Physical Diagnosis Midterm - H&p/vitals

Front 1

Step 1 of Interview, Histories and Write Ups

Back 1

Set the stage for the interview (30-60 sec)

Front 2

Step 2 of Interview, Histories and Write Ups

Back 2

Elicit chief concern & set agenda (1-2 min)

Front 3

Step 3 of Interview, Histories and Write Ups

Back 3

Begin the interview with non-focusing skills that help the patient to express him/herself (30-60 sec)

Front 4

Step 4 of Interview, Histories and Write Ups

Back 4

Use focusing skills to learn 3 things: Symptoms story, personal context, and emotional context (3-10 min)

Front 5

Step 5 of Interview, Histories and Write Ups

Back 5

Transition to middle of the interview (clinician-centered phase) (30-60 sec)

Front 6

Step 6 of Interview, Histories and Write Ups

Back 6

Obtain a chronological description of the HPI (History of present illness)

Front 7

Step 7 of Interview, Histories and Write Ups

Back 7

Past medical history

Front 8

Step 8 of Interview, Histories and Write Ups

Back 8

Social history

Front 9

Step 9 of Interview, Histories and Write Ups

Back 9

Family history

Front 10

Step 10 of Interview, Histories and Write Ups

Back 10

Review of systems

Front 11

Step 11 of Interview, Histories and Write Ups

Back 11

End of the Interview: diagnosis, prognosis, plan

Front 12

History of present illness (HPI)
Should include the seven attributes:

Back 12

1) Location
2) Quality
3) Quantity or severity
4) Timing/Onset
5) Setting
6) Factors aggravating or alleviating
7) Associated manifestations

Front 13

REVIEW OF SYSTEMS: General

Back 13

Wgt Δ; weakness; fatigue; fevers

Front 14

ROS: Skin

Back 14

Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails

Front 15

ROS: Head

Back 15

Headache; head injury; dizziness

Front 16

ROS: Eyes

Back 16

Vision Δ; corrective lenses; last eye exam; pain; redness; excessive tearing; double vision; blurred vision; scotoma

Front 17

ROS: Ears

Back 17

Hearing Δ; tinnitus; earaches; infections; discharge

Front 18

ROS: Nose/Sinuses

Back 18

Colds; congestion; discharge; itching; hay fever; nosebleeds

Front 19

ROS: Throat

Back 19

Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse

Front 20

ROS: Neck

Back 20

Lumps; swollen glands; goiter; pain; neck stiffness

Front 21

ROS: Breasts

Back 21

Lumps; pain; discomfort; nipple discharge

Front 22

ROS: Pulmonary

Back 22

Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains

Front 23

ROS: Cardiac

Back 23

Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema

Front 24

ROS: GI

Back 24

Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance

Front 25

ROS: Urinary

Back 25

Frequency; nocturia; urgency; dysuria; hematuria; incontinence

MALES:  caliber of urinary stream; hesitancy; dribbling

Front 26

ROS: G/U (General)

Back 26

Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure

Front 27

ROS: Male G/U

Back 27

Discharge from or sores on penis; testicular pain/masses

Front 28

ROS: Female G/U

Back 28

Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP

Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;

Front 29

ROS: Peripheral Vascular

Back 29

Claudication; leg cramps; varicose veins; hx of blood clots

Front 30

ROS: MSK

Back 30

Muscle or joint pain; joint stiffness

Front 31

ROS: Neuro

Back 31

Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements

Front 32

ROS: Heme

Back 32

Hx of anemia; easy bruising or bleeding; blood transfusions

Front 33

ROS: Endo

Back 33

Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria;  glove or shoe size

Front 34

ROS: Psych

Back 34

Nervousness/anxiety; depression; memory changes; suicide attempts

Front 35

What is the appropriate cuff width?

Back 35

About 40% of the upper arm circumference.

Front 36

Why is appropriate cuff size mandatory?

Back 36

If cuff is too big, BP will falsely read Low, and if too small will falsely read high.

Front 37

What is subclavian steal (Dx from BP on both arms)?

Back 37

- Narrowing of the proximal subclavian artery causing retrograde flow from vertebral or carotid arteries to supply the arm with blood

- Lung cancer, or lightheadedness.

Front 38

If a BP difference between arms is more than 10-15 mm Hg, what could that indicate?

Back 38

Subclavian Steal syndrome or aortic dissection.

Front 39

What is aortic dissection (Dx from BP on both arms)?

Back 39

- Tear in the inner arterial wall of the aorta causing blood to flow between layers of the artery and tearing them apart.

- This is associated with severe chest pain radiating to the back typically.

Front 40

Pre-hypertension

Back 40

120-139/80-89

Front 41

Hypertension

Back 41

Stage 1 - 140-159/90-99
Stage 2 - >160/>100

Front 42

Hypertension Urgency

Back 42

>180/ >100

* no signs of end organ damage

Front 43

Hypertension Emergency

Back 43

>210/ >110

***signs of end organ damage (EOD)

Front 44

What does unequal blood pressures in arms and legs indicate?

Back 44

Possible coarctation of the aorta or occlusive aortic disease

Front 45

Coarctation of the aorta

Back 45

- Narrowing of the thoracic aorta resulting in lower blood pressures in the legs compared to hypertension in the arms.

* normal in children

Front 46

Occlusive aortic disease

Back 46

- Has HTN in the arms and low in the legs due to narrowing of the aorta.

- In adult male may lack hair on legs.

Front 47

Orthostatic hypotension

Back 47

Fall of standing BP > 20 mm Hg or rise in heart rate >10-20

Front 48

Pulsus alternans

Back 48

- Abnormal pulse that alternates amplitude (intensity) from beat to beat despite the rhythm being regular.

- Indicates left ventricular failure and may be accompanied by S3 beat.

Front 49

Pulsus paradoxical

Back 49

- Decrease in amplitude on quiet respirations and usually increases with quiet inspiration.

- Found in cardiac tamponade, constrictive pericarditis, and COPD

Front 50

Cheyne-Stokes

Back 50

- Deep breathing alternating with periods of apnea

- Could signify heart failure, uremia, respiratory depression from drugs or brain damage

Front 51

Obstructive Breathing

Back 51

- Expiration phase is prolonged because of narrow airways that increases resistance.

Front 52

Kussmual

Back 52

- Deep and labored ax with acidosis, DKA and renal failure

- Form of hyperventilation

Front 53

Fever

Back 53

Temperature of >100.5

Front 54

Estimate verage weight for adult

Back 54

- Male: 106 lbs for 5’ + 6 lbs for every inch above

- Female: 105 lbs for 5’ + 5 lbs for every inch above

Front 55

Acromegaly- presentation

Back 55

- Elongated head, prominence of the boney forehead, and lower jaw.

- Soft tissue – large elongated ears, nose and lips

Front 56

Turner Syndrome (genetic defect in females)- presentation

Back 56

- Significant edema of the hands and feet at birth may be a sign.

- Short statue, broad chest, low hair line, webbing of the neck, low set ears, lymphedema, reproductive sterility, amenorrhea

Front 57

Down Syndrome: (trisomy 21) - presentation

Back 57

- Most common chromosomal abnormality

- Congnitive dysfunction, wide flat nasal bridge, small oral cavity my result in protruding tongue, short stature, low set ears

Front 58

Heart rate

Back 58

"Normal range is 50-90 beats per minute (bpm) Most commonly the radial artery is used, femoral, and carotid are also used."

Front 59

Tachycardia

Back 59

Elevated heart rate >90 bpm for adults, for infants rate typically exceeds 115 bpm

Front 60

Normal tachycardia

Back 60

Associated with pain, exercise, stress, and other

Front 61

Serious tachycardia

Back 61

Shock, pulmonary embolism, CHF, hemorrhage, and many more

Front 62

Rhythm

Back 62

"The regularity of the occurrence of beats. Irregular rhythms are associated with benign and serious medical illnesses."Steps to evaluate rhythm 1. Initially evaluate if the rhythm is regular or irregular 2. Next does the irregularity vary with respirations 3. Is the rhythm regularly irregular or irregularly irregular. (predictable irregularity or “all over the place”) 4. Attempt to recognize type of irregular rhythm and potential concerns."

Front 63

Amplitude of pulse

Back 63

"Absent pulse - not palpable = 0
Weak/thready - hard to feel, obliterated w/ slight pressure = +1
Normal pulse - easily palpable, obliterated w/ strong pressure = +2
Bounding pulse - readily palpable, not easily obliterated = +3

Front 64

Respiration rate

Back 64

Normal range is 14-22 breaths per minute for adults and up to 44 per minute for infants

Front 65

Apnea

Back 65

Pauses or stops in breathing.

Front 66

Bradypnea

Back 66

Slow respirations, often seen with pain meds

Front 67

Tachypnea

Back 67

Fast respirations, seen with stress, anxiety, pain, etc.

Front 68

Respiratory effort

Back 68

Effort of breathing at times is more significant then rate or rhythm.

Front 69

Labored

Back 69

Struggles to breath

Front 70

Accessory muscle use

Back 70

Using forced shoulder and rib expansion to aid in breathing

Front 71

Tripoding

Back 71

A position of the patient with labored breathing (common in children and COPD). The patient leans forward and places hands on the thighs or knees and may lift the head in efforts to aid breathing

Front 72

Respiratory distress

Back 72

A constitution of symptoms that result in poor oxygenation, increased or decreased respiratory rate, increased or decrease effort (pending cause), systemic symptoms secondary to poor oxygenation

Front 73

Hypoxia

Back 73

A general lack of adequate oxygen to the whole body, and may cause low pulse oximetery

Front 74

Cyanosis

Back 74

The result of increased deoxyhemoglobin due to decreased oxygenation of tissues causing bluish or purple skin or mucus membranes. This can appear at any site, however if the cause is central (with in the lungs) this is typically evident in the lips face, thorax, or tongue. If peripheral this is most common on the fingers and toes, as seen in peripheral artery disease, Raynauds, and other

Front 75

Hypoventilation

Back 75

Occurs when the respiratory system is inadequately ventilating for the demand needed. This causes a build up of systemic carbon dioxide (CO2) which is termed hypercapnic respiratory failure resulting in lower pH and respiratory acidosis. Typically seen in brain injury, drugs, and other

Front 76

Hyperventilation

Back 76

Occurs with rapid excessive breathing causing a decrease in systemic CO2 and raises the bodies pH resulting in respiratory alkalosis. Typically seen in anxiety, exercise, compensation for metabolic acidosis, and many other

Front 77

Temperature

Back 77

"Normal range: “37C or 98.6F”
- Temperature actually is a range usually 96.4F -99.1F (35.8C or 37.3C)
- Rectal temperatures are higher than oral by an average 0.7-0.9F
- Axillary temps are lower than oral, by 1 degree"

Front 78

Taking oral temp

Back 78

Must be taken with patients lips closed and preferably under the tongue. Usually takes 1-3 minutes. Use a disposable cover!!

Front 79

Taking rectal temp

Back 79

Needs lubrication, a disposable cover and typically takes 10 seconds to 3 minutes pending type used

Front 80

Tympanic membrane temp

Back 80

Quick and easy. They measure core temperature which is higher than oral, however highly variable with technique

Front 81

Hypothermia

Back 81

Temp <95F (35C)

Front 82

Hyperpyrexia

Back 82

Temp >106F (41.1C)

Front 83

Signs of distress

Back 83

Pain, anxiety, chest pain, tachycardia, tachypnea, pallor, diaphoretic, altered mental status (AMS), skin color, etc…

Front 84

Signs of shock

Back 84

A disruption of homeostasis resulting in reduction of blood flow to tissues, depriving them of Oxygen and nutrients. (Ischemia) Typically resulting in tachycardia, tachypnea, hypotension, agitation, decreased urine output, and cool clamy skin.

Front 85

Weight

Back 85

"Average male: 106lbs for 5' + 6lbs for every inch above
Average female: 105lbs for 5' + 5lbs for every inch above"

Front 86

Calculate BMI

Back 86

"[Weight (lbs) x 700*/Height (in)]/Height (inches)

Front 87

BMI ranges

Back 87

"Normal: 18.5 – 24.9%
Overweight: 25.0 – 29.9%
Obesity: 30.0 – 39.9%
Morbid Obesity: > 40%"

Front 88

Weight loss goals for pts

Back 88

"A goal of ½ to 1 lb per week is optimal, more rapid does not lead to better results at 1 year
- Low calorie diet of 800 -1500 kcal/day
- Exercise of 30 minutes per day of moderate exercise most days of the week. (ie: walking 2 miles in 30 min)"

Front 89

The most common reason for rapid weight gain in a short time interval is?

Back 89

Fluid retention.

Front 90

Cardiac complications of obesity

Back 90

HTN, CHF, CAD, PE, OSA (obstructive sleep apnea)

Front 91

Endocrine complications of obesity

Back 91

Diabetes, hyperlipidemia, PCOS, infertility

Front 92

GI complications of obesity

Back 92

GERD, NASH, cholelithiasis, colon cancer

Front 93

GU complications of obesity

Back 93

Stress incontinence, hypogonadism, pregnancy related

Front 94

MSK complications of obesity

Back 94

Arthritis, LBP, gout

Front 95

Neuro complications of obesity

Back 95

CVA, meralgia paesthetica, parasethesias

Front 96

Respiratory complications of obesity

Back 96

OBS, obesity hypoventilation syndrome, pickwickian syndrome, asthma

Front 97

Marfan syndrome

Back 97

"A genetic disorder causing connective tissue abnormalities.
- Unusually tall, with long limbs, and long thin fingers, weak wrists.
- Abnormalities in the heart valves and aorta are the most serious complication.

Front 98

Hirsutism

Back 98

"A clinical sign of abnormal androgenic (male) pattern of hair growth in women. Caused by increase androgenic hormones. Typically in locations women don’t grow terminal body hair.
Typically seen in obesity, PCOS, Cushing syndrome and other."

Front 99

Cushing disease

Back 99

An increased adrenal cortisol production, “moon faces”, red cheeks, hirsutism, buffalo hump, obesity, striae, menstrual abnormalities, hypertension, elevated glucose.

Front 100

Anorexia nervosa

Back 100

"An eating disorder resulting from an irrational fear of gaining weight. Associated with body dysmorphic disorder, depression, anxiety, abuse, etc…
Dry skin, dental caries, anemia, osteoporosis, hypotension, amenorrhea, BMI <17.5, muscle wasting"

Front 101

Precocious puberty

Back 101

"Excessive sex hormones resulting in puberty in an unusually early age (prior to age 7). Typically caused by tumors, trauma, and some infections.
Typical puberty signs: genital hair, breast formation, penis and testes enlargement, and other"

Front 102

Hypopituitary dwarfism

Back 102

"Dwarfism due to a lack of adequate growth hormone. Children early may grow normally then slow as they age. Caused by genetic, tumor, or damage to the pituitary.
Growth of the body not proportional to the legs and arms"

Front 103

Metabolic syndrome

Back 103

A constellation of lipid and non-lipid risk factors of metabolic origin. Typically associated with obesity, insulin resistance, and physically inactive.

Front 104

Criteria for metabolic syndrome

Back 104

"Abdominal obesity; waist circumference in men >102cm and women >88cm.
Triglycerides; >150
HDL; men <40, women <50
BP; >130/>85
Fasting glucose; >110"