Introduction to PE, General Survey, Review on Vital Signs, and Spx Aspects of Interviewing Flashcards
What are the steps in preparing for PE?
- Reflect on you approach to px
- Adjust the lighting and the environment
- Check equipment
- Make px comfy
- Observe SOP
- Sequence, scope, and position of exam: CARDINAL TECHNIQUES
- Sequence, scope, and position of exam: SEQUENCE OD EXAMINATION
- optimal for inspection
- jugular, pulses, thyroid gland
- apical impulses of the heart
Tangential
Reduced shadows
Perpendicular
What are the cardinal techniques?
Inspection
Palpation
Percussion
Auscultation
Close observation of the px (appearance, behavior, and movement)
Inspection
Tactile pressure from the palmar fingers or fingerpads
Palpation
Use the striking or plexor finger (usually the 3rd finger) to deliver a rapid tap to the pleximeter finger (3rd distal finger of the left hand)
Percussion
Heart, lung, bowel sounds, bruit, and turbulence over arterial vessels
Auscultation
What is the sequence of examination?
- Head to toe
- Notes for reminders
- Develop your examination
- Right side
What estimates in examining px on right side more reliable?
JVP (Jugular venous pressure)
Palpating hand rests more comfortably where?
On the apical impulse
Which side of the kidney is more palpable?
Right
Sitting position
Gen survey VS Skin Head and neck Thorax and lungs Breasts Musculoskeletal system
Positions for cardiovascular
- lying supine, w head of bed raised 30°
- lying supine, turned partly to left side
- sitting, leaning forward
What is the position for breast & axilla, abdomen, peripheral vascular system, nervous system?
Lying position
What are the positions for musculoskeletal system, skin, and nervous system?
Standing and sitting
Position for pelvic and rectal exam
Lying supine, w hips flexed, abducted, and externally rotated, and knees flexed (lithotomy position)
Position for prostate and rectal exam
Lying on the left side (left lateral decubitus)
Skinny body type
Ectomorph
Medium body type
Mesomorph
Body type that has a larger bone structure and fat mass
Endomorph
What is the technique and response for a consciousness of an ALERT person?
Technique: speak to px in normal voice tone
Response: opens eyes, looks at you, responds appropriately
What is the technique and response for a consciousness of LETHARGY?
Technique: speak in loud voice
Response: drowsy, but opens eyes and looks, responds to questions then falls asleep
What is the technique and response for a consciousness of OBDUNTATION?
Technique: shake px as if awakening a sleeper
Response: opens eyes and looks, but responds slowly and somewhat confused
What is the technique and response for a consciousness of STUPOR?
Technique: apply painful stimulus
Response: arouses fr sleep; verbal responses are slow or absent; lapses into unresponsive state when the stimulus ceases
What is the technique and response for a consciousness of COMA?
Technique: apply REPEATED painful stimulus
Response: unarousable, eyes closed; no evidence of response
What composes the General Survey?
- General state of health
- Appearance
- Behavior
- Grooming, personal hygiene, odor, breath
- Body type
- Lvl of consciousness
- VS
- Ht and wt (BMI)
Macule and patch, tumor, papule, plaque, nodule, vesicle and bullae, pustule, wheal. These are what type of lesions?
Primary lesions
In PE of the eyes, what do you check?
V/A
Position
Alignment
-> inspect eyelids, eyebrows, sclera, conjunctiva, ocular fundi
-> pupillary size and rxns, EOM (Extraocular movement)
In PE of the ears, what do you check?
Inspect auricle canals and eardrums
Auditory acuity and bone conductionn
In PE of the nose and sinuses, what do you check?
Inspect: external nose, nasal mucosa, septum and turbinates
Palpates: tenderness maxillary; frontal sinuses
In PE of the throat, mouth, and pharynx, what do you check?
Inspect: lips, oral mucosa, gums, teeth, tongue, palate, tonsils, pharynx
In PE of the thoras/lungs, what do you check?
Inspect and palpate: spine and muscles of upper back
Inspect, palpate and percuss: the chest
Auscultate: breath sounds
Duration of sound: Inspiratory, lasts longer than expiratory
Expiratory intensity: Soft
Expiratory pitch: Relatively low
Loc: Both lungs
Vesicular
Duration of sound: Inspiratory and expiratory are equal
Expiratory intensity: Intermediate
Expiratory pitch: Intermediate
Loc: 1st and 2nd interspaces anteriorly and between the scapulae
Broncho-vesicular
Duration of sound: expiratory, lasts longer than inspiratory
Expiratory intensity: Loud
Expiratory pitch: Relatively high
Loc: Over the manubrium (larger proximal airways)
Bronchial
Duration of sound: Inspiratory and expiratory are equal
Expiratory intensity: Very loud
Expiratory pitch: Relatively high
Loc: Over the trachea in the neck
Tracheal
Cardiovascular system: inspect and palpate what?
The precordium: location, diameter, and amplitude
Cardiovascular system: auscultate what?
Abn sounds and murmurs
What are the 3 systems involved in the lower extremities?
1) Peripheral vascular system
2) Musculoskeletal
3) Nervous
PVS: Inspect and palpate what?
Inspect: edema, discoloration, ulcers
Palpate: pulses and edema
2mm or less disappears immediately
1+
2-4mm few second rebound
2+
4-6mm
10-12 s rebound
3+
6-8mm
>20 s rebound
4+
Musculoske: Inspect and palpate what?
Inspect: deformities, enlarged joints
Palpate: joints, check the range of motion
Observe for gait and ability to walk
Nervous sys
MMSE (Mini Mental State Examination)
- Orientation to time
- Registration - let px repeat 3 words u said
- Naming -ID
- Reading
12 Cranial Nerves
Nerve type: SENSORY
I - Olfactory - Smell
II - Optic - Vision
VIII - Vestibulocochlear - Hearing, balance
12 Cranial Nerves
Nerve type: MOTOR
III - Oculomotor - Most eye movement IV - Trochlear - Moves eye VI - Abducens - abducts eye XI - Accessory - Shoulder shrug XII - Hypoglossal Swallowing, speech
12 Cranial Nerves
Nerve type: SENSORY AND MOTOR
V - Trigeminal - Face sensation, mastication
VII - Facial - Facial expression, taste
IX - Glossopharyngeal - Taste, gag reflex
X - Vagus - Gag reflex, parasympa innervation
- Muscle bulk, tone, and strength
- Cerebellar fxns, gait
Motor sys
Assess for pain, temp, touch, vibration and discrimination
Sensory sys
Complete paralysis
Grade 0
A flicker of contraction only
Grade 1
Power detectable only when gravity is excluded by postural adjustment
Grade 2
Limb can be held against gravity but not resistance
Grade 3
Limb can be held against gravity and some resistance
Grade 4
Normal power
Grade 5
NS: Very brisk response, w spread to other muscle grps and clonus
4+
NS: Brisk response, often w spread to other muscle grps
3+
NS: Active response, Normal or average
2+
NS: Diminished response; elicitation may require re-enforcement
1+
Absent
0 response grade
Atria fill w bld wc begins to flow into ventricles as soon as their walls relax
Diastole
Contraction of ventricles pumps bld into aorta and pulmonary arteries
Ventricular systole
What is c/b turbulence in the blood flow d/t compression of artery?
Korotkoff sound
First appearance of faint clear tapping sounds wc gradually increase in intensity
Phase 1
The softening of sounds wc may become swishing
Phase 2
The return of louder sounds
Phase 3
Muffling of sounds
Phase 4
The complete disappearance of sounds
Phase 5
Which is the systolic and diastolic pressure in the phases?
Phase 1: Systolic pressure
Phase 5: Diastolic pressure
CO
SV
HR
Peripheral resistance
Vascular structure
Vascular fxn
What are the physiologic factors affecting BP?
- CO
- Vascular resistance
- BV
- Bld viscosity
- Elasticity of arterial wall
What should be the width of the inflatable bladder of the cuff?
About 40% of the upper arm circumference (12-14 cm in ave adult)
What should be the length of the inflatable bladder?
About 80% of upper arm circumference
Standard cuff
12 x 23 cm
Cuff size discrepancy:
- Too small (narrow):
- Too large (wide)
> on small arm:
> on large arm:
- Too small (narrow): Inc BP
- Too large (wide)
> on small arm: Dec BP
> on large arm: Inc BP
Brachial artery below and above heart lvl
Below: Inc
Above: Dec
Slow or repetitive inflations of the cuff, venous congestion is?
Decreased systolic, increase diastolic
Artery when you get BP on the legs
Dorsal pedal artery
Artery when you get BP on the thighs
Popliteal artery
Normal BP
<120, <80
Pre HPN
120-139
80-89
Stage 1 HPN:
Ages 18-60; diabetes/renal dse
140-159
90-99
Stage 1 HPN:
Age >60 y.o.
150-159
90-99
Stage 2 HPN:
> 160, >100
JNC 8 Recommendations
> 60: <150, <90
<60: <140, <90
18 w CKD or w diabetes: <140, <90
> 140/90 medical setting;
<135/85 ambulatory reading
Whitecoat HPN (Isolated clinic HPN)
<140/90 office;
>135/85 ambulatory testing
Masked HPN
What is more serious, inc risk CVD and end organ damage?
Masked HPN
<10% fall of BP: >20% rise
Nocturnal HPN
dp of SBP at least 20mmHg or in DBP at least 10mmHg
Orthostatic HPN
What give info on the elasticity of large vessels and resistance in the arterioles and capillary?
Pulse
What give info on the circulatory status?
Pulse
What is used to assess the apical pulse when the peripheral pulse is difficult to locate?
Auscultation
What is the most accurate pulse?
Apical pulse
Device used when pulse can’t be detected by palpation
Doppler
Bounding
+3
Normal, brisk
+2
weak, thread, diminished - shock
+1
absent pulse
0
Normal respiration for adults
16-20 bpm
Normal respiration for NB
40-60 bpm
What is the normal PR to RR ratio?
4:1
When is our temperature lowest?
Early morning
When is our temperature highest?
Afternoon and evening
“gold std” blood temp
in the pulmonary artery
Pyrexia
body temp: 37.7
oral: >37.5
rectal: >38
Hyperpyrexia
> 41.1
Hypothermia
<35
What is more accurate than axillary, less than rectal?
Oral
Oral is lower than rectal by average of?
0.4-0.5C
Oral is higher than axillary by
1C
What is the most accurate of all routes?
Rectal temp
What are used in px w rapid respi rates?
Rectal temp
CIx of rectal temp
1 px w cardiovascular dse
2 px has hemorrhoids
3 rectal, vag and prostate surgery
4. diarrhea, colitis or cancer of rectum fecal impaction and rectal bleeding
Underwt
<18.5
N BMI
18.5-24.9
Overwt
25-29.9
Obese
I: 30-34.9
II: 35-39.9
III (extreme): >/=40
What is a primary chronic neurobiological dse w genetic, psychosocial, envi factors influencing its development and manifestation?
Addiction
