Ppt04

Chapter 4
Beginning the
Physical Examination:
General Survey, Vital Signs,
and Pain
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Components of General Survey
• General appearance
• Height and weight

General Appearance - Description
• Apparent state of health
– Acute or chronically ill, frail
• Level of consciousness
– Awake, alert, responsive or
lethargic, obtunded,
comatose
• Signs of distress
– Cardiac or respiratory; pain;
anxiety/depression
• Skin color and obvious lesions
• Dress, grooming, and
personal hygiene
– Appropriate to weather
and temperature
– Clean, properly
buttoned/zipped
• Facial expression
– Eye contact, appropriate
changes in facial expression
• Odors of body and breath
• Posture, gait, and motor activity

Height and Weight
• Height
– Measure in stocking feet
– Short or tall
– Build: slender and lanky, muscular, or stocky
– Body symmetry
– Note general body proportions and any deformities
• Weight
– Emaciated, slender, plump, obese
– If obese, is fat distributed evenly or concentrated over
trunk, upper torso, or around the hips?
• Calculating the body mass index (BMI)

Body Mass Index
• A calculation based on height
and weight
• Used to classify patients as:
Methods to Calculate Body Mass Index
(BMI)
Unit of
Measure
Method of Calculation
Weight in
pounds,
height in
inches
(1) Body Mass Index Chart
(see table on p. 91)
(2) Weight (lbs) x 700*
Height (inches)
Height (inches)
Weight in
kilograms,
height in
meters
squared
(3) Weight (kg)
Height (m2)
Either (4) “BMI Calculator” at website
www.nhlbisupport.com/bmibmical
c.htm
Classification of Overweight and
Obesity by BMI
Obesity
Class
BMI (kg/m2)
Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity I 30.0-34.9
II 35.0-39.9
Extreme
obesity III >40

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

Question
A patient presents with a 6-day history of rapid
weight gain. The most likely explanation is:
a. Dysphagia
b. Excessive absorption of nutrients
c. Diabetes mellitus
d. Accumulation of body fluids

Answer
d. Accumulation of body fluids
Rapid changes over a few days suggest changes
in fluid.

Vital Signs
• Blood pressure
• Heart rate and rhythm
• Respiratory rate and rhythm
• Temperature
• Pain

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 a little above the patient’s waist,
or support the patient’s arm with your own at his mid-chest
level

Blood Pressure – Cuff Size and Position
• Width: 40% of upper arm circumference
• Length: 80% of upper arm circumference

Measurement of Blood Pressure
• Center the inflatable cuff over the brachial artery with the
lower border 2.5 cm above the antecubital crease
• Secure the cuff snugly, not tightly, and position the patient’s
arm so that it is slightly flexed at the elbow
• With the fingers of your opposite hand, palpate the radial
artery and inflate the cuff until the radial pulse disappears; add
30 mm Hg to this pressure
• Deflate the cuff promptly and completely and wait 15-30
seconds
• Place the bell of the stethoscope lightly over the brachial artery
• Inflate the cuff to the sum pressure previously determined and
deflate slowly
– The point at which you hear the first two consecutive beats
is the systolic pressure
– The disappearance point is the diastolic pressure

Measurement of Blood Pressure (cont.)

Blood Pressure
• Auscultatory gap
– A silent interval that may be present between the
systolic and diastolic blood pressures; i.e., the sound
disappears for a while, then reappears
• Orthostatic blood pressure
– Measure blood pressure and heart rate with the
patient supine; wait 3 minutes, then have the patient
stand up; now repeat the measurements
o Normal: systolic BP drops slightly or remains
unchanged; diastolic BP rises slightly
o Orthostasis: systolic BP drops >20 mm Hg or
diastolic BP drops >10 mm Hg

Normal and Abnormal Blood Pressure
• Normal (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”
o Occurs in 10%–20% of all patients
o Try to relax the patient and retake BP later
in the visit

Heart Rate and Rhythm
• Radial pulse is commonly used to measure the heart
rate
– Use the pads of the index and middle fingers
– If the rate seems normal (50–90 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.

Respiratory Rate
• Observe rate, rhythm, depth, and effort of breathing
– Normal rate: ~20 breaths/minute
o Count for 60 seconds
– Observe rhythm: regular, irregular
– Observe depth: shallow, gasping
– Observe effort: normal, labored

Temperature
• Average oral
temperature:
37°C or 98.6°F
• Diurnal variation:
35.8°C (96.4°F) to
37.3°C (99.1°F)
Rectal 0.5°C (1°F) > oral
temperature
Axillary 0.5°C (1°F) < oral
temperature
Tympanic 0.8°C (1.4°F) >
oral temperature

Pain
• Assess location, severity, associated features, attempted
treatments/medications, related illnesses, impact on daily
activities
• Types of pain
– Nociceptive or somatic – related to tissue damage
– Neuropathic – resulting from direct trauma to the peripheral
or central nervous system
– Psychogenic – relates to factors that influence the patient’s
report of pain
o Psychiatric conditions
o Personality and coping style
o Cultural norms
o Social support systems
– Idiopathic – no identifiable etiology

Question
A patient presents a routine check-up. You see that the
patient’s vital signs have already been recorded as follows:
T 98.4 F, HR 74, R 18, BP 180/98
What would be the MOST appropriate action related to this
patient’s vital signs?
a. The blood pressure should be repeated at the next visit
b. Repeat the blood pressure and verify in contralateral arm
c. Check the heart rate again to see if it is regular
d. Listen to the patient’s lungs for adventitious sounds

Answer
b. Repeat the blood pressure measurement and verify
in the contralateral arm

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