Head to Toe (Lecture 2) Flashcards
Hand Hygiene
Foam in, Foam out
SOAP - Objective
Findings you can Observe. Includes:
- Vital Signs
- General survey of the patient
- Physical examination findings
- Results from lab or diagnostic studies (think: you observe the results in the MAR)
Expected vs. Unexpected
Expected is not always normal (displaced PMI in a big heart) / Unexpected does not always mean abnormal disease (cardiac murmur)
BMI
BMI based on height and weight. In pounds:
[(weight (lb) * 700) / (height inches)] / height inches
In kg: weight (kg) / height^2
Normal: 18.5 - 24.9
Overweight: 25 - 29.9
Obesity: 30.0 - 39.9
Extremely Obese: 40.0+
Vital Signs (5)
Blood Pressure Heart rate and rhythm Respiratory rate and rhythm Temperature Pain
Pain
5th Vital Sign
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, coping style, cultural norms, social support systems)
Idiopathic: no identifiable etiology
Physical Exam
Generally conducted in head-to-toe order, with painful or invasive components done last
General Appearance
- Apparent state of health (acute vs. chronic ill)
- LOC
- Signs of distress
- Skin color, obvious lesions
- Dress, grooming, and personal hygiene
- Facial expression
- Odors of body, breath
- Posture, gait, motor activity
Odors
Ketoacidosis –> fruity odor to breath
Liver failure –> ammonia odor to breath
Alcohol –> sweet odor to breath
GI disorders –> fecal odor to breath / old blood
Poor oral hygiene –> bad breath
Provider Patient Positioning
Stand in front, or to the right of the patient, or behind
With GI exam, exam should be on patient’s right side
Order of Exam Techniques (all except GI)
IPPA
INSPECTION
Palpation
Percussion
Auscultation
Order of Exam (Abdomen)
IAPP
INSPECTION
Auscultation
Percussion
Palpation
Percussion
Listen For: Flatness / Dullness / Resonance / Hyperresonance / Tympany / Loudness
Types of Percussion
Direct Percussion - Sinuses
Indirect Percussion - Abdomen
Fist Percussion - CVA tenderness
Percussion Sounds: Flatness
Less Less Air, More Tissue // Soft // Muscle (thigh)
Dullness
Less Air, More Tissue // Medium // Liver
Resonance
Air = Tissue // Loud // Lung
Hyperresonance
Air > Tissue // Very Loud // Hyperinflated Lung (COPD)
Tympany
Air»_space; Tissue // Loud // Stomach (Gastric Bubble)
Ausculation
Chest piece secure on SKIN
General Survey
Documented to help identify a patient and paint a picture of the patient’s overall presentation and status
Overall Objective Documentation
Should flow logically from the subjective - and should reflect differential diagnoses
Objective
Physical Exam + lab results, other diagnostic tests
State name of test, then provide values. Avoid things like WNL, or “normal” - allow other readers to make their own interpretation of the values
*If the tests will be ordered, document in P (plan)
Pathologic / Pathophyscilogic Process
Types
Congenital: born that way? Inflammatory: knee pain Infectious Immunologic Neoplastic: cancer Metabolic Nutritional Vascular Traumatic: from an injury? System failure (cardiac, liver, etc) Idiopathic: don't know
Start thinking about - where is this coming from?
Psychopathologic
Mood Disorder
Depression
Headache as an expression of somatization
Are symptoms coming from something else, that isn’t physiologic?
Make a hypothesis about the nature of the patient’s problem
Then test your hypothesis and establish a working diagnosis
Working diagnosis
Define problem in terms of structure, process, and cause.
Assessment = Impression
What you come up with after looking at the patient
Your impression/diagnosis CAN be a symptoms. For instance: back pain, headache
Be careful (ex. hypertension) - it is OK if you don’t know yet just to put the symptom!
Differentials
List of possible explanations for the symptoms the patient presents with
Assessment
First thing: chief complaint
Two: also have hypertension (can list out the other things they have) / can put “see past medical history”
Examples of Assessment with Differentials
Palpitations r/o a-fib, anemia, thyroid disease, anxiety, caffeine, intolerance, ventricular arrhythmias
“Worst case scenario”
Include worst case… and make sure you have ruled this out based on your findings
