L4-5: Beginning the Physical I & II Flashcards
Visual acuity: What is normal? Explain what this reading means? What is the standard distance between the patient and the chart (in other words, what is normal)?
- Normal is 20/20. Top reading is the distance between the patient and the eye chart (this is the standard distance between the pt and the chart). Bottom reading is the distance at which a person with normal acuity reads the charge. The lower this fraction, the worse the pts vision. Fraction of 1.0 (20/20) is normal vision. Vision not correctable to greater than 20/200 is considered legally blind.
Pulse oximetry: What is being measured? What is the proper technique?
- Pulse oximetry measures the percentage of hemoglobin saturated with oxygen. - Proper technique is accomplished by placed pulse oximeter to area that is translucent and has good blood flow, eg. Fingers, ear lobes and big toes (for peds)
Pulse: What is the proper technique used to assess this? What is the normal range? What are abnormal ranges called? What is the scale for pulse? How to chart pulse?
- Proper technique: auscultate apical chest wall or palpate flexor surface of radial wrist using 2nd/3rd finger pads. Count pulse for 30 seconds and double (or 15 seconds and mult by 4). If pts heart beat is irregular, take for full 60 seconds. - Normal resting range: 60-100 BPM - Abnormal resting range: less than 60 BPM = bradycardia; greater than 100 BPM = tachycardia - Pulse scale: 4+ = bounding, aneurismal pulse 3+ = full, increased pulse 2+ = normal / expected / standard pulse 1+ = diminished, barely palpable pulse 0 = absent, non-palpable pulse - Charting pulse: chart pulse with scaling (eg. 2+ radial bilaterally OR 2/4 radial bilaterally OR use stick figure with pulse scale)
Blood pressure: What is the proper technique used to measure BP? What are correct measurements for bladder length? If too small or large of cuff, what occurs – hypertensive or hypotensive reading? What is normotensive? What is hypertension? If a pt has HTN, what are your goals for treatment per JNC8? How are orthostatic BP readings obtained? What is orthostatic hypotension and autonomic insufficiency?
-Proper technique:
A.) have pt sit still / rest in chair for 5 minutes, no nicotine/caffeine for 30 minutes, free of clothing, palpate artery, arm needs to be rested at heart level, estimate made for systolic pressure by palpating radial pulse and inflating cuff til pulse is no longer felt and inflate to 20-30 mmHg over, wait 15-30 seconds with cuff inflated, release at rate of 2 mmHg per second, read to nearest 2 mm Hg.
B.) Adults:
Bladder width: 1/3rd to ½ of limb circumference
Bladder length: twice width of limb (80% of circumference)
C.) Children:
Bladder width: 2/3rd length of UA (70% distance bw olecranon/acromion) / thigh OR 40% of arm circumference at midpoint
Bladder length: 80-100% of circumference of arm/thigh
D.) Too large cuff = underestimate = hypotensive
E.) Too small cuff = raised reading artificially = hypertensive
- normotensive =
- hypertensive = >140/>90
- JNC8 goals
>= 60:
chronic kidney disease or DM or 18 years:
-Orthostatic BP readings: BP readings are taken with pt in supine, sitting and standing positions. Each reading is taken within 3 minutes of changing position. Orthostatic hypotension = systolic drop of 20 mmHg, diastolic drop of 10 mmHg and rise in HR by 15 BPM. Autonomic insufficiency is a drop in BP (as in orthostatic hypothension) without a rise in HR.
Ophthalmoscopy: What is the correct technique for ophthalmoscopic/fundoscopic exam? What are each of the apertures used for? Explain the diopter settings.
- Technique: darken room, have pt focuse on wall straight ahead, set lens disc to 0 diopters, set aperture to small, round white light, match your eye to pts eye (if visualizing pts left eye, use your left eye with left hand), remove your glasses, start 15 inches away at a 15 degree angle, observe red reflex first, move inward with both eyes open, look at optic disc and retina. - Apertures: Large: dilated eye and general exam Small: undilated eye Micro: small undilated eye Red-free ie. green light: observe optic disc for pallor and minute vessel changes, retinal vasculature and hemorrhages Slit: to view anterior chamber and for elevation of lesions Grid: to measure lesions and provide location of where they are Blue: to observe corneal scratches, foreign bodies after staining with fluorescein - Diopter settings: equivalent to magnification power of lens Black numbers: positive or plus lenses Red numbers: negative or minus lenses Range from +/- 20 to +/- 140: more positive focuses anteriorly/superficially, while more negative focuses posteriorly/deeper
What is the correct technique for holding the otoscope?
- Hold it like a pencil in hand with little finger pressing against pts face. Use left hand to exam pts right ear and vice versa.
What are monofilaments used for?
- These are used to test for loss of sensation
What are standard vital signs? What is the fifth vital sign? Is there anything else included?
- Standard vital signs: BP, RR, HR, temp - Fifth vital sign: pain - Oxygen saturation should also be included
Doppler: What does it measure? What is it used for?
- Doppler makes use of ultrasound to measure systolic blood pressure, fetal hear sounds, locating blood vessels, weak pulses and assessing vessel patency.
Temperature: What is the proper technique used to assess this? What are normal ranges? What are abnormal ranges called? What is the proper way to document this on EMR? How to document temperature? What is the best / most accurate way to measure temperature – when should this always be used? How does one convert between Fahrenheit and Celsius?
- Proper technique: oral, axillary, rectal and tympanic temperature measure with various thermometers
- Normal ranges (afebrile = rectal temp of 36-37.9 deg C OR 97-100.3 deg F)
A.) oral: 37 deg C, 98.6 deg F
B.) axillary: lower than oral by 0.6 (36.4 deg C) or 1 (97.6 deg F)
C.) rectal: higher than oral by 0.4-0.5 (37.4 – 37.5 deg C) or by 0.7-0.9 (99.3– 99.5 deg F)
D.) tympanic: higher than oral by 0.8 (37.8 deg C) or by 1.4 (100 deg F)
- Abnormal ranges:
- Febrile: >= 99.4 orally and 100.4 deg F/38 deg C (rectally)
- Fever/pyrexia: elevated body temperature
- Hyperpyrexia: extreme elevation temp above 41.1 deg C or 106 deg F (rectally)
- Hypothermia: abnormally low temp below 35 deg C or 95 deg F (rectally)
- How to document: list route used (without correction) or if not listed, make sure it is corrected because oral temp is assumed.
- Best/most accurate temperature: rectal. Always use on elderly and critically ill children.
- Conversion: F = C(9/5) + 32 ; C = (F-32).5/9
What are standard precautions and what are the components/implications/practices?
- Standard precautions are a set of procedures designed by CDC to prevent spread of infections (known and unknown sources). Applies to blood, body fluids, excretions and secretions of skin and oral mucosa. Exception is sweat. - Implications/practices/components: A.) Needles should not be recapped, unless you can safely use the one-handed technique and should be discarded in safety containers B.) PPE (personal protective equipment) should be used C.) Hands should be washed before and after entering room, after contact with fluids, immediately after removing gloves and between patients D.) Respiratory hygiene and cough etiquette must be adhered to including wearing mask, having pt wear mask and coughing into upper sleeve or elbow, not into hands
Describe the parts to a stethoscope. What are each used for? What is the correct technique for using stethoscope?
- Parts of stethoscope, use of each part: - Diaphragm: side with cover, used for high-pitched sound (S1 and S2) - Bell: open side, used for low-pitched sound (S3, S4 and arteries) - Earpieces should be placed into ears angling forward - When using stethoscope, stabilize between your 2nd and 3rd fingers. - Modern stethoscopes can listen to both low and high frequencies by altering light/firm pressure. Deep diaphragm – firm pressure (used for high-pitched sound). Light bell – light pressure (used for low frequency low-pitched sounds). Pediatric side can be converted to traditional bell by removing diaphragm and replacing with nonchill bell sleeve.
What are the various examination positions?
- Supine: pt lies on back, draping covers chest to knees/toes - Prone: pt lies on stomach, draping covers torso - Dorsal recumbent: pt in supine position with knees bent and feet on table, used for genital or rectal area exams - Lateral recumbent: pt lies on side with legs extended or flexed - Lithotomy: pt is in dorsal recumbent position with legs in stirrups, used for pelvic exams - Sims: pt is lateral recumbent with top leg flexed and hip and knee, bottom leg is slightly flexed, used for rectal exam (including taking rectal temp)
What are examination techniques used? Explain the order that these techniques are used in.
- Inspection: mere observation - Palpation: use of hands (palmer surface: fingers and pads; ulnar surface: hand and fingers and dorsal surface of hand), light palpation = 1 cm, deep palpation = 4 cm - Percussion: direct (without separation between percussing device/doctor and pt) and indirect (use of separator between percussing device/doctor and pt) - Auscultation: use of stethoscope directly on the skin - Order of techniques: inspection, palpation, percussion, auscultation (may vary dependent on exam being done)
In order for a diagnosis of hypertension to be made, what must occur?
- Three readings are required over three days.
