Physical assessment + BP measurement + Resp/cardiac/endocrine/Neuro assessment Flashcards
What are 4 basic techniques for physical assessment? IPPA
- Inspection
- Palpation
- Percussion
- Auscultation
What does inspection consist of?
- Discolouration? – Any jaundice, paleness?
- Their age
- Tremors?
- Breathing speed?
- Drooping or asymmetrical facial features?
- Speech
What does palpation consist of?
What do you assess with it
the use of touch to determine physical characteristics
- feel pulsations
- feel vibrations
- locate body structures (i.e hip bones for waist circumference)
- Assess size
- Assess texture
- Assess temperature
- Assess tenderness
What is percussion?
Sounds of low density? High density? Examples
Body surface is struck to produce a sound
Low density (lungs) = low pitch sounds
High density (thigh) = high pitch sounds
How to properly strike a body structure to produce a sound?
- last 2 phalanges of left middle finger rest firmly on patients
- strike the last joint of your left middle finger, impact should be crisp
- ensure none of your other fingers is touching the patient to minimize any dampening
Describe each sounds of percussion: high/low pitch, type of sound, correlated body aprt
Tympany
Hyperresonance
Resonance
Dullness
Flatness
Tympany:
- high pitch
- loud, drum sound
- Gastric air bubble
Hyperresonance
- low pitch
- loud booming sound
- distended lungs in emphysema
Resonance
- low pitch
- hollow sound
- normal lung
Dullness
- muffled thud
- liver,
- fluid filled space
Flatness
- high pitch
- soft sound
- muscle
What does auscultation mean? Examples
Listening for sounds produced by body
Ex
- gas moving in gut
- blood flow through valves (korotkoff sounds)
- air moving in/out of lungs.
What does gait imply?
A person’s manner of walking
- Parkinson’s? certain meds (antipsychotics)
How to calculate BMI
underweight
normal
overweight
Class 1 obese
Class 2 obese
Class 3 obese
BMI = Kg/Height^2
underweight: <18.5
normal: 18.5-24.9
overweight: 25-29.9
Class 1 obese: 30-34.9
Class 2 obese: 35.0-39.9
Class 3 obese: 40.0+
What are risks associated with low BMI (4)
- undernutrition
- osteoporosis
- infertility
- impaired immunocompetence (impaired wound healing)
What are risks associated with high BMI (7)
- Type 2 diabetes
- Dyslipidemia
- HTN
- Coronary heart disease
- Gallbladder disease
- Obstructive sleep apnea
- certain cancers
What BMI do you measure waist circumference?
Effect on category
Normal values for men and women
If BMI = 25-35
- bumps up 1 category
Men: 40 inches
Women: 35 inches
When is BMI not accurate? (4)
- Adults who are not finished growing
- Adults who naturally have a very lean or very muscular build
- certain racial and ethnic groups
- adults over the age of 65 (range for overweight 25-29.9)
What is a normal temperature
36.4 - 37.2
How to convert celsius to farenheit
(Degrees in C) x (9/5) + 32
What is the mean temp of the following age groups
Pediatric
Adult
Geriatric
Pediatric: 37.2
Adult: 37
Geriatric: 36
Which age group is tympanic thermometer not recommended in?
Birth - 2 years
which age group is rectum temp reading used?
Birth to 5 years old
What is recommended temperature route for older than 5 years
Mouth
What can cause increased temperature? (4)
Fever = 38.2 degrees orally
Infection
Medication
Inflammation
- blood clots (DVT, PE, MI)
Cancer tumours
When should you refer for fever? (5)
- Fever lasting more than 3 days
- Recurrent fever
- High fever (40.5+)
- Assoc with confusion, stiff neck, chest pain etc
- fever in neonates and infats
Is it possible to have an infection without a fever?
Which group of people is it common in?
Yes
- children <6m
- Immunocompromised people
- Elderly people
Confusion or delirium in these populations is indicative of an infection
What is a normal heart rate in
Child 1-6
Child 6-12
Adult
Child 1-6:
- 75- 160 bpm
Child 6-12:
- 80-120 bpm
Adult:
- 60 - 100 bpm
Where can you measure pulse for rate & rhythm (4)
Radial
Carotid
Femoral
Brachial
What are pulse sites to assess PAD, diabetic foot? (3)
Popliteal
Posterior tibial
Dorsalis Pedal Pulse
What HR defines bradycardia
Cause? (3)
< 60 bpm
Drug related
- BB, CCB, digoxin
Cardiac dysfunction, athletes/fit
What HR defines tachycardia
Cause? (4)
> 100 bpm
Due to stress, anxiety, dehydration
Medication
- Ventolin, Caffeine, stimulants (pseudoephedrine, phenylephrine)
Arrhythmias (afib)
What do you have to note when measuring a pulse (3)
Rate
Rhythm
Amplitude (absent, weak, normal, full)
Normal respiratory rate?
12 - 20 rpm
What do you have to note when measuring resp rate (5)
Rate
Rhythm (regular/ irregular)
Depth (shallow, deep)
Effort (laboured, accessory muscles used)
Sound (wheezes present)
What is tachypnea characterized as?
Symptoms? (4)
Conditions? (3)
> 20 rpm
Sx:
Exertion, fever, pain, distress
Conditions:
Heart failure, pneumonia, DKA
What is bradypnea characterized as?
Cause? (3)
<12 rpm
Cause
- CNS (brainstem stroke)
- Sedation (alcohol, ilicit drugs)
- Narcotics
What is a normal adult BP
120/80
What are factors that affect BP (7)
- Age
- Time of day
- Weight
- Exercise
- Emotion
- Medication
- Caffeine and smoking
In the stethoscope, what is the diaphragm used for? what is the bell used for?
diaphragm
- BP, lung sounds
Bell (smaller circle)
- Low frequency (DO NOT PUT PRESSURE)
- Heart murmur
How much should the bladder inside the cuff encircle the patient’s arm?
80%
What are the 5 phases of kortkoff sounds (6)
Phase 1: First sound = systolic
Phase 2: sounds soften and have a swishing quality
Auscultatory gap: sounds may disappear for a short time
Phase 3: The return of sharper sounds which may exceed intensity of phase 1 sounds
Phase 4: distinct abrupt muffling of sounds, become soft and fainting away
Phase 5: Sounds disappear = diastolic
Which of the following errors gives falsely high/low BP values (general & specific SBP, DBP): Rationale?
Anxious
Arm position above level of heart
Arm position below level of heart
Patient supports own arm
Legs are crossed
Cuff to small
Cuff to loose or uneven
Not palpating radial artery
Deflating cuff too quickly
deflating too slow/not waiting 1-2 min before repeating
Anxious
- false high
- SNS (wait 5 minutes)
Arm position above level of heart
- False low
- eliminates effect of hydrostatic pressure
Arm position below level of heart
- false high
- additional force of gravity added to brachial artery
Patient supports own arm
- false high DBP
- sustained muscular contraction
Legs are crossed
- False high SBP and DBP
- blood pooling from legs to thoracic area
Cuff to small
- False high DBP
- need excessive pressure to occlude brachial artery
Cuff to loose or uneven
- False high
- need excessive pressure to occlude brachial artery
Not palpating radial artery
- False low SBP
- miss initial systolic tapping
Deflating cuff too quickly
- False low SBP or high DBP
- insufficient time to hear tapping
deflating too slow/not waiting 1-2 min before repeating
- False high DBP
- Venous congestion in forearm
What indicated hypertension in visit 1?
What indicates no HTN?
What indicates further assessment?
What indicated hypertension in visit 1?
- 180/110+
What indicates no HTN?
What indicates further assessment?
- AutomatedOBP 135/85+
- OfficeBPM: 140/90+
What out of office assessment is preferred? Ambulatory or home BP measurement
Ambulatory BP measurement
Do clinicians overestimate/underestimate BP measurement?
Overestimate
- by at least 10/5 mmHg
- maybe by 20/10 mmHg
Which is more accurate BP device, mercury or oscillometric
Mercury
Which BP measurement is the preferred method for in office BP determination according to CHEP
Automated blood pressure measurement
- easier to use
- when properly done has a similar reading as a 24h ambulatory BP reading
How many minute intervals between each BP measurement
1-2 minutes
What BP device used in the SPRINT study? How many tests average of?
Omron HEM-907
- average of 3 readings after 5 minutes of rest
What is the width of the cuff size of arm circumference?
Length of bladder of arm circumference
Width: 40% arm circumference
Length: bladder inside the cuff encircle 80% of the patient’s arm
Where should the lower edge of cuff be after centre of bladder over brachial artery?
Lower edge of cuff 2-3 cm from elbow crease
How do you estimate systolic BP before measuring BP
- Determine HR and estimate the SBP
○ Palpate the radial pulse, for 15s (multiplied by 4, if regular HR) - Inflate cuff until pulse is gone. Note the SBP.
- Deflate the cuff and wait 60s to allow the venous congestion to dissipate.
- This helps you hear the sounds better when you auscultate in the next step.
How much you inflate the cuff? How much do you deflate the cuff
Inflate
- 30 mmHg higher than the systolic
Deflate
- rate of 2mmHg / HR
How many times do you repeat BP readings?
Which arm?
3 times in the same arm
- discard the first
- average the next 2
Always measure BP in arm that gives the HIGHER reading
- which means measure in both arms at least once
What to document when taking down BP (5)
Avg BP to the nearest 2 mmHg
Which arm
Position of the patient (seated)
HR (note if regular or not)
Note if patient was anxious, upset, in pain
What are home blood pressure measurement valuable for (2)
- Identifies white-coat hypertension
- Identifies masked hypertension or masked uncontrolled hypertension (if on meds)
How often does the ambulatory BP measure BP?
Every 15-30 minutes while awake
every 30-60 minutes while sleeping
11 essential elements to proper BP measurement
- Patient resting 5 minutes prior
- Legs uncrossed
- Feet on floor
- Arm and back supported
- Correct cuff size
- Cuff placed over bare arm
- no talking
- No phone
- BP taken in both arms
- Correctly identifying which arm is higher
- Correctly identifying which arm to use
How often should you measure BP in the self-measure series
2 readings are taken each morning and each evening for 4-7d (ideally 7d)
Recommend them to discard the first reading but keep the next 2, though some guidelines recommend them to discard the entire first day of readings
How is Orthostatic hypotension diagnosed?
Considered for?
Sitting to standing (wait 1 minute in between)
- drop in 20 mmHg in systolic OR
- drop in 10 mmHg in diastolic
Consider for
- Older frail individuals
- those with orthostatic symptoms
- unexplained falls
- patients with DM
What are the 4 common respiratory symptoms
Cough, SOB, sputum, wheezing
What conditions can cough be associated with? (7)
Characteristics?
- URTI
- Asthma
- dry hacking or wheezing - COPD
- productive
- a lot in the AM - Pneumonia
- productive (sometimes not) - Drugs (ACE)
- dry, non productive - GERD
- Heart Failure
- Night-time, sometimes sputum
What colour is an infectious cause of sputum?
What colour is pulmonary edema secondary to HF?
What colour is an infectious cause of sputum?
- purulent and yellow-green or rust
What colour is pulmonary edema secondary to HF?
- frothy and pink
Which conditions does dyspnea (SOB) occur in? (5)
Characteristics?
- Asthma
- SOB with wheezes in acute attacks - COPD
- Mild to severe SOB with exertion - Pneumonia
- CHF
- SOB while laying flat due to fluid overlaod (orthopnea) - Angina
- SOB during angina
Define barrel chest. What condition is it most common in?
COPD due to years of overinflation
Barrel chest means “front-to-back” is = “side-side” length
Define kussmal breathing
Condition?
Rapid, deep, sighing breaths (a form of hyperventilation)
- metabolic acidosis DKA
Define cheyne-stokes respiration
Condition?
- Breathing and periods of not breathing
- Common in infants but also in end-of-life or post-stroke/brain stem damage
Longer apneas when closer to death
What condition does use of accessory muscle indicate?
Refer/not refer
COPD
- refer
How to tell if someone has normal breaths by palpation
If not, what condition?
When you place your hands on someone’s back as they take deep breaths,
your hands should spread apart and come back evenly
Condition
- pneumonia
- atelectasis (collapsed lung)
- splinting
What sound does the following percussion noises make in lungs?
normal
Hyperresonance
Dullness
normal
- Resonant
- long, loud, low pitched
Hyperresonance
- very loud, low pitched
- emphysema (alveoli damage in lungs, SOB)
Dullness
- consolidation (air is replaced with fluid)
- pneumonia, aspiration, cancer
What are the following adventitious sounds caused by?
What condition?
Crackles (2)
Wheezes (1)
Rhonchi (2)
Stridor (1)
Crackles
- Air through fluid
- CHF, infection
Wheezes
- airway narrowing
- Asthma
Rhonchi
- secretions
- bronchitis or pneumonia
Stridor
- loud, high-pitched crowing sound
- airway obstruction, needs immediate attention
What does the Peak flow meter measure?
What is it useful for?
How to record value?
Measures peak expiratory flow (PEF)
- maximum forced expiratory flow obtained during FVC
Useful to see
- effectiveness of bronchodilator
- in patients with poor control of asthma
Document
- take 3 readings and record the highest one
What do the 3 zones mean in respiratory in terms of
PEF
Symptoms
Meds
Green zone
- Good control
- PEF: >80%
- Symptoms: No wheezing or SOB
- Meds: as usual
Yellow zone:
- Mod exacerbation
- PEF: 50-80%
- Symptoms: persistent wheezing OR SOB
- Meds: take B2 agonist
Red zone
- Severe exacerbation
- PEF: <50%
- Symptoms: SEVERE wheezing AND SOB
- Meds: Take B2 agonist
What are common cardiac symptoms
N/V
Anxiety
SOB
Pain
Weakness
Pallor/cyanosis
Diaphoresis
Change in LOC
Syncope
Hypotension
Hypertension
Palpitations
Decreased urinary output
How to differentiate chest pain in Cardiac, GI, MSK in terms of:
History
Type of pain
Precipitating factors
Relieved by
Cardiac:
- History: Risk factors for CHD
- Type of pain: Heavy pressure, crushing
- Precipitating factors: Exertion or stress
- Relieved by: rest or NTG
GI
- History: Gastritis or indigestion
- Type of pain: burning
- Precipitating factors: food
- Relieved by: antacids
MSK
- History: trauma
- Type of pain: Sore, achy, or sharp pain
- Precipitating factors: physical movement
- Relieved by: Rest, heat, pain meds
What conditions/drugs cause edema
Solution for drugs?
Conditions
- HF
- thrombophlebitis (inflammation of wall vein)
Meds
- Amlodipine
- ACE
Switch to ARB
Describe the following edema
Mild pitting
Moderate pitting
Deep pitting
Very deep pitting
Mild pitting
- slight indentation
Moderate pitting
- indentation subsides quickly
Deep pitting
- indentation remains for a short time
Very deep pitting
- indentation remains a long time, sig swelling
Heart sounds
S1 and S2
Valves?
Onset?
Shorter/longer
S1
- AV valves closing (tri & bicuspid valve)
- Onset of systole
- Longer duration
S2
- Pulmonary and aortic valves close
- End of systole
- Shorter than S1
T/F S3 is not normal children and adolescents
False
S3
Cause?
Onset?
Conditions?
Cause?
- LV failure and volume overload
- blood leaves atria and crashes into full ventricle
Onset?
- Early in diastole
Conditions?
- HF
- MI
- Pulmonary edema
S4
Cause?
Onset?
Conditions?
S4
Cause?
- LV hypertrophy
- Blood from Left atrium trying to enter a stiff, non-compliant left ventricle during atrial contraction
Onset?
- end of diastole
Conditions?
- Atrial gallop
What does diabetic polyneuropathy present with?
Intensely painful feet
Pain, paresthesias (pins and needles),
Sensory loss
What are the 2 pulses on the foot
Dorsalis pedis
Posterior tibialis
Why do we care about foot ulceration?
Acute ulcers
Chronic plantar ulcer
Foot deformities
- Muscle atrophy
What is the tuning fork test and monofilament test
Hit fork on distal part of great toe
Ask the patient to tell you when they can’t feel a vibration,
Count until you can’t feel it, if more than 8 = peripheral neuropathy
Monofilament
- poke around bottom of foot and 1 on top of foot
What are the 5 components of a neurological exam
- Mental status
- Cranial nerve
- Motor
- Reflexes
- Sensory
What to look for in mental status>
Appearance
Mood
Affect
Speech
Though process
Active recall
What do you make sure a person is oriented to?
Person (name)
Place (where are you)
Time (date, month, day of the week)
What medical conditions and medications can decrease orientation?
Medical
- UTIs in elderly
- Hepatic encephalopathy
Medications
- Anticholinergics
- Benzodiazepines
How to assess level of consciousness? Whats the name of scale? What are the 3 areas
Glasgow Coma Scale
3 areas
1. Eye opening
2. Best verbal response
3. Best motor response
What are cranial exam abnormalities caused by? (5)
Compression
Stroke
Inflammation
Head trauma
Medications
What to assess for in motor function (5)
- Strength
- Gait
- Balance
- Coordination
- Abnormal movements
What is the cogwheel rigidity when assessing for strength
Wrist is unable to flex and extend normally (very jerky)
- Associated with Parkinson’s
What is gait?
What is ataxia?
Abnormal body position and arm movements while walking
Ataxia
- inability to coordinate muscle movements
What test do you use to test for balance
Romberg test
- stand feet together
- close etes for 20-30 seconds
What are possible cause of not having a good balance?
Vestibular dysfunction
Cerebellar dysfunction
Intoxication
What are you assessing for when you ask a patient to have rapid alternating movements
i.e touch thumb to each finger of same hand
OR pat thigh while alternating fron and back of hand
coordination
What Abnormal movements are you looking for? (2)
Tremors
Dyskinesia - involuntary uncontrollable movements (caused by antipsychotics)
