H&P Exam #3
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)
