H and P

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Author:
ed70
ID:
37664
Filename:
H and P
Updated:
2010-09-27 12:03:07
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General survey vitals skin
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General survey, vitals, skin
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  1. Greet and develop rapport with a patient.
    • Meeting the patient
    • Examination
  2. Meeting the patient
    • Knock before entering
    • respect
    • Introductions
    • Identify yourself (name and title)
    • Shake hands?
    • Always start formally
    • “Who did you bring with you today?”
    • “Bedside manner”
    • Appear calm, organized, confident
    • Take your time
    • Be there
    • Listen-your patient will give you the answers
    • Eye contact
    • Know when to be quiet
  3. Examination Tidbits
    • Physical exam is traditionally done from patient’s right side
    • Make sure your patient is comfortable
    • Room temperature
    • Draping
    • Equipment
    • Tell them what you are doing
    • Clear instructions
    • Be gentle but don’t be afraid to cause discomfort
    • Organize your physical exam
  4. Demonstrate a general survey of the patient noting general appearance, level of consciousness, signs of distress, development, motor activity and apparent state of health.
    • Apparent state of health - Acutely or chronically ill, frail, or fit and robust
    • Level of consciousness - Is the patient awake, alert, and responsive to you and others in the env’t
    • Signs of distress - Cardiac or respiratory, Pain, Anxiety or depression
    • Development - Sexual, Body habitus – ex: boy with arm length down to his knees
    • Motor activity - Posture, gait , Speech
    • Appearance - Odors, hygiene, grooming; Facial expressions
  5. Vital Signs
    • Baseline indicators of patient’s health status
    • Can do all at the beginning of exam or spread out with respective organ systems
    • Often will have them done for you by other staff-if something doesn’t seem right repeat them yourself (important)
  6. Pulse (heart rate)
    • Number of cardiac cycles per minute
    • Anywhere you feel arterial pulsation
    • Carotid, brachial, radial, femoral, etc.
    • Auscultate apical
    • Pads of 2nd and 3rd fingers on flexor surface of lateral wrist
    • Count pulsations (rate), note rhythm, amplitude (strong or weak), contour
    • Normal HR=50-90 bpm
  7. Respirations
    • Number of respiratory cycles/minute (regularity and depth, ease of breathing)
    • Inspection
    • Observe the rise and fall of chest, also make note of regularity, rhythm, depth and ease of breathing
    • Normal respiratory rate=14-20
  8. Blood Pressure (BP) definition
    Peripheral measurement of cardiovascular function

    Blood pressure is the force in the arteries when the heart beats (systolic pressure) and when the heart is at rest (diastolic pressure).
  9. Blood pressure - tool and where you place it
  10. Sphygmomanometer (mercury, aneroid) and stethoscope
    • Size does matter!
    • Upper arm and brachial artery
    • Can use forearm and radial pulse if necessary or even lower extremity (always record where BP was measured)
  11. Blood Pressure - Importance of size
    • Must use appropriate size cuff
    • Too wide=underestimate BP
    • Too narrow=overestimate BP
    • Adults-choose a cuff with a bladder width that is about 40% limb circumference, bladder length should be about 80% of limb circumference
    • Children-bladder width should not exceed ⅔ length of the upper arm
  12. Blood Pressure - what you do
    • Proper position of patient, limb, cuff and stethoscope
    • Find palpable systolic blood pressure first
    • Put cuff on, feel radial artery, inflate cuff till you cant find it anymore
    • Inflate cuff 20-30 mmHg above palpable systolic pressure, then slowly deflate listening for Korotkoff sounds
  13. Blood Pressure - numbers
    • Normal = <120/<80
    • Prehypertension - 120-139/ 80-89
    • Hypertension stage 1 = 140-150/ 90-99
    • Hypertension stage 2 = >= 160/ >= 100

    Gola for diabetes mellitus is <130/80
  14. Temperature
    • Routes-oral, rectal, axillary, tympanic
    • Route choice will depend on age of patient and clinical setting
    • Tympanic membrane shares blood supply with hypothalamus
    • Tympanic requires proper technique
    • With glass thermometers wait 3 minutes, rectal insert 1 1/2 inches.
    • Rectal temps average 1° higher, and axillary temps 1° lower than PO (oral)
    • Normal variation may be up to 101°
  15. Height & Weight
    • Measured on platform & electronic scales, infants lying supine
    • Infants: pounds and ounces
    • Stadeometer: Height device on scale
    • Infants length measured supine
    • Calibrate equipment
    • Measure infants on same scale dressed the same (especially if concerned with weight/ example: diaper)
    • Plot height & weight on standard graphs
    • Body Mass Index (BMI)-ratio of weight to height (kg/m²)
  16. Pain
    • Often considered the 5th vital sign
    • Numeric scale 0-10
    • Assessing changes
    • Pictorial scale
    • Kids
  17. History of Present Illness (HPI)
    • Ch-character
    • L-location
    • O-onset
    • R-radiation – pain move anywhere
    • I-intensity
    • D-duration
    • E-event (precipitating)
    • P-provacating factors
    • P-palliative factors
    • A-associated symptoms (Review of systems)
    • P-previous episodes
  18. HPI: Skin, hair, nails
    • Changes in skin, hair or nails?
    • Location? Generalized vs. local
    • Temporal sequence?-onset, duration, etc.
    • Associated symptoms?
    • Pruritus, pain, exudate, bleeding, color changes, fever, fatigue, weight gain, arthralgias
    • Recent exposures? Toxins, around others with a rash? Have they traveled?
    • What have they tried? At home to make better?
    • Meds-OTC/prescription?
    • Hygiene products – shampoo etc
  19. Past Medical History (PMHx)
    • Inquire about:
    • Previous problems with skin, hair, or nails
    • Tolerance to sunlight
    • Cardiac, respiratory, liver, hematologic, rheumatologic, endocrine (thyroid) or other systemic diseases
    • Nutrition
  20. Family History
    • History of dermatologic diseases
    • Psoriasis, eczema, infestations, infections, melanoma, or other skin cancers
    • Allergic hereditary diseases
    • Familial hair loss
    • History of autoimmune diseases
    • Systemic lupus erythematous, Rheumatoid arthritis, etc.
    • History of endocrine diseases
    • Thyroid, diabetes mellitus
  21. Social/Personal History
    • Skin/hair/nail care habits? products
    • Exposure to hazards?
    • Occupational, recreational
    • Recent stress?
    • Alcohol/recreational drug/tobacco use?
    • Sexual history? To estimate risk
  22. Physical Exam
    • Inspection
    • Always start with this
    • Lighting (daylight, overhead, tangential)
    • Exposure-you don’t have x-ray vision! Need to get their clothes off
    • Percussion – use fingers to cause sound waves to bounce of what is below
    • Palpation - feeling
    • Your dermatology finger
    • Pads of your fingers
    • Auscultation – listening with stethescope
  23. Examination of Skin
    • Color changes
    • Hyperpigmentation, hypopigmentation, pallor, erythema, jaundice, cyanosis, ecchymosis (bruising)
    • Brown, black, blue, salmon. . .
    • Lesions
    • Measure (with device) in centimeters
    • Palpation
    • moisture/dryness
    • Warmth-dorsum of hand, symmetry
    • Texture
    • Turgor (should be able to "tent" and it should return back to normal) - example --> dehydration and edema
    • Lesions
  24. Examination of Hair
    • Inspect hair
    • Color
    • Distribution
    • Quantity
    • Palpate
    • Texture
    • Hair isn’t just on your head-make note of all hair bearing areas
  25. Examination of Nails
    • Inspect
    • Color
    • pink
    • Length
    • Configuration
    • Symmetry
    • Cleanliness
    • Palpate
    • Nail plate
    • Nail bed
    • Clubbing
  26. Skin Lesions
    • Primary or secondary (later evolution)
    • Names often used inaccurately
    • Good description is essential IMPORTANT
    • Characteristics
    • Location and distribution
    • Localized, regional, diffuse
    • Discrete or confluent
    • Size, shape, color, texture, elevation or depression, pedunculation, exudates, configuration (annular, discoid, grouped, linear, arciform)
  27. Primary Skin Lesions
    • Macule
    • Papule
    • Wheal
    • Nodule
    • Tumor
    • Vesicle
    • Bulla
    • Pustule
    • Cyst
    • Telangiectasia
    • Scale
    • Lichenification
    • Erosion
    • UlcerExcoriation
    • Fissure
    • Scar
    • Keloid
    • Crust
    • Atrophy
  28. Macule
    • Flat, circumscribed change in color of skin; less than 1 cm = marcule
    • Examples: Freckles (ephilides), flat moles (nevi), petechiae

    • If > 1 cm then is called a Patch
    • Examples: Vitiligo, Mongolian spots
  29. Papule
    • Elevated, firm, circumscribed; less than 1 cm
    • ≥ 1cm=Plaque
    • Wart (verruca), elevated nevi
    • Psoriasis, seborrheic keratosis
    • Maybe very subtle
  30. Wheal
    • Elevated (palapable), irregular shaped area of cutaneous edema
    • Hives (urticaria), insect bites

    In NC=“Whelp”
  31. Nodule
    • Elevated, firm, circumscribed; deeper in dermis than papule
    • >.5 cm
    • Ex: lipoma (fatty, tumor), erythema nodosum
  32. Tumor
    • Elevated, solid, deeper in dermis
    • >2cm
    • Neoplasms, lipoma
  33. Vesicle
    • Elevated, circumscribed, NOT into dermis
    • Serous (clear) fluid
    • <1cm
    • Varicella (chicken pox), Herpes simplex
  34. Bulla
    • Elevated, circumscribed, superficial
    • > 1 cm
    • Serous fluid
    • Blister, pemphigus vulgaris, bullous pemphigoid
  35. Patule
    • Elevated, superficial
    • Purulent material (has pus in it)
    • Impetigo, acne
  36. Cyst
    • Elevated, circumscribed, encapsulated (wall around them)
    • Dermis or subcutaneous layer
    • Fluid or semi-solid
    • Epidermal inclusion cyst, cystic acne
  37. Telangiectasia
    • Fine, irregular
    • Capillary dilation
    • Rosacea, Generalized Essential Telangiectasia
  38. Secondary Lesions
    • Evolution of primary lesions
    • Maybe due to trauma of primary lesion (scratching, picking, etc.)
    • Can obscure primary lesion, making identification difficult
  39. Scale
    heaped-up, heratinized, flaky
  40. Lichenification
    • Rough, thickened epidermis
    • (due to chronic scratching)
  41. Erosion
    • Loss of part of epidermis, depression, moist
    • Rupture of vesicle
  42. Ulcer
    Loss of epidermis and dermis
  43. Excoriation and Fissure
    Excoriation - loss of epidermis, linear (scratch)

    Fissure - linear crack from epidermis into dermis (moist or dry) (deaper scratch)
  44. Scar and Keloid
    • Scar - fibrous tissue following surgical incision or injury
    • Keloid - irregular-shaped, elevated, grows beyond borders of wound
  45. Crust and Atrophy
    • Crust - dried serum, blood, or purulent exudate
    • Example of impetigo

    Atrophy - thinning of skin surface, loss of skin markings (stretch marks)
  46. Writing it up
    •General- Ms. Hills is well nourished, well developed, and appears her stated age. She is well groomed and in no acute distress.

    •Vital Signs-Temp 98.6°, Pulse 82 and regular, Respirations 12 and unlabored, BP 114/68 both arms, seated; Ht 5’8”, Wt 110, BMI 16.7


    •Skin/Hair/Nails-Skin is warm, dry, and soft throughout, turgor with instant recoil. No rashes or abnormal lesions noted. Hair is soft, silky, and well groomed with normal distribution. Nail beds pink without clubbing. Nails smooth, well attached, nontender, without deformity or pitting.

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