H&P Exam #3

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

1 drink is defined as

12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits

normal respiration rate adults children? how to take respiration rate

14-20 breaths per minute up to 44 in children count for 60 seconds subtly

percentage of children overweight? obese?

15% overweight 17% obese

BP cuff should sit

2.5 cm above anticubital crease

Results of EHR study among practitioners:

4% had an extensive, fully functional EHR and 13% reported having a basic system primary care physicians and practitioners in large groups, hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records financial barriers were seen as having the greatest effect on resistance to adopting EHR systems

normal pulse: how to take?

60-90 bpm in adults (some say 50-100) count for 30 seconds then multiply by 2; if abnormal count for 60

hypoxia

<92% SpO2

tachycardia bradycardia

>100 bpm <60 bpm unless conditioned athlete

An example of what we think we are An example of what we feel

"I feel inadequate as a guitar player" "I feel disappointed/impatient/frustrated with myself as a guitar player"

examples of how we think others react or behave toward us:

"I feel unimportant to the people I work with" "I feel misunderstood" "I feel ignored" none of those reflect individual feelings. You may feel sad that friends are ignoring you, but feeling ignored is how you think others are reacting to you

meaningful use: Stage 1

DATA CAPTURE AND SHARING electronically capture info track clinical conditions (getting an idea of how many patients have xyz condition) communicate information for care coordination begin reporting of Clinical Quality Measures (pick something you feel you could improve, like decreasing BPs) use information to engage Pts and families (portal, clinical summary handouts, etc.

oral temps must:

begin with temp below 35ºC under tongue with closed lips wait 10-15 mins after drinking or smoking

factors affecting pulse:

body habitus (obesity, edema) circulation disorders (shock, peripheral vascular disease) hydration status

factors affecting SpO2

body temperature circulation nail abnormalities (polish, bruising, onychomycosis- fungal infection causing thick, brittle nails)

sporadic (sinus arrhythmia) rhythm

heart varies cyclically, usually speeding up with inspiration and slowing down with expiration

cardiovascular exam:

heart: listen and feel for point of maximal impulse, rate, rhythm, and any murmurs, rubs, or gallops jugular veins carotid bruits

home BP HTN reading: ambulatory BP normal readings:

home: HTN if > 135/85 average ambulatory HTN if - 24hr average > 130/80 - daytime average > 135/85 - nighttime average > 120/70

Our feelings result from

how we choose to receive what others say and do, as well as from our particular needs and expectations in that moment

clinical decision making steps:

identify the abnormal localize anatomically interpret findings in terms of probable cause- problem with structure, physiology, or in the mind? develop hypotheses about the cause test hypotheses establish working diagnosis

checking orthostatic hypotension

lay supine for 3-10 minutes check BP and heart rate with Pt supine stand Pt up within 3 minutes check BP and heart rate again Note if patient is symptomatic or not be prepared to brace Pt if becomes lightheaded of has a syncopal episode (fainting)

challenges to EHR

limited computer literacy significant cost and time (expensive to implement and support; time consuming implementation) electricity and connection dependent (if system crashes, so do you) exchange of information (lack of system to system connection) reduced independent thinking and practice (rely on calculation tools and boxes to click) "blind" documentation (overuse of templates) robotic (all notes identical/no provider voice) documentation focused rather than Pt focused (make computer "fit" the Pt)

most frequent causes of pain:

low back pain headache/migraine knee and neck pain

temperature normal: normal range: rectal: tympanic: axillary:

normal: 37ºC (98.6ºF) normal range: 35.8-37.3ºC (96.4-99.1ºF) rectal: higher than oral by 0.4-0.5ºC (0.7-0.9ºF) [used if unconscious or cannot close mouth] tympanic: higher than oral by 0.8ºC (1.4º) axillary: typically lower by 1º [take 5-10 minutes and are less accurate]

benefits of a comprehensive history

provide fundamental and personalized knowledge about the patient strengthens the patient-provider relationship (person to person) helps identify or rule out physical causes related to patient concerns provides baselines for future assessments creates a platform for health promotion through education and counseling develops proficiency in the essential skills of physical examination (if you never do the skills, you'll forget how!)

best place for pulse

radial artery or apex (bottom) of heart

Tachypnea: hyperpnea: bradypnea:

rapid, shallow breathing >20 breaths per minute rapid, deep breathing aka hyperventilation slow breathing <12 breaths per minute

what is considered pertinent info?

red flags portions aligning with CC chronic conditions pertinent negatives relating to CC (have to prove what it isn't before proving what it is)

subjective data

relating to the way a person experiences things in his or her own mind; based on feelings or opinions rather than facts what the patient tells you; not untrue just not supported by facts the symptoms and the history from the CC to the ROS Ex: "Mrs. G is a 54 yo hairdresser who reports pressure on her L-side chest "like an elephant sitting there" which goes into her L neck and arm" pain score is always subjective

the fourth component of nonviolent communications involves

requesting that which would enrich life this process addresses what we would like to request of others in order to enrich life for us

nociceptive or somatic pain:

result of tissue damage

psychogenic pain:

resulting from factors influencing the Pts' report of pain

Which HIPAA rule focuses on electronic health information protection

security rule

fatigue: weakness: fever:

sense of weariness or loss of energy demonstratable loss of muscle power abnormal elevation in body temperature

SPIKES Protocol

set up the interview assess the Pt's perception obtain the Pt's invitation give information and knowledge to Pt address Pt's emotions with empathy strategy and summary

SPIKES- first S

set up the interview: arrange for privacy involve significant others sit down connect w/ patient (eye contact/rapport) manage time constraints/interruptions

ausculatory gap

silent interval between systolic and diastolic pressure due to arterial stiffness and atherosclerosis can cause errors, like a much lower recorded BP

effect on BP: aortic regurgitation subclavian steal syndrome aortic dissection occlusive disease

sounds may not ever disappear uneven between arms uneven between arms (10-15 mmHg) weak or inaudible sounds (Raise arm before inflating cuff; inflate cuff and have Pt make a fist several times)

demonstration of meaningful use:

stage 1: Data Capture and Sharing (2011-2012) stage 2: Advance Clinical Processes (2014) stage 3: Improved Outcomes (2016)

Emotional Slavery to Emotional Liberation stages

stage 1: emotional slavery- we see ourselves responsible for others' feelings stage 2: the obnoxious stage- we feel angry and no longer want to be responsible for others' feelings stage 3: emotional liberation- we take responsibility for our intentions and actions

How to correct common speech patters that tend to mask accountability for our own feelings

substitute in "I feel.... because I...." "I feel really irritated when spelling mistakes are in our brochures because I want our company to have a professional image" "I feel angry that Bob broke his promise because I was counting on getting that long weekend to visit my brother" "I am disappointed when you don't finish your food because I want you to grow up strong"

how do you document ROS?

system by system positives first negatives second do not repeat: if already in HPI say "see HPI"

We request that which would enrich life through

using positive action language making requests consciously asking for a reflection requesting honestly make requests rather than demands

sporadic or regularly irregular rhythm

(ventricular premature contractions) a beat of ventricular origin comes earlier than the next expected normal beat. A pause follows and the rhythm resumes

medicare incentives for meaningful use? year? Who does it include?

$44,000 over 5 consecutive years per provider must begin by 2014 MD, DO, Doctors of Dental Surgery or Dental Medicine, doctors of podiatry, doctors of optometry, and chiropractors

medicaid incentives for meaningful use? year? who does it include?

$63,750 over 6 years per provider must begin by 2016 Physicians, NPs, Certified Nurse Midwives, Dentists, PA's in PA-Led Federally qualified health centers or rural health clinics

BMI calculation

((weight lbs. x 700) / height in.) / height in. weight kg / height m^2

irregularly irregular rhythm

(atrial fibrillation) the ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may sound regular

four options for receiving negative messages

1. blame ourselves 2. blame others 3. sense our own feelings and needs 4. sense others' feelings and needs

Four steps to promote optimal weight and nutrition

1. measure BMI and waist circumference 2. assess dietary intake 3. assess the Pts motivation to change 4. provide counseling about nutrition and exercise

Nonviolent communication:

A process language that discourages static generalizations, instead making observations specific to time and context ex: "Hank is a poor soccer player" vs. "Hank has not scored a goal in twenty games"

meaningful use: Stage 2

ADVANCED CLINICAL PROCESSES increased information exchange increased E-prescribing and electronic lab result incorporation electronic patient care summaries increased patient-controlled data

when do you calculate waist circumference

BMI > 35

sighing respiration

Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome—a common cause of dyspnea and dizziness. Occasional sighs are normal

central sensitization pain:

CNS processing altered resulting in amplified pain signals

rhythm: depth: effort:

FOR PULSE regular or irregular shallow, normal, or gasping normal or labored

meaningful use was a part of: what did this do?

HITECH (health information technology for economic clinical health act) reimbursed providers (through medicare and medicaid) for demonstration of meaningful use essentially, the swap to EHRs was incentivized through better reimbursements

meaningful use: Stage 3

IMPROVED OUTCOMES improve quality, efficiency, and safety decision support for national high priority conditions improve population health comprehensive patient data through Information Exchange increased Pt self-management tools

a focused health history requires

knowledge of a comprehensive health history to know how to select the pertinent elements for a focused history

Cardinal Techniques of Examination

Inspection: close inspection of the details of the Pt (appearance, behavior, mood, facial expression, etc)- generally visual Palpation: use of pressure with fingerpads to assess how things feel Percussion: use of tapping to evoke sound waves Auscultation: use of stethoscope to evaluate sounds throughout the body (location, timing, duration, pitch, and intensity)

the first component of Nonviolent Communication entails:

Observing without evaluating separate observation from evaluation clearly observe what you are seeing and hearing without mixing in any evaluation (i.e. you're non-compliant)

BP normal ranges 2017 AHA/ACC update

Normal: Less than 120/80 Elevated: Systolic between 120-129 and diastolic less than 80 Stage 1 HTN: Systolic between 130-139 or diastolic between 80-89 Stage 2 HTN: Systolic at least 140 or diastolic at least 90 Hypertensive crisis: Systolic over 180 and/or diastolic over 120 always read to the higher number if systolic and diastolic do not align

SpO2 of 90% =

PaO2 of 60 mmHg

SPIKES- Second S

Strategy and Summary: ask if the Pt is ready for planning share responsibility with Pt check Pt understanding set clear expectations

night sweats are common with

TB and malignancy (cancer)

meaningful use

the use of EHRs by providers to achieve significant improvements in care

orthostatic blood pressure

a drop in systolic pressure > 20mmHg or a drop in diastolic pressure > 10 mmHg when changing from supine to standing position especially when accompanied by tachycardia and lightheadedness

common speech patters that tend to mask accountability for our own feelings

Use of impersonal pronouns such as "it" and "that" ("it really irritates me when spelling mistakes are in our brochures" or "that bugs me a lot") Use of the expression "I feel (an emotion) because..." followed by another person or personal pronoun other than "I" ("I feel hurt because you said you didn't love me" or "I feel angry because Bob broke his promise") Statements that mention only the acts of others ("when you don't call me on my birthday I feel hurt" or "I am disappointed when you don't finish")

what is a comprehensive health history

a holistic assessment of all factors affecting a Pt's health status, including information about social, cultural, familial, and economic aspects of the Pt's life style that affects health style and well-being

weakness can indicate:

a neurologic problem

atrial or nodal premature contractions rhythm

a beat of atrial or nodal origin comes earlier than the next expected normal beat. A pause follows and the rhythm resumes

What is ROS? why do we collect it?

a comprehensive review of symptoms had within the past year; a series of yes or no questions relating to specific symptoms the patient has experienced may uncover overlooked problems and may provide detail for the HPI

focus health history (aka _______):

a directed health history a health assessment that focuses on the body areas or systems as indicated by the Pt's CC

hypothermia

abnormally low temperature <35.5ºC (95ºF) taken rectally

security risks for EHRs

access from anywhere (would be a violation, but it is possible) internet hacking (info is stored in the cloud/server and may be through another country with different rules and regulations) varied laws around the world- be careful!

The third component of nonviolent communication-

acknowledgement of the root of our feelings

When do you use a focused history?

acute visits (urgent care and emergency room settings) specialized settings* (will do a comprehensive history for their own specialty)

SPIKES- E

address Pt's emotions with empathy: NURS response observe and identify the emotion understand/acknowledge the emotion support the patient

Preparing for the physical exam:

adjust the environment (lighting, temperature, bed height) check equipment (make sure you have everything, everything works) preparation (reflect on yourself, take a deep breath, remain calm and confident, acknowledge your status as a student)

security for EHRs

administrative: security guards, training/retraining, routine security analysis physical safeguards: building alarms, office locks, screen shields technical safeguards: secure user IDs and passwords, role-based access rights (receptionist doesn't have same access as PA), routine audits of access, anti-hacking/anti-malware software, data backup plans, encryption organizational standards: regular reviews of business associate agreements (for others who have access to EHR like insurance), updates as necessary policies and procedures: written policies and procedures, staff training, regularly scheduled reviews, routine updates, clear documentation

old BP guidelines JNC VIII

adult > 60 with no diabetes or heart disease = <150/90 adult < 60 with no diabetes or heart disease = <140/90 all ages with diabetes but no heart disease = <140/90 all ages with heart disease and with or without diabetes = <140/90

Pertinent historical information (always included)

alcohol, tobacco, drugs (documented in HPI only if relevant pregnancy status for all women with childbearing potential injuries; with upper extremity always include dominant side injuries; include mechanism of injury and be specific

judgments, criticisms, diagnoses, and interpretations of others are all

alienated expressions of our needs when we express our needs indirectly through use of evaluations, interpretations, and images, others are likely to hear criticism and are likely to invest their energy in self-defense or counter attack

marphan syndrome

all limbs, no torso. Armspan is greater than height disproportionate stature

what is the BP gold standard? but?

ambulatory BP limited in practice due to insurance coverage

"if you don't eat balanced meals your health will be impaired" is an example of

an evaluation instead: "if you don't eat balanced meals I fear your health will be impaired"

pain:

an unpleasant sensory and emotional experience associated with tissue damage often recorded using a visual analogue scale- always subjective

challenges to breaking bad news

anxiety about giving bad news feeling responsible for the bad news fear of negative feedback from the Pt fear of the Pt's emotions destroying hope

causes of tachycardia causes of bradycardia

anxiety, electrolyte abnormalities, conduction disorders, medications (pseudoephedrine) extreme conditioning in athletes, conduction disorders, heart failure, medications (beta blockers)

general appearance of general assessment includes

apparent state of health (fit, robust, wasting, chronically ill, frail, etc. level of consciousness (awake, alert, lethargic, somnolent, disoriented) signs of distress (tripoding, Levine's sign- clutching chest, wheezing, etc.) general skin color/obvious lesions (jaundice, cyanosis, pallor, redness, rashes, etc.) dress, grooming, and hygiene (excessive clothing, unkempt appearance, worn clothing/shoes) facial expression (flat, sad, lack of expression-parkinson's, prominent eyes, etc.) body/breath odor (fruity-acetone, alcohol, drugs, infection, diet) posture, gait, and motor activity (assistive devices, tremors, leaning, paralysis, etc.)

SPIKES- P

assess the Pt's perception: determine what the Pt knows correct misinformation identify denial tendencies (wishful thinking, omission of important details, unrealistic treatment expectations)

Human needs:

autonomy integrity celebration interdependence play spiritual communion physical nurturance

True blood pressure

average BP measured over days and weeks

General assessment components

general appearance weight height BMI

objective data

based on facts rather than feelings or opinions; existing outside of the mind and in the real world what you detect during the examination all physical exam findings, or signs ex: "Mrs. G is an older, overweight white female who is pleasant and cooperative. Height 5'4", weight 150lbs, BMI 26, BP 160/80, HR 90 and regular, respiratory rate 24, temperature 97.5ºF"

guidelines for broaching sensitive topics:

be non-judgemental explain why you need to know certain information find opening questions for sensitive topics and learn specific kinds of information needed for your shared assessment and plan consciously acknowledge any sort of discomfort you are feeling. Denial may lead to avoiding the topic

amplitude of pulse

bounding, weak, thready, etc.

ataxic breathing/Biot breathing

breathing is irregular- periods of apnea alternate with regular deep breaths which stop suddenly for short intervals (meningitis, respiratory depression, brain injury at medullary level)

steps of the physical exam:

general survey vital signs skin head, eyes, ears, nose, throat (HEENT) neck back thorax and lungs cardiovascular system abdomen breast lymph musculoskeletal peripheral vascular lower extremities nervous system additional (rectal or genital exams)

intentional weight loss: unintentional weight loss:

can be normal and healthy if overweight; anorexia chronic illness or malignancy, metabolic disorders, drug use, financial strain, disability

neck portion of physical exam:

cervical lymph nodes trachea thyroid carotid arteries* jugular veins* skin* *probably documented with cardiovascular

Considerations when someone dies:

clean the body as much as possible focus on the family tell them in person prepare the family for what they'll see answer questions don't rush the family provide support (use resources)

when the temperature is high, Pt feels: when the fever breaks, Pt feels:

cold- has chills hot- has sweats

pulsus alternans

completely regular pulse but has alternating strong and weak beats indicates left ventricular failure

what is often done with HEENT exam

cranial nerve exam

CAGE questions

cutting down annoyance when criticized guilty feelings eye openers

in general assessment and vitals try to avoid:

generalized statements such as: well developed well-nourished in no acute distress instead describe exactly what you see in the patient

neuropathic pain:

damage to peripheral or central nerves

components of a comprehensive history

date and time of encounter identifying info source of information and reliability CC HPI medications and allergies past medical history family history social history sexual history ROS physical examination lab/diagnostic study results assessment plan

kassumaul respirations

deep breathing in metabolic acidosis rate can vary due to trying to breathe off CO2

paradoxial pulse

detected by a palpable decrease in the pulse amplitude on quiet inspiration systolic pressure decreases on inspiration

SPIKES- K

give the Pt knowledge and information: warn of the bad news provide bad news using language the Pt understands Be direct NOT blunt give small amounts of information at a time Stay as positive as possible

the second component of nonviolent communication involves

distinguishing feelings from thought and distinguishing what we feel and what we think we are

common causes of orthostatic hypotension

drugs blood/fluid loss prolonged bed rest autonomic nervous system disease old age

benefits of a focused history

efficient for urgent or acute concerns maintains focus on the specific area of concern limits the examination to only that relevant to assessing the concern in as precise and careful way as possible

EHR= EMR= EPR= CPR=

electronic health records electronic medical records electronic patient record computer-based patient record

"you seldom do what I want" is an "he comes over three times a week" is an "the last three times I've initiated an activity you've said you don't want to do it" is an "he frequently comes over" is an

evaluation observation observation evaluation

obstructive breathing

expiration is prolonged due to narrowed airways increasing resistance to air flow (asthma, chronic bronchitis, COPD)

causes of hypothermia

exposure, paralysis (lack of movement), interference with vasoconstriction due to old age, shock, anaphylaxis

hyperpyrexia

extreme fever >41.1ºC (106ºF)

EHR utilization:

familiarize yourself with the system know your setup to know where to click/add things have IT's number on standby have a paper chart backup think first- don't let the computer think for you, focus on the Pt not the computer, inform the Pt and tell them what you are doing, proofread, proofread, proofread to match Pt for the current visit

common or concerning symptoms

fatigue and weakness fever, chills, night sweats weight change pain

pyrexia:

fever > 38ºC (100ºF)

with any kind of visit you must ask:

fever, chills, sweats, etc.

the elderly population are less likely to have

fever- more susceptible to hypothermia ex: old person with flu symptoms comes in without fever. Still suspect flu bc they wouldn't show fever

when do you use a comprehensive health history?

first time at a family practice/primary care office annual well-check, routine wellness and health maintenance visit new patients establishing care evaluation of conditions with numerous possible causes

Benefits of EHR

immediate access to health information (rapid result sharing) comparison of current and past results (access to results in one click) efficient order and prescription management clinical decision making support (provide alerts, reminders, prompts, etc./prevents medical errors) enhanced communication with Pts and providers (improved legibility and consistency) patient support materials (handouts, comparison charts/images, patient portal access) improved administrative and reporting processes (online scheduling, automatic billing and coding, enhanced auditing to keep honest)

quoting is used:

in the CC and rarely in the HPI used to describe something unique

Bisferiens pulse

increased atrial pulse with a double systolic peak

causes of fever

infection, trauma, malignancy, blood disorders, drug reactions, and immune disorders

interacting with the Pt during physical exam as a student

inform along the way avoid interpreting findings maintain a poker face take your time provide instruction to Pt

clues to physical and sexual abuse

injuries that are unexplained, seem inconsistent with Pt story, are concealed by Pt, or cause embarrassment delay in getting treatment for trauma Hx of repeated injury or "accidents" alcohol or drug abuse in Pt or partner partner tries to dominate the visit, will not leave room, seems unusually anxious pregnancy at a young age, multiple partners repeated vaginal infections and STIs fear of pelvic exam or physical contact fear of leaving examination room

breast physical exam

inspect in relaxed position, with arms elevated, and with hands on hips palpate for any masses or tenderness includes axillary node exam

abdominal exam order:

inspect, auscultate, percuss, palpate lightly and then deeply observing for any pain, masses, or organomegaly

what is the leading cause of serious injury and the second leading cause of death among US women of reproductive age?

intimate partner violence

questions to ask yourself for a better write-up

is the order clear? does the included data contribute directly to the assessment? are pertinent negatives specifically described? are there overgeneralizations or omissions? is there too much detail? are phrases and short words asked appropriately? is the writing style succinct? are you being redundant? are diagrams and measurements used appropriately?

waist circumference is measured

just above iliac crest men <40 women <35 greater than this indicates risk for diabetes, HTN, and cardiovascular disease

MACRA stands for

medicaid access and CHIP reauthorization act of 2015

standards for drinking indicative of a low risk for developing an Alcohol Use Disorder

men: no more than 4 drinks on a single day or 14 drinks a week women: no more than 3 drinks on a single day or 14 drinks a week healthy adults over 65 not taking medication: no more than 3 drinks a day or 7 drinks a week

what replaced meaningful use? when?

merit-based incentive payment system (MIPS) 2017

2 payment tracks for MACRA

merit-based incentive payment system (MIPS) Advanced Alternative Payments Model (APM)

MIPS parts?

merit-based incentive program system: quality advancing care improvement activities cost

bigeminal pulse

mimics pulsus alternans caused by a normal beat alternating with a premature contraction

home and ambulatory BP measurements

more accurate than periodic office readings more predicative of BP-related damage/disease eliminates clinician error and "white coat" syndrome

Specifically naming emotions allows us to:

more easily connect with one another and be vulnerable by expressing our feelings, which can resolve conflicts

what is often done with musculoskeletal exam?

motor, sensory, and reflexes exams

What is important about the abdominal exam?

must do it IN ORDER as to not push contents around first and then hear abnormal sounds

how many US adults are overweight or obese?

nearly 69% including 71% of men and 66% of women 35% of US adults are obese

blood pressure optimal conditions

no caffeine or nicotine 30 minutes prior quiet room with comfortable temperature sitting with feet flat on floor for five minutes no clothing around arm no lymphedema, fistulas, or ports viable brachial pulse

pulse oxygen saturation (SpO2)

normal is 95-100% in a healthy individual (usually at or above 97%) <92% is considered low in healthy patient

fatigue may be due to

normal reaction (no sleep, under stress, have kids, etc) acute illness (strep, GI illness, mono, flu, cold, etc.) chronic illness (diabetes, anemia, hypothyroidism, cancer, etc) psychiatric illness (depression, anxiety, BPD, etc.)

what is the difference between comprehensive and targeted history?

only document pertinent portions of PMH, FH, social history, sexual history, ROS, and physical examination

important topics for health promotion and counseling

optimal weight, nutrition, and diet blood pressure and dietary sodium exercise

What happens when we combine evaluation with observation:

others are apt to hear criticism and resist what we are saying

WHO definition of the goal of providers for those facing/dealing with death

our goal is "the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual"

evaluations are based on:

observations specific to time and context

SPIKES- I

obtain the Pt's invitation: discuss before you order the Pt's tests ask how much info the Pt wants and how they want to hear the information answer questions to Pt's satisfaction involve family if desired by the Pt

white coat syndrome masked HTN nocturnal hypertension dysrhythmias coarctation of aorta

office readings are high (>140/90) when ambulatory/home readings are normal (<135/85) home readings are high (>135/85) when office readings are normal (<140/90) nocturnal fall of <10% of daytime values variations in readings; averaging is important in these patients unequal readings between arms and legs

peripheral vascular physical exam

often while evaluating lower extremities femoral, popliteal, posterior tibial, and dorsalis pedis pulses inguinal nodes radial pulses capillary refill

measuring BP

palpate radial pulse and inflate cuff till you can no longer hear it and note pressure deflate cuff and wait 15-30 seconds place bell of stethoscope over brachial artery inflate cuff 30 mmHg above noted pressure deflate cuff 2-3 mmHg per second first two consecutive beats is systolic disappearance point is diastolic check twice, at least 2 minutes apart check in both arms at least once, repeat on the higher arm (total of three times)

cheyne-strokes breathing

periods of deep breathing alternate with periods of apnea (no breathing) normal in children and older adults during sleep (heart failure, uremia, drug-induced respiratory depression, brain injury- usually bihemispheric)

factors affecting BP measurements

poor technique: inability to hear cuff too small: high reading cuff too big: low reading on small arm and high on large arm loose cuff: high reading brachial artery above heart: low reading brachial artery below heart: high reading unrecognized ausculatatory gap repetitive or slow inflation of cuff (venous congestion resulting in low systolic or high diastolic reading)

When someone dies: telling the family

prepare a private location find out what they know determine how the info should be handled deliver the news- be empathetic but direct respond to emotions establish goals and priorities develop a plan

vital signs

temp, pulse, respirations, BP, pain

Nonviolent communication distinguishes:

the expression of actual feelings from words and statements that describe thoughts, assessments, and interpretations

what is a major factor in influencing the relevancy of information?

the practice setting

considerations for a focused H&P

there is no one right way (each condition, patient, and location has a different focus) the format is consistent experience helps you out (if you stay current) there is no such thing as perfect

common misconceptions about focused histories

they're always short they aren't very detailed they are easier than a comprehensive history they're the same from clinician to clinician they're the same for each disease/injury process they're the same for each patient

the back is often done with which exam?

thorax and lungs

how did meaningful use allow for improvements in care?

through improving safety, quality, and efficiency through engaging Pts and families (providing easier contact with Pts through portals) through improving coordination and continuity of care through increasing security of health information

what is more variable than oral or rectal temps

tympanic

underweight healthy weight: overweight: obese 1: obese 2: extreme obesity/obese III/morbid obesity: clinically significant weight loss:

underweight: BMI < 18.5 healthy: BMI = 18.5 and 24.9 overweight: BMI = 25.0-29.9 obese 1: BMI =30-34.9 obese 2: BMI = 35.0-39.9 BMI >40 loss of 5% or more of usual body weight over a six month period

correct BP cuff: standard cuff:

width = 40% of the upper arm circumference length = 80% of upper arm circumference 12x23 cm is standard

when do you measure SpO2

with any respiratory complaints or diagnoses

How did EHR begin

with billing and reimbursement "how can we better bill and get reimbursed?"

idiopathic pain:

without identified reason

what words are often used as exaggerations which cause observations and evaluations to mix?

whenever, always, never, ever, etc.

preferred method for recording general assessment and vitals:

vitals first with a paragraph of general assessment after

universal precautions of physical exam

wash before and after wear appropriate PPE (gloves, gown, aprons, masks, protective eyewear)


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