Problem Based Physical exam
Allows for the teaching of all examinations skills for a particular system and diseases belonging to that system
What is General Appearance?
- It is the overall observation of the patient at the opening of the encounter - or the "first impression" that the health care provider has of the patient's mental functioning. (includes weight, height, and general)
Features of General Appearance
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random disease
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General Appearance: Level of consciousness
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General Appearance:Level of consciousness (GCS)
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How to calculate a patient's Glasgow coma score
GCS= E + V + M - Max. Score: 15 - Comatose patient: <8 - Min. Score: 3
General Appearance: Signs of Distress
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General Appearance:Skin Color
- Cultural background - Abnormalities in skin color - Lesions on the skin (rashes/ nevi/ scars)
General Appearance: Dress / Grooming / Hygiene
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General Appearance:Facial Expression
- Affect (objective): observation of the patient's outward emotional state - Mood (subjective): is described in the patient's own words --- Appropriate vs.inappropriate --- Intensity:Blunted,exaggerated, flat
General Appearance: Posture
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General Appearance: Gait
Observe the two phases of gait - Stance (foot is on the ground and bears weight)- Swing (foot is in motion with no weight bearing)
General Appearance: Abnormal Gaits
- Antalgic - Ataxic - Spastic - Hemiplegic (Circumduction) - Diplegic (Scissor) - Choreiform - Trendelenburg - Myopathic - Neuropathic - Parkinsonian
General Appearance: Position
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General Appearance: Built
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General Appearance: Body Mass Index (BMI) calculation
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General Appearance:Body Mass Index (BMI)
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General Appearance: Age
• Do not write the actual age of the patient in the Objective section of the SOAP note. This would be done in the Subjective section. • Use descriptive terms
General Appearance: Odors substances
- Alcohol - Tobacco - Marijuana
General Appearance: Odors body
- Musty odor (PKU) - Ketone/fruity breath (DKA) - Urine/feces (Post-ictal phase seizure/incontinence)
Other features of a patient's general appearance
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General Appearance: Sample Documentation
- Sample 1: The patient is a middle-aged overweight Caucasian male lying supine in bed in no cardiopulmonary distress. He is alert, wellgroomed and cooperative. - Sample 2: The patient is an elderly afro- female sitting on the chair, alert with facial asymmetry and slurred speech in no cardiopulmonary or painful distress. She is noted to be anxious with a flat affect.
Vital Signs
Vital signs provide critical initial information that often influences the tempo and direction of the assessment Consist of:- Blood pressure - Heart rate /Pulse - Respiratory rate - Temperature - Pulse oximetry*
Vital Signs: What is Normal?
- There is no exact number to qualify as "normal" - VS may reveal sudden changes in a client's condition in addition to changes that occur progressively over time. - A baseline set of VS are important to identify changes in the patient's condition
Vital Signs: Temperature
- Core temperature -temperature of the body tissues,is controlled by the hypothalamus (control center in the brain)-maintained within a narrow range. - Skin temperature rises & falls in response to environmental conditions & depends on blood flow to skin & amt. of heat lost to the external environment
Vital Signs: Temperature values
- Fever or pyrexia refers to an elevated body temperature. Values vary on practice Medicine: 100.4º F (38ºC) or above Surgery: 101.5º F (38.6º C) or above - Hyperpyrexia refers to an extreme elevation in temperature,above 41.1°C (106°F) - Hypothermia refers to an abnormally low temperature below 35°C (95°F)
Causes of normal temperature variations
- Sex - Activity - Environmental temperature - Oral intake - Time of Day - Menstrual Cycle
Vital Signs: Blood Pressure
Arterial blood pressure is the pressure exerted by a column of blood against the arterial wall
Vital Sign: Blood Pressure Technique
1. Patient should avoid caffeine,smoking, or exercise 30 minutes prior to measurement 2. Sit with feet on the floor for 5 minutes 3. Expose selected arm 4. Palpate the brachial artery 5. Position arm at the heart level (seated: rest on the table, standing: support at patient's 4th ICS) 6. Select the correct BP cuff The width should occupy 40% of arm circumference Length should occupy 80% of arm circumference 7. Position cuff 2.5cm above the antecubital fossa 8. Determine systolic pressure by palpation 9. Add 30mmHg to the systolic pressure 10. Place stethoscope bell over the artery and auscultate the korotkoff sound to determine systolic and diastolic
Vital Sign: Blood Pressure points to remember
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Classification of Blood Pressure
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Blood pressure: What do you do if....
- Case 1:New patient with elevated BP: Repeat BP after 2 minutes,if values vary >5mmHg take additional readings - Case 2:Complains of dizziness: Assess for orthostatic hypotension - Case 3: Cannot hear the korsakoff sounds: Recheck placement of stethoscope/venous engorgement. Still cannot hear? Raise the arm before inflation then lower. Still cannot hear? Make a fist several times - Case 4:No arm cuff can fit an obese patient:Use a thigh cuff
Vital Signs: Pulse
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Vital Signs: Pulse The technique of measuring pulse
- Two-finger:index and middle finger - Do NOT use the thumb
Features of an arterial pulse
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more Features of an arterial pulse
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Features of an arterial pulse: Contour
- Speed of the up-stroke - Duration of the summit - Speed of the down-stroke
Pulse deficit
- the difference between the radial pulse and the apical pulse - indicates a decrease in peripheral perfusion from some heart conditions i.e.Atrial fibrillation
Vital Signs: Respiration
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Features of respiration
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Respiratory Patterns
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Vital Signs: Pulse Oximetry
Measures arterial hemoglobin oxygen saturation (SpO2)
Why is General appearance and vital signs important?
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