General survey and vital signs

Question 1

The general appearance of a patient includes…

Answer 1

Apparent state of health
Level of consciousness
Discomfort or distress
Skin color and lesions
Dress, grooming and personal hygiene
Facial expression
Odors of body and breath
Posture, gait and motor activity

Question 2

Nociceptive pain + neuropathic pain

Answer 2

Nociceptive: somatic pain
- linked to tissue damage to the skin, MS, or visceral
- sensory nervous system is intact
- acute or chronic
- “dull, pressing, pulling, throbbing”

Neuropathic:
- lesion or ds affecting somatosensory system
- may be independent of inciting injury
- “pins and needles”, shock-like, electric, stabbing, burning

Question 3

Odors of body and breath

Answer 3

alcohol scent
acetone: diabetes
uremia
liver failure

Question 4

CI for obtaining BP

Answer 4

lymphedema: swelling
paresis
paralysis
venous catheters
arterial catheters
mastectomy on BP side
dialysis shunts
ID band prohibiting arm use

Question 5

General Survey:

Answer 5

• Close observation begins at beginning and continues throughout the Hx and PE
  -Be specific; use graphic and detailed adjectives to paint a picture of your patient
• Avoid general terms such as “well developed” or “in no acute distress”
• Can be a single concise sentence or 2-3 sentences to form a short paragraph

Question 6

Weight: Things to consider

Answer 6

-Rapid changes in weight = change in fluid not tissue
- Weight gain: nutrition vs. medical causes
- Weight loss: medical vs. psychosocial causes

Question 7

Loss of ____% or more of usual body weight over a 6-month period = SIGNIFICANT wt loss

Answer 7

5%

Question 8

What might excess clothing reflect?

Answer 8

Cold intolerance of hypothyroidism
Hide skin rash or needle marks
Mask anorexia
Signal personal lifestyle preferences

Question 9

Fat distribution:

Answer 9

Generalized fat distribution:
- simple obesity

Truncal fat with relatively thin limbs:
- Cushing syndrome
- metabolic syndrome

Question 10

What stares should be watched out for?

Answer 10

Hyperthyroidism: bulging eyes
Immobile facies or parkinson
Flat or sad affect of depression

Question 11

What is the preferred posture for COPD or acute pericarditis?

Answer 11

Leaning forward w/ arms braced (tripod position)

Question 12

What is the preferred posture for someone with left-sided heart failure?

Answer 12

Sitting upright

Question 13

BMI: ranges

Answer 13

underweight BMI: <18.5
Normal: 18.5-24.9
overweight BMI: 25-29.9
obese BMI:
- I: 30-34.9
- II: 35-39.9
- Extreme III: >40

Question 14

What are important things to consider when taking a patients BP?

Answer 14

Back supported and legs uncrossed
Avoid smoking
Caffeine
Exercise for 30 min prior to measurement
Rest 5 minutes prior to measuring BP
Rest the arm on a table a little above the patient’s waist, or support the patient’s arm with your own at his mid-chest level

Question 15

The width of the inflatable bladder of cuff should be _________ of upper arm circumference. what happens when the cuff is too small/large

Answer 15

40%

If the cuff is too small the BP will read too HIGH

If the cuff is too large the BP will read LOWER

Cuff Size:
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference

Question 16

Length: ____% of upper arm circumference

Answer 16

80%

Cuff Size:
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference

Question 17

What is an auscultatory gap associated with? + what is it

Answer 17

Arterial stiffness
Atherosclerotic disease

Auscultatory gap: A silent interval that may be present between the
systolic and diastolic blood pressures; Ex: the sound disappears for a while, then reappears

Question 18

An unrecognized auscultatory gap may lead to…

Answer 18

Underestimation of systolic pressure or overestimation of diastolic pressure

Question 19

When does a pressure difference of >10-15 between arms occur?

Answer 19

Subclavian steal syndrome
Supravalvular aortic stenosis
Aortic dissection

Question 20

How to measure BP:

Answer 20

• Center the inflatable cuff over the brachial artery with the lower border 2.5 cm above the antecubital crease
• Secure the cuff + position the patient’s arm so that it is
  slightly flexed at the elbow
• With the fingers of your opposite hand, palpate the RADIAL artery and inflate
  the cuff until the radial pulse DISSAPEAR
• add 30 mm Hg to this pressure
• Deflate the cuff promptly and completely and wait 15-30 seconds
• Place the BELL of the stethoscope lightly over the brachial artery
• Inflate the cuff to the SUM pressure previously determined and deflate slowly
• The point at which you hear the first two consecutive beats is the systolic
  pressure
• The disappearance point is the diastolic pressure

Question 21

Deflate the cuff slowly at a rate no faster than ________ mmHg per second

Answer 21

2-3

Question 22

Taking Blood pressure: how many readings to take on each arm and how long do you wait in between. when do you repeat the reading?

Answer 22

Take 2 reading that are 1 minute apart + avg your readings

Repeat additional BP if difference between the first two readings is >5 mmHG
Repeat if BP is elevated and verify in the contralateral arm

Question 23

Orthostatic BP:

Answer 23

1) take BP and HR with them supine and wait 3 min
2) take BP and HR with pt standing
Diagnostic: systolic drops by 20 or diastolic drops by 10 in 3 minutes

Causes:
- mod-severe blood loss,
-drugs
- prolonged bed rest

Question 24

Heart Rate

Answer 24

• RADIAL pulse is commonly used to measure the heart rate
• Use the pads of the index and middle fingers

Normal rate (60–90 bpm) + regular rhythm:
- count the rate for 30 seconds and multiple by 2.
If the rate is fast or slow and/or the rhythm is irregular:
- count for a full 60 seconds.
- Abnormal HR should be confirmed with EKG

Question 25

Respiratory rate:

Answer 25

Observe rate, rhythm, depth, and effort of breathing Normal rate: ~20 breaths/minute (12-20) - Count for 60 seconds Abnormal rate: - Under 12 or over 25 breaths/min Observe rhythm: regular vs irregular Observe depth: shallow vs gasping Observe effort: normal vs labored

Question 26

Acute Pain:

Answer 26

Typically lasts < 3-6 months Common with trauma, acute illness, and surgery Protective function Resolves as injured tissue heals

Question 27

Chronic Pain:

Answer 27

Not associated with cancer or other medical conditions that persists > 3- 6 months OR Lasts > 1 month after an acute injury or illness Recurring at intervals of months or years

Question 28

Types of pain

Answer 28

Nociceptive or somatic: - related to tissue damage Neuropathic : – resulting from direct trauma to the peripheral or central nervous system Psychogenic : – relates to factors that influence the patient’s report of pain - Psychiatric conditions - Personality and coping style - Cultural norms - Social support systems Idiopathic : – no identifiable etiology

Question 29

What increases systolic and diastolic blood pressure?

Answer 29

Acute caffeine use Acute nicotine use or exposure Bladder distention Cold exposure Paretic arm White coat effect Insufficient rest period Legs crossed at knees Unsupported arm Arm lower than heart level Talking during movement Incorrect smaller cuff size

Question 30

What decreases systolic and diastolic blood pressure?

Answer 30

Acute meal ingestion Acute alcohol ingestion Incorrect larger cuff size

Question 31

fatigue vs weakness

Answer 31

Weakness: - loss of muscle power - associated with neuropathy and myopathy fatigue: - sense of weariness or loss of energy - “I don't feel like getting up in the morning”… - common symptom of depression and anxiety; infections; endocrine etc

Question 32

Recurrent shaking chills what does it suggest

Answer 32

suggest more extreme swings in temperature and systemic bacteremia.

Question 33

Edema from extravascular fluid retention: what conditions

Answer 33

heart failure nephrotic syndrome liver failure venous stasis.

Question 34

Temperature body

Answer 34

- lowest in the early morning and highest in the afternoon and evening - Women have a wider range of normal temperature than men Axillary temperatures: - take 5-10 minutes to register - less accurate Tympanic: - can be more variable than oral or rectal temperatures Oral: - generally lower than core body and rectal Rectal: - 0.5 degrees C warmer than oral temp - glass rectal: Gold standard

Question 35

Three scale of assessing pain

Answer 35

Visual Analog Scale (VAS) Numeric Rating Scale (NRS), Wong-Baker FACES® Pain Rating Scale VAS - horizontal line with verbal descriptive anchors at each end to express the extremes of pain. - Patients mark the point on the line that best corresponds to their symptom severity

Question 36

Body temperature: scale of hypothermia, pyrexia and hyperpyrexia

Answer 36

Hypothermia: 95 F, 35 C Fever/pyrexia: elevated body temperature hyperpyrexia: 41.1 C, 106 F coolest in morning and warmest temp in afternoon (~1 C change during day)