current exercise habits
interview- other ideas
-marital status
-transportation
-occupation
this is the END of the interview portion
examination- general state
-abnormal findings?
-patient complains?
-general observation (does patient appear comfortable/distressed? anxious? healthy or frail? well nourished or undernourished?)
**see slide 15
examination- BP, HR, + respiratory rate
-collect vitals during EVERY appointment with the patient, even if you are doing just the interview
-vitals tell us a lot about the current state of the person, are relatively noninvasive, + easy to get so no reason not to
how frequently should you collect vitals (BP, HR, respiratory rate)
every appointment
examination- BP
know how to classify BP (found on following cards)
-pay attention to and/or
normal BP
systolic less than 120
AND
diastoic less than 80
prehypertension BP
systolic 120-139
OR
diastolic 80-89
what is 120/80 classified as
prehypertensive
stage 1 hypertension BP
systolic 140-159
OR
diastolic 90-99
stage 2 hypertension BP
systolic greater than or = 160
OR
diastolic greater than or = 100
HR- unexplained tachycardia
greater than 100 bpm
HR- unexplained bradycardia
less than 40 bpm
examination- HR
MUST write down UNEXPLAINED tachycardia/bradycardia not just tachy/bradia
examination- respiratory rate
unexplained SOB (shortness of breath) or labored breathing
the more you see a patient, what will happen during vitals of examination
you will get a better idea of what is normal for them
beta blockers
reduce resting heart rate by 10-15 bpm
tachypnea
respiratory rate greater than 20 breaths per minute
bradypnea
respiratory rate less than 8 breaths per minute
hypoxia
blood oxygen saturation below 95%
examination- body fatness
-height, weight, BMI
-circumferences (WHR)
-skinfolds
-BIA
-underwater weighing
-bod pod
-DEXA
what is important when taking height + weight
everything must be calibrated
what is used to take height + weight
-stadiometer
-scale
stadiometer
-stand up TALL
-shoes off
-stand nice + tall up against the wall
scale
-take shoes off
-EMPTY POCKETS
-take coat off
-set purse down
body mass index (BMI)
-estimate of body fatness
-assumes one’s weight should be proportional to height
units for BMI
kg/ (m^2)
downfall of BMI
doesn’t differentiate fat vs lean mass
-solely based on HEIGHT + WEIGHT
should BMI be used as a measure of body composition
NO
-most clinical settings use this but choose something more accurate if there are signs like the person is a bodybuilder
BMI classifications
-underweight
-normal
-overweight
-obese class 1
-obese class 2
-obese class 3
BMI- underweight
less than 18.5
BMI- normal
18.5-24.9
BMI- overweight
25-29.9
BMI- obese class 1
30-34.9
BMI- obese class 2
35-39.9
BMI- obese class 3
greater than 40
WHR
waist to hip ratio
waist to hip ratio (WHR)
-based on fat distribution using circumference measurements
-looks at where you carry excess fat
-android (apple) vs gynoid (pear)
is WHR similar to BMI
yes, but not a measure of body fatness
-rather, WHR indicates likelihood of developing chronic diseases
what does WHR indicate
likelihood of developing chronic diseases
-this is why we use it in the clinical setting
in WHR, where is excess fat bad
around midsection
WHR- android
apple
-person carries excess weight in thier midsection
-NOT IDEAL
WHR- gynoid
pear
-person is narrow at the top + wider at the bottom
-less indicative of disease risk
WHR- android or gynoid is worse
android is worse
units for WHR
cm
-inches can be used too, as long as units for waist + hip are same
WHR equation
WHR = waist (cm) / hip (cm)
for WHR, define where waist is measured
smallest circumference of midsection
for WHR, define how hip is measured
largest circumference around hips
WHR value meanings
-lesser than 1 = waist is smaller from hip measurement, LOWER RISK
-closer to 1 = GREATER RISK
WHR- women vs men
values are different for women + men because women tend to have higher body fat + tend to carry in hips/thighs due to childbearing reasons
skinfold assessment
-premise that subcutaneous fat levels correlate highly with total body fat
-based on thickness of several skinfolds across the body
for skinfold, all measurements are taken on what side of the body
ALL measurements done on right side of body
subcutaneous fat
fat just beneath the skin
-highly correlated to total body fat levels
why are several skinfolds taken
because everyone holds fat in different areas
how many sites are used for skinfold
7
skinfold can be used to get what
body density
-which leads us to % fat
biggest downfall of skinfold assessment
takes a lot of practice to be good at
-even the best administrators still have about 3% degree of error
BIA
bioelectrical impedance analysis
bioelectrical impedance analysis (BIA)
-uses physics
-fat is highly impedant to electricity
-muscle + water are not impedant to electricity
BIA- muscle + body water
-electricity flows easily
-low resistance
-low impedance
BIA- fat
electricity does not flow
-high resistance
-high impedance
what values does BIA give us
% body fat + BMI
pros of BIA
-quick
-straightforward
-cheap
what do you have to account for with BIA
our body has a lot of water which can fluctuate a LOT on a daily basis
-depending on hydration status, body fat % will change
-if you use this machine, you must give the patient pre-appointment instructions to drink lots of water for A FEW DAYS BEFORE
what must patient do before BIA
drink lots of water for a FEW DAYS beforehand
2 types of BIA
-handheld
-laying down
laying down BIA
-used in the clinical setting, more in hospitals
-gives a much more breakdown of fat, lean, mass, AND hydration status
when comparing BIA over the course of months for a patient, what is the first thing you should look at
hydration status
what would dehydration do to BIA
overestimate body fat
-therefore more impedance
what is the gold standard
bod pod
why is bod pod the gold standard
super simple + quick
cons of bod pod
patient could be claustrophic, would not want to use for this instance
how does bod pod work
works through air displacement
-seal the door + the machine will standardize the amount of air inside + measure that
-looks at when the person is in it, how much air they displace; hence why they must wear tight clothes + head cap so air doesn’t get trapped in between
what must you know about DEXA
x-ray/radiation is used
can anyone administer a DEXA
no, must be a tech
can a pregnant woman do DEXA
no- becasue radiation
is DEXA or bod pod more accurate
equally accurate
-we use bod pod over DEXA because DEXA is expensive
-bod pod doesn’t have radiation
does hydration status affect DEXA
no
-however, it does PROVIDE hydration status
what do colors of DEXA mean
-yellow/orange colors represent fat
-light blue/dark blue represents bone/lean tissue
what does DEXA do
tells us where we have most of our fat mass
auscultation
the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis
examination- pulmonary system
auscultation of the anterior + posterior chest surfaces for breath sounds, characterized as:
-normal
-decreased or absent
-coarse
-wheezing
-crackling
(all are present in COPD)
regardless of why you are seeing a patient, what should be included in every exam
auscultation of pulmonary system
auscultation of pulmonary system- decreased/absent sounds
likely means this person has airway issues, hard time getting air in/out
auscultation of pulmonary system- coarse
rough sounds
auscultation of pulmonary system- wheezing
high pitched whistling noise
auscultation of pulmonary system- crackling
best described as a wood burning fire
examination- cardiovascular system
-cardiac pulse can be palpated in wrist + feet
-skin temperature/moisture should be warm/dry
-look for peripheral edema
what is pulsed used for in cardiovascular part of examination
used to get an idea of circulatory issues
which pulses should you palpate
radial pulse + ankle pulse
-because might not have same circulation in both places
cold/clammy skin temperature/moisture means what
poor perfusion
peripheral edema aka swelling of extremities is a sign of what
congestive heart failure (CHF)
signs of someone with poor circulation
-white hands/fingers/feet
-cold + clammy
-might feel sweaty
(all these are signs of poor circulation)
peripheral edema
swelling on the outskirts of the body
pitting
when you push on skin + there is a dimple that doesn’t rebound right away
what is pitting a sign of
peripheral edema
examination of musculoskeletal system looks at what 3 things
-gait
-joints
-LBP, red flags
examination of musculoskeletal system- what do we look at for gait
-normal
-antalgic
-hemiplegic
-shuffling
-wide
-etc.
antalgic gait
limping
hemiplegic gait
leg abducts in semicircle
examination of musculoskeletal system- what do we look at for with joints
-redness
-warmth
-swelling
-tenderness
examination of musculoskeletal system- what do we look at for LBP
-radiating pain or numbness present? (indicate nerve involvement which is much more serious than muscle tissue)
-new onset?
if LBP is new onset, what must we do
send them back to PCP to get checked for clearance
functional fitness tests
dry run of the patient’s physical performance before the real exercise testing
-gives us a baseline measure of the patient’s functional status
3 types of functional fitness test
-6 min walk test
-time up + go (TUG)
-short physical performance battery (SPPB)
functional fitness test- time up + go
patient sits in chair, administrator has stop watch, patient walks down + turns around, comes back + stops watch once they sit down
-uses weight shifting, lateral, etc.
functional fitness test- short physical performance battery
gives better representation than just a walking test because there are 4 things involved
-balance, chair stands, short walk
-KNOW it has more functional components than just a walk
chair stand
patient sits in chair, crosses arms, + measures how many times they can stand + sit for 30 seconds to 1 minute
balance test
Berg balance scale
what is Berg balance scale used for
basline balance testing
what else important to do for a patient in an exercise program
educate + motivate the patient
