Lecture 2.1: Gen. survey & vitals (4%) Flashcards
1
Q
List health history red flags
A
1) Weakness and fatigue
2) Fever, chills, and night sweats
3) Weight change
2
Q
What’s the difference between weakness and fatigue?
A
1) Weakness: denotes demonstrable lack of strength.
2) Fatigue: is more nebulous but it points toward a lack of energy
3
Q
What can fatigue correlate with for each category? (psych, infection, endocrine, cardiac, respiratory, renal, hepatic, heme, and miscellaneous)
A
1) Psych: depression/anxiety
2) Infection: mono, TB, endocarditis
3) Endocrine disorders: hypothyroidism, adrenal insufficiency, DM (diabetes mellitus)
4) Cardiac: heart failure
5) Resp: chronic lung disease
6) Renal: CKD
7) Hepatic: liver failure, hepatitis
8) Heme: anemia
9) Misc: electrolyte imbalance, malignancy, nutritional deficit, medications (beta blockers)
4
Q
1) Define pyrexia
2) What is it correlated with?
A
1) Elevated temp
2) Infection, trauma (surgery or crush injury), malignancy, drug rxn (SSRI overdose), and immune disorders
5
Q
What point to temperature change?
A
Chills/shivers/rigors
6
Q
What does true shaking raise concerns for?
A
Bacteremia.
7
Q
What are night sweats correlated with?
A
Both TB, and malignancy
8
Q
1) What temperature will immune compromised patients with sepsis have?
2) What else is this true for?
A
1) Fever may actually be absent or low
2) Recent ingestion of ASA, NSAIDS, and steroids; may also mask fever`
9
Q
What is a benign cause of elevated temperature?
A
Menopause; can cause hot flashes
10
Q
1) How much does temperature vary throughout the day?
2) What indicates low temp?
3) What indicates high temp?
4) When does temperature drop? What happens when there’s a fever?
A
1) ~1C throughout the day.
2) Hot flashes and sweating
3) Chills and “cold sweats”
4) Normally, temperature drops at night; when this phenomenon is affected by fever, pts experience night sweats
11
Q
1) What two questions should you ask if a patient says their weight changed?
2) What does rapid weight gain over a few days indicate?
3) What does that indicate?
A
1) “Is this rapid or gradual? Is this intentional?”
2) More likely portends fluid retention.
3) Indicates potential for heart failure, nephrotic syndrome, liver failure, and venous stasis
12
Q
What can induce chronic weight gain? (6 things)
A
Medications such as:
1) Tricyclic antidepressants
2) Insulin and sulfonylurea
3) *Contraceptives
4) *Glucocorticoids
5) *Some SSRI’s
6) Others
* = important
13
Q
What can unintended weight loss raise suspicion of?
A
1) CA
2) Hyperthyroidism
3) HIV/AIDS
4) Anorexia nervosa/bulimia
5) GI absorption disease
6) Malnutrition
14
Q
When should you investigate weight loss in a patient?
A
Weight loss of more than 5% over 6 months needs further investigation
15
Q
How many Americans experience chronic pain?
How many experience acute pain every year?
A
1) 100 million Americans
2) 12%
16
Q
1) How should you treat pain?
2) What should you do in your diagnoses?
A
1) Like any other complaint and ensure that you apprehend the 7 attributes of a symptom.
2) In your diagnoses, attempt to localize and define the pain – pinpointing its source
17
Q
1) What does proper chronic pain management target?
2) Is pain a vital sign?
A
1) Targets ADLs, not a 1-10 score
2) Pain is not a vital sign.
18
Q
What are the elements of health promotion?
A
1) Optimal weight, nutrition, diet
2) Blood pressure and dietary sodium
3) Exercise
19
Q
1) What percent of adults are overweight in the US?
2) What about kids?
A
1) 69% of U.S. adults are overweight or obese (BMI > 25 lbs/in^2)
2) 15% of kids are overweight and 17% are obese
20
Q
Why does obesity matter?
A
Increases risk of diabetes, heart disease, and numerous types of cancers
21
Q
What percent of healthcare providers are willing to mention obesity risks to obese patients?
A
Only 65% of health care providers
22
Q
What can reducing weight by 10% do?
A
Improve BP, lipids, glucose tolerance and reduce DM risk
23
Q
What can the right patient education do?
A
Can pull someone from the brink of prediabetes
24
Q
What should you measure and assess regarding weight and nutrition? What should you screen for?
A
Measure objective data and assess risk factors, so screen for metabolic syndrome
25
What are the indicators of metabolic syndrome? How many to make a diagnosis?
1) Waist circumference >/= 40 in in men and >/= 35 in women
2) Fasting glucose >/= 100
3) HDL < 40 in men and < 50 women
4) Triglycerides >/= 150
5) Blood Pressure >/= 130 over 85
-3 or more = diagnosis
26
What are the classifications of overweight and obese based on BMI?
1) Underweight < 18.5
2) Normal 18.5 – 24.9
3) Overweight 25 – 29.9
4) Obese I 30 – 34.9
5) Obese II 35 – 39.9
6) Extreme obesity >/= 40
-“Eighteen point five to twenty-five, then count by fives”
27
How do you calculate BMI?
Take lbs x 700 and divide by the height in inches twice
28
What is the second step in promoting weight?
Take a diet history and assess eating patterns.
(It sometimes helps to walk through the last 24hours of diet; don’t forget beverages)
29
What is the 3rd step of promoting weight loss?
Assess motivation to change
(You can use the “change model” in your book for this.
As an entre into this, you can use the 1-5 scale and have them describe their reasoning
Precontemplation contemplation preparation action maintenance)
30
When counseling a patient about weight, what should you do?
-Remember the 10% stat we learned
-A safe amount of wt loss is 0.5-2 lbs per week
-Strategies for promoting weight loss
-Start with daily walking
-Make one diet change at a time
-Celebrate successes!
31
What are the 4 steps of promoting optimal weight?
1) Measure objective data and assess risk factors – to this end, screen for metabolic syndrome
2) Take a diet history and assess eating patterns
3) Assess motivation to change
4) Provide counseling
32
What kind of diet should you recommend to a patient trying to lose weight?
-One which produces a calorie deficit of 500-1000 calories
(Intake of added sugars, solid saturated/trans fats, and refined grains make it difficult to achieve optimal nutrition!)
33
What are shortcuts to weight loss?
1) Cut out sugar
2) Exercise daily
3) Eat “real food”
4) Avoid liquid calories
5) Make one change in the diet category and one change in the exercise category per week
6) Celebrate your victories!
34
1) How much salt is too much?
2) How much do most Americans eat, and what is the biggest contributor of salt to a diet?
1) More than 2,300 mg per day
2) Most Americans eat 3,400 mg daily; the major contributor of salt is processed food
35
How much exercise should someone get a week?
At least 2 ½ hours / week of “moderate intensity exercise.”
36
Give examples of moderate intensity exercise
Hiking
Yard work
Dancing
Golfing
Cycling (slowly)
Weights
Walking
Stretching
37
More than 90% of the time, what is the cause of HTN?
Idiopathic
(Idiopathic = we don't know)
38
What are some risk factors of HTN?
-Age > 40
-Genetic Hx
-Black ancestry
-Obesity and wt gain
-Excessive salt intake
-Physical inactivity
-Excessive ETOH use
39
What are some conditions that can cause secondary HTN?
1) Chronic Kidney disease
2) Renal artery stenosis
3) Pheochromocytoma
4) Cushing’s disease/syndrome
5) Hyperaldosteronism
6) Obstructive sleep apnea
7) Thyroid disease
8) Parathyroid disease
9) Coarctation of the aorta
40
1) What is the BP screening recommendation?
2) Who is at risk for high BP?
3) How often are they screened?
1) Grade A recommendation: strongly encouraging annual BP screening of adults aged 40 + and those with increased risk
2) BP 130-139/85-89, overweight or obese, or black ancestry
3) They are screened every 3-5 years
41
1) What is the general survey?
2) When does it begin?
3) What does it include?
1) The broad view of a patient.
2) The moment you lay eyes on the patient, but will continue to crystalize as you proceed through the interview and physical
3) Economic status, nutrition, genetic makeup, physical fitness, mood, sex, geographic location, age, and state of health/illness all contribute to this picture.
42
What are some questions to consider regarding apparent state of health? (5)
1) Acutely ill-appearing?
2) Chronically ill?
3) Frail?
4) Fit?
5) Robust?
43
What are the 6 parts of a general survey?
1) Apparent state of health
2) Level of consciousness
3) Distress
4) Dress, grooming, and personal hygiene / odors
5) Facial expression
6) Posture, gait, motor activity
44
What questions should you ask when considering level of consciousness? (6)
1) Awake and alert?
2) Understand questions?
3) Respond appropriately, quickly, or lose track of topic.
4) Silent?
5) Somnolent?
45
1) Define alert
2) Define lethargic
3) Define obtunded
1) Pt opens eyes, looks at you, and responds appropriately
2) Pt is drowsy, but opens eyes and responds when you speak loudly
3) Pt will open eyes if you shake them, responds slowly and is confused
46
1) Define stuporous
2) Define comatose
1) Stuporous: pt responds to painful stimuli and verbal responses are slow or absent
2) Comatose: pt does not respond
47
How is orientation quantified?
Oriented x [. . .]
48
1) What does oriented x3 mean?
2) What about oriented x4?
1) Oriented x 3: Person, place and time
2) Oriented x4: Person, place, time, and event
49
Define grossly oriented
Patient is generally able to interact without obvious deficits
50
What should you consider about distress?
1) Cardiac or respiratory distress?
-Clutching chest, pallor, diaphoresis, labored breathing wheezing or coughing
2) Pain?
-Wincing, diaphoresis, protectiveness of affected area, grimacing, unusual posturing
3) Anxiety/depression
51
What should you consider regarding Anxiety/depression
when looking at distress?
Anxious expressions, fidgeting, cold moist palms, flat affect, avoidant eye contact, psychomotor slowing?
52
What should you consider regarding dress, grooming, and personal hygiene/ odors? (3 major things)
1) How are they dressed? Is clothing suitable of temp and weather? Is pt clean?
2) “Cut out” shoes
3) Neglected appearance may point to depression or dementia (but compare with norm)
53
1) What could excess clothing indicate?
2) What could cut out shoes indicate?
1) Hypothyroidism, rash, needle marks, anorexia nervosa
2) Gout, bunions, edema, chronic ulcer/abscess
54
What should you consider about patient odors? Should it always be mentioned?
Only mention if medically significant; if a pt smells “fruity” consider DKA, and note if you smell ETOH (alcohol)
55
What should you look out for regarding a patient's facial expression? (4 things)
1) Watch for stare: of hyperthyroidism (Grave’s disease).
2) Immobile face: of Parkinson’s
3) Flat affect: of depression or negative sx of schizophrenia
4) Eye contact: sustained and unblinking, avoidant
56
What should you consider regarding pt posture, gait, and motor activity?
1) Pt’s tend to sit upright in CHF and lean forward in COPD
2) Anxious patients or those with drug toxicity are often hyperkinetic
3) Pts in extreme pain often avoid movement or seek to find comfortable posture
4) Does you patient move tentatively, as if they fear falling? Do they have balance?
5) Look for tremor, immobility, decreased mobility, involuntary movements, impaired gait
57
What 5 questions should be considered about motor activity specifically?
1) Tremor
2) Immobility
3) Decreased mobility
4) Involuntary movements
5) Impaired gait
58
1) What are the vital signs?
2) What should you do if they're already provided?
1) Ht/wt, blood pressure, heart rate, respiratory rate, temperature
2) If already provided (as they often will be) review them; they are vital!
59
1) What may short stature indicate?
2) What may long limbs indicate?
3) What causes height loss?
4) What does central obesity occur in?
1) Turner’s, hyperpituitary and achondroplastic dwarfism, childhood renal disease
2) Long limbs seen in hypogonadism and Marfan syndrome
3) Associated with osteoporosis and vertebral compression fx in the elderly
4) In Cushing syndrome/disease, sometimes in metabolic syndrome
60
A single office measurement has a sensitivity and specificity of _____ when compared with ambulatory BP
75%
61
What is ambulatory BP?
BP taken automatically every 15-20 min during day and 30-60 min at night for 1-2 days
62
1) To make diagnosis of HTN in the office, what do you need?
2) What should you consider?
1) Take the average of 2 readings over 2 different readings on two separate visits
2) “White coat” and “masked” hypertension
63
1) If BP is taken at home, what do you need to do?
2) What are the benefits of taking BP at home?
1) Must properly educate pt about use of the equipment
2) Benefits: the ability to differentiate white coat HTN and pick up both masked and nocturnal HTN
64
1) Define white coat HTN
2) Define masked HTN
3) Define nocturnal HTN
1) White coat: Over 140/90 in office and less than 135/80 at home
2) Masked: Less than 140/90 in office and more than 135/80 at home
3) Nocturnal: Less than 10% dip in sleeping pressure
65
1) How do you choose the right size BP cuff?
2) Where should it be placed?
1) Width of bladder should be 40% of arm circumference
-Length should be 80% of arm circumference
2) Should rest 2.5 cm above antecubital crease
66
List the 8 steps of taking blood pressure
1) Take radial pulse
2) Inflate cuff until pulse is no longer palpable
3) Add 30 mmHg, release the pressure, and wait 30 seconds
4) Place stethoscope, inflate again, and start at the above pressure reading and slowly deflate cuff 2-3 mmHg/s
5) When you hear 2 beats in a row you have the systolic pressure
6) You may hear a systolic gap when the sounds go away
7) You will hear sounds permanently disappear – this is the diastolic pressure
8) Wait 2 minutes, average 2 readings and use 2 arms
67
What does a difference in pressures of more than 10mmHg between a pts arms mean?
Has to do with aorta
68
What 4 things should you consider when interpreting a BP reading?
1) General (exercise)
2) Mouth (caffeine, smoking)
3) Upper extremity (clothing, fistula, scar, lymphedema, arm too high/low)
4) Lower extremity (feet not flat on floor?)
69
1) Describe general affects on BP
2) Describe affects of the mouth on BP
3) Describe affects of the upper extremity on BP
1) General: Exercise 30 min prior
2) Mouth: Caffeine, smoking
3) Upper extremity:
-Arm not at heart level
-Clothing on the arm!
-Fistula in the arm
-Scar from brachial artery cutdown (cardiac cath)
-Lymphedema
70
1) How can the lower extremities affect a BP reading?
2) What are latrogenic affects on BP?
1) Lower extremity: Feet are not flat on the floor
2) Latrogenic: Cuff is too narrow or wide
(latrogenic = PAs fault)
71
What should you base your final BP number on?
The highest of your readings; do the same with your diagnosis
72
1) What is normal BP
2) What is prehypertension systolic? What about diastolic?
3) What is stage 1 systolic for ages 18-59? What abt diastolic?
1) <120/<80
2) Systolic: 120-139 Diastolic: 80-89
3) Systolic: 140-159 Diastolic: 90-99
73
1) What is HTN stage 1 60+ y/o systolic? What about diastolic?
2) What is stage 2 HTN systolic? What abt diastolic?
1) Systolic: 150-159, Diastolic: 90-99
2) Systolic: >/= 160, Diastolic: >/= 100
74
Hypertension causes damage throughout the body, so when you are performing a PE on a pt with known or newly diagnosed HTN, what should you check?
1) Eyes: looking for hypertensive retinopathy
2) Heart/PMI: looking for displacement secondary to LVH
3) Kidneys: assess with UA and GFR, possible arteriogram
4) Brain/Neuro: to assess for CVA secondary to HTN
75
When should you check other body systems for damage from HTN?
Check symptomatic pts or those with critically high B/P
76
What do you need to remember about low blood pressure?
Put pressure in context; 110/70 looks great unless it occurs in a patient with a pressure of 145/95 for the last 8 years
77
What is orthostatic hypotension?
Dizziness when going from sitting/ laying to standing
78
Why can orthostatic hypotension occur? (5 main reasons)
1) Drugs (say, BP meds like metoprolol)
2) Blood loss
3) Bed rest
4) Nervous system disease
5) Elderly patients (20% of people over 65)
79
How do you measure orthostatic HTN?
Measure BP and HR in 2 positions:
1) First supine after 3 minutes rest
2) Then within 3 minutes after standing
80
When does a pt have orthostatic HTN?
1) Systolic drop more than 20mmHg upon standing
2) Diastolic drop more than 10mmHg upon standing
3) HR rise more than 20 bpm upon standing
4) OR GETTING DIZZY!
81
What are some Special BP Situations you may run into?
1) Weak or inaudible Korotkoff sounds
-Takayasu arteritis, giant cell arteritis, atherosclerosis
2) White Coat
3) Obese or Very Thick
-Cuff variability “tight = high” “lose = low”
4) Arrythmia
-Reflex to EKG if rhythm is off
5) Higher pressures in the arms than legs?
-Think coarctation of the aorta
82
What may cause weak or inaudible Korotkoff sounds? (3 things)
Takayasu arteritis, giant cell arteritis, atherosclerosis
83
What should you do when measuring BP if pt has an arrythmia?
Reflex to EKG if rhythm is off
84
How do you do leg blood pressure?
-Use a long thigh cuff with bladder size 18 x 42
-Listen over popliteal artery
-If possible, keep patient prone
85
How do you measure radial pulse?
1) Use pads of index and middle fingers, compress radial artery until pulsation is detected
2) If rhythm is regular, proceed to counting the rate for 30 seconds and multiply by 2 to get BPM
3) But if it appears fast or slow, count for the full minute
-60-100 is normal
86
What is normal radial pulse rate?
60-100 (if pt is very athletic, 50 can be normal)
87
What should you do if something in HR or rhythm seems off?
-Listen to the heart as well; you may hear beats that are not transmitted to the periphery
-You may also pick up on rubs, gallops, or murmurs
-If something seems off, have a low threshold to obtain an EKG
88
1) What should you observe about respirations?
2) How do you count respirations?
3) What is a normal respiration rate?
1) Rate, rhythm, depth, and effort
2) Count the number of respirations in 1 min by watching or listening
3) About 12-20 respirations per minute with the occasional sigh
89
1) What respiratory abnormalities should you look for?
2) What about listen for?
1) Tripoding, increased AP diameter/Barrel chest, cyanosis, and retractions
2) Dyspnea, wheezing, grunting, coughing, crackles
90
1) What is normal core body temp?
2) How do you convert to F?
1) 37 C
2) Multiply by 9, divide by 5, then add 32
91
1) What temp is lower than core body temp?
2) What temp is more accurate?
3) What temp is more variable than oral or rectal?
4) What is the least accurate temp?
1) Oral temp is lower than core body temp
2) Rectal temp is more accurate but also more invasive
3) Tympanic is more variable than oral or rectal
4) Axillary is the least accurate
92
1) Is temporal temperature accurate?
2) How low does this temp run? What else runs about the same temp?
1) Temporal artery, along with oral and rectal remains accurate
2) Temporal, along with oral, reads about 0.5 C below rectal
93
1) Define chronic pain
2) How do you address a chronic pain CC?
1) Chronic pain is that which is not associated with CA or other medical condition, lasting min of 3 months
2) Begin by interviewing just as you would any other CC; it is ok to use a standardized pain rating scale, but don’t forget to focus on ADLs
94
What should you consider when evaluating the amount of pain a patient is in?
Health disparities; it is well documented that Black and Hispanic patients have received less analgesia when studied
95
What are the 5 types of pain?
1) Nociceptive pain
2) Neuropathic
3) Central sensitization pain
4) Psychogenic pain
5) Idiopathic pain
96
1) What is nociceptive pain?
2) What causes nociceptive pain?
3) What mediates it?
1) Plain ol’ pain pain
2) Tissue damage of skin, MSK, or viscera
3) Mediated by C fibers of sensory system
97
1) What causes neuropathic pain?
2) How long does it last?
3) What does it feel like?
1) Direct damage to nervous system
2) May last beyond initial injury
3) Takes a burning, or shock-like character
98
What is central sensitization pain?
Ongoing research on this, but includes fibromyalgia and somatization disorders
99
What can cause psychogenic pain? (3 things)
Anxiety/depression, personality, and coping style
100
What is idiopathic pain?
Unknown pain
101
1) Define tolerance
2) Define dependence
1) Pt adapts to a drug and one of more components of the drug lose their perceived effectiveness over time, requiring higher dosing.
2) Pt adapts to the drug and has physical symptoms if drug is abruptly discontinued or decreased in dose.
-Does NOT mean the pt is addicted.
102
What are the 3 categories of addiction factors?
What are some addiction behaviors?
Has genetic, psychosocial, and environmental factors.
Pt begins to demonstrate behaviors such as:
1) Impaired control over how to take the drug
2) Compulsive use
3) Continued use even when causing physical or psychological harm
4) Craving
5) Taking meds in a manner other than prescribed
6) Lying to get dose increased
103
What are the risks of pain medication?
1) Using more than the prescribed amount
2) Taking the medicine more often than prescribed
3) Taking medicine for other reasons
-All are red flags for addiction
104
What are the six targets for general appearance? (from lab)
1) Health
2) Awareness/ LOC (level of consciousness)
3) Distress
4) Grooming/ hygiene
5) Face
6) Posture/ motor
