Week 2: Phys Exam General Principles Flashcards
Clinical Observation
Observation starts when you first see the patient, for example:
◦ Look at movement, facial expression, the way they speak & articulate, demeanour, posture
Sequence of overall clinical observation (head-to-toe):
◦ General/overall incl. skin & hands ◦ Head & Neck ◦ Rest of body ◦ Limbs
- overall health
- signs of distress (cardio, pain, anxiety)
- stature- height and weight
- skin colour- cyanosis, lesions etc
- Dress, grooming, hygiene
- facial expression
- posture, gait, motor
- hands (clubbing etc)
◦ What do all these regions possibly tell you??
Stages of the Clinical Consultation for a Chiropractor
- Case history (clinical interview) – covered in week 1
- The general survey, including observation of the skin & hands
- Vital signs
- Relevant Physical Examination (including general observation within each system)
- Further examination, usually a relevant regional neurological & orthopaedic examination
- Process of deriving the primary (working) diagnosis and differential diagnoses
- Decision on plan of management and report of findings to the patient
What are some Important Aspects of the Health History
- Changes in weight:
- Rapid or gradual?
o Rapid changes over a few days suggest changes in fluid, not tissue
- Weight gain: nutrition vs. medical causes
- Weight loss: medical vs. psychosocial causes
- Fatigue and weakness:
- Fatigue: a sense of weariness or loss of energy
- Weakness: a demonstrable loss of muscle power
- Medical vs. psychosocial causes
- Fever, chills, and night sweats:
- Ask about exposure to illness or any recent travel
- Some medications may cause elevated temperature
What’s are some general observations that should be made?
Posture, gait and abnormal motor movements ◦ Preferred posture(s), limp, asymmetry ◦ Tremor ◦ Tics
• This then leads on to taking the vital signs and the rest of the examination…
Specifics: Examination of the Hands
Nails
• Clubbing
• Known causes • Fungal infections • Terry’s nails
• Chronic liver and renal disease • NIDDM
Muscles of the hands
• Fasciculation or wasting
• Where would you best observe this?
Tendons & joints
• Swelling or deformity in arthritis
• OA • RA
What are the Vital Signs that must be checked?
- Heart rate and rhythm (Pulse)
- Respiratory rate (and rhythm)
- Blood pressure
- Temperature
(easily examined in the above order)
Vital signs
1. Heart Rate and Rhythm (Pulse)
Radial pulse is commonly used to measure the heart rate
• Use the pads of the index and middle fingers
• If the rate seems normal (60–100 bpm) and the rhythm is regular, count the rate for 30 seconds and multiple by 2. If the rate is fast or slow and/or the rhythm is irregular, count for a full 60 seconds.
• 100 = tachycardia
Vital signs
2. Blood Pressure – Optimal Conditions
Avoid smoking or drinking caffeinated beverages 30 minutes prior to measurement
• Ensure that the room is quiet and comfortably warm
• Patient should be seated quietly in a chair with feet on the floor for
at least 5 minutes
• Patient’s arm should be FREE of clothing
• Palpate the brachial artery
• Position the arm so that the brachial artery is at heart level
• Rest the arm on a table or support the patient’s arm with your own at his mid-chest level.
Optimal (adults older than 18 years)
• Systolic: ≤120 mm Hg
• Diastolic: ≤80 mm Hg
• If blood pressure is elevated:
• Repeat blood pressure and verify in the contralateral arm
• Consider “White Coat Hypertension (syndrome)”
o Occurs in 15%–30% of all patients
o Try to relax the patient and retake BP later in the visit
Refer to the table on slide 18
Vital signs
3. Respiratory Rate and Rhythm
Observe rate, rhythm, depth, and effort of breathing at the thorax • Normal rate: 12-20 breaths pm
o Count for a minimum of 30, ideally 60 seconds
o 20 = tachypnoea
• Observe rhythm: regular, irregular
• Observe depth: shallow, gasping
• Observe effort: normal, labored
• Recording the RR…
Vital signs
4. Temperature
Average oral temperature: 37o C • Diurnal variation: 35.8o C to 37.3o C • Oral • Rectal 0.5o C > oral temperature • Axillary 1o C < oral temperature • Tympanic 0.8o C > oral temperature
Examination of the hands:
Clubbing
Presentation
Causes
Presentation:
- distal phalanx of fingers is rounded and bulbous
- angle between plate and proximal nail fold increases to disease
- over active thyroid gland
- liver cancer
Hands:
Terry’s nails
Causes
White with a ground glass appearance
- chronic liver and renal disease
- non-insulin dependant diabetes mellitus
Hands:
Arthritis
Presentation
-deneneration and progressive loss of cartilage within joints
-damage to underlying bone
-formation of a new bone at margins of cartilage
Presentation:
-location-knees, hips, hands, wrists, Cervical and lumbar spine
-stiffness in joints after getting out of bed/sitting for prolonged periods
-swelling or tenderness in one or more joints
-crunching feelings/sound of bone on bone
Cause/ risk factors:
- overweight
- age
- injury to joint
- joints not formed properly
Causes:
Rhematoid arthritis
Chronic inflammation of synovial membrane
- secondary erosion of adjacent cartilage and bone, and damage to ligaments and tendons
- autoimmune disease
- often chronic with remissions and exacerbation s
Presentation:
- symmetric deformity in hand and wrist joints with ulnar deviation
- multiple joints affected
- joints may be swollen, tender,, stiff
- systematic complaints of fatigue, weight loss, fever and weakness
Risk factors p:
- begins Middle Ages
- women more likely
Causes:
- hereditary
- environment
- hormones
Diabtes mellitus:
-endocrine disorde- blood glucose levels are too high
Type 1: insulin dependant -body don't make insulin -develops in childhood -no cure- insulin injection forever, nutrition Presentation: -thirst, appetite -frequent urination -fatigue -unintentional weight loss -dry, itchy skin -tingling sensation in feet-loss of feeling -blurred vision -nausea and vomiting
Cause: autoimmune destruction of insulin making cells in pancreas
Type 2: non-insulin dependant
Risk factors:
-age, lifestyle (smokingm no exercise, obese) fam history
Presentation:
- thirst, appetite
- frequent urination
- fatigue
- unintentional weight gain especially around waist
- Terry’s nails
- slow healing wonds
- blurred vision
- high blood pressure
- high cholesterol
