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1 Physical Examination On admission General Survey –Conscious, coherent, stretcher-borne, in cardiorespiratory distress Vital Signs –BP: 200/100, supine.

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Presentation on theme: "1 Physical Examination On admission General Survey –Conscious, coherent, stretcher-borne, in cardiorespiratory distress Vital Signs –BP: 200/100, supine."— Presentation transcript:

1 1 Physical Examination On admission General Survey –Conscious, coherent, stretcher-borne, in cardiorespiratory distress Vital Signs –BP: 200/100, supine LUE; 190/100, RUE, SBP 190, LLE, SBP 190 RLE; –PR: 88, regular; –HR:88, regular; –RR:24; –T 36.5 Upon PE –Conscious coherent, ambulatory, not in cardiorespiratory distress –BP: 110/70; –PR: 76, regular; –HR: 76, regular; –RR: 20, regular; –T 36.0 Anthropometric Measurements : Height: 157cmWeight: 74kgBMI: 30

2 2 Physical Examination On admission Skin –Warm, moist skin, no flushing, no active dermatoses HEENT –Pink palpebral conjunctivae, anicteric sclera, (+) ROR, hazy cornea –No nasoaural discharge, septum midline, moist buccal mucosa –No tragal tenderness AU, non- hyperemic external auditory canal AU, intact tympanic membrane AU Upon PE –Warm, moist skin, no flushing, no active dermatoses –Pink palpebral conjunctivae, anicteric sclerae, (FUNDOS) –no nasal or aural discharge, no nasal deformities, midline septum –Intact tympanic membrane, no tragal tenderness

3 3 Physical Examination On admission HEENT –Moist buccal mucosa, tongue midline, non- hyperemic PPW, tonsil not enlarged –no limitation in motion, Trachea midline, thyroid gland not enlarged, neck veins not distended, no cervical lymphadenopathy, (-) carotid bruits Upon PE –Moist buccal mucosa, no oral ulcers –supple neck, thyroid gland not enlarged, no palpable cervical lymphadenopathy, trachea midline, neck veins not distended

4 4 Physical Examination On admission Cardiovascular –Adynamic precordium, JVP 3cm at 30 degree, AB at 6 th LICS 11cm from the midsternal line, tapung, 2cm in diameter, no heaves, no thrills, no lifts S1>S2 apex, S2>S1 base, no murmurs –Pulses full and equal, no edema, no cyanosis, no clubbing Upon PE –Adynamic precordium, apex beat at 6 th LICS 11cm from the midsternal line, no heaves trills lifts, apex S1>S2, base S2>S1, no murmurs, JVP 4cm at 30 degrees –No edema, pulses full and equal on all extremities

5 5 Cardiac Auscultogram P T A M S1 S2 S1 Precordial Activity: Adynamic precordium No heaves, lifts, or thrills Apex beat: 6 th LICS 11 cm from midsternal line JVP 3 cm at 30° CAP rapid upstroke gradual down stroke

6 6 Physical Examination On admission Pulmonary –Symmetrical chest expansion, no retractions, no lagging, equal tactile and vocal fremiti, resonant on percussion, clear breath sounds Upon PE –No chest retractions, no use of accessory muscles, normal breathing pattern, symmetrical chest expansion, unimpaired transmission of voice and tactile fremiti, resonant on both sides, vesicular breath sounds on both sides

7 7 Physical Examination On admission Gastrointestinal –Flabby abdomen, no striaes, no visible peristalsis, NABS, (-) bruits, tympanitic on percussion, no tenderness, liver edge not palpable, Traube’s space not obliterated Upon PE –Flabby abdomen, normoactive bowel sounds, tympanitic, non-tender, liver dullness 10 cm, Traube’s space not obliterated

8 8 Physical Examination On admission Neurologic –Awake, alert, conscious, oriented to 3 spheres –CN: no anosmia, pupils 2- 3mm ERTL, EOMs intact, V1V2V3 intact and equal, can clench teeth, can smile, can frown, intact hearing, (+) gag reflex, can raise both shoulders against resistance, uvula midline on phonation, can shrug shoulders, tongue midline on protrusion Upon PE –Conscious, awake, oriented to person, place and time, can follow commands –Cranial nerves intact, (PUPIL) no facial asymmetry, can smile, frown, clench teeth, puff cheeks, normal gross hearing, uvula midline, (+) gag reflex, able to shrug shoulders, turn face against resistance

9 9 Physical Examination On admission Neurologic –Motor: 5/5 on the lower extremities, 5/5 on the upper extremities, no fasciculations, atrophy –No babinski, bilateral –No sensory deficit –No nuchal rigidity, Kernig’s, Brudzinski’s Upon PE –Motor 5/5 over all extremities, good tone, no atrophy, no fasciculation –No sensory deficits –(-) Babinski, Kernig, Brudzinski –No nuchal rigidity

10 10 Salient Features Pertinent Positive BP on admission: 200/100; RR: 24 (in cardiopulmonary distress) BMI = 30 Apex beat at 6 th LICS 11cm from the midsternal line (EYE PE)

11 11 Salient Features Pertinent Negative Neck veins not distended No heaves, no thrills, no lifts S1>S2 apex, S2>S1 base, no murmurs Pulses full and equal, no edema, no cyanosis, no clubbing No chest retractions, no use of accessory muscles, symmetrical chest expansion, unimpaired transmission of voice and tactile fremiti, clear breath sounds

12 12 Chest Pain Cardiovascular Pulmonary Gastrointestinal

13 13 Blood pressure The pressure or tension of the blood within the systemic arteries, maintained by the – contraction of the left ventricle –resistance of the arterioles and capillaries –elasticity of the arterial walls –viscosity and volume of blood Stedman’s medical dictionary, 5 th Ed

14 14 Blood Pressure Classification On Admission LUE 200/110 RUE 190/100 LLE 190 systolic RLE 190 systolic Systolic, mmHgDiastolic, mmHg Normal<120<80 Prehypertension Stage 1 hypertension Stage 2 hypertension≥160≥100 Isolated systolic hypertension ≥140<90 Harrison’s Internal Medicine, 17 th Ed Upon PE 110/70

15 15 Clinical Disorders of Hypertension Essential hypertension/ primary/ idiopathic Secondary hypertension –a specific mechanism for the blood pressure elevation is apparent –a specific underlying disorder causing the elevation of blood pressure can be identified –Renal, endocrine, adrenal… Harrison’s Internal Medicine, 17 th Ed

16 16 Apex beat Normal left ventricular apex impulse –left midclavicular line in the 4 th or 5 th LICS Left ventricular hypertrophy –exaggeration of the amplitude, duration, and often size of the normal left ventricular thrust –impulse may be displaced laterally and downward into the 6 th or 7 th ICS (left ventricular volume load; aortic regurgitation or dilated cardiomyopathy) Harrison’s Internal Medicine, 17 th Ed Patient’s Apex beat at 6th LICS 11cm from the midsternal line

17 17 Body Mass Index weight (kg)/height (m)2 CLASSIFICATION OF WEIGHT STATUS AND RISK OF DISEASE BMI Risk of Disease Underweight<18.5 Healthy Weight Overweight Increased Obesity Class I High Obesity Class II Very High Extreme Obesity Class III ≥40Extremely High Harrison’s Internal Medicine, 17 th Ed Patient’s BMI = 30

18 18 Relevant History Cardiovascular consequences, comorbidities, lifestyle Common symptoms: headache, dizziness, palpitations, easy fatigability Duration of hypertension, previous therapies Family history – father (+)HTN, mother (+) HTN, siblings (+) HTN, DM Diet – fond of sweet and salty weight change **notes from history needed Harrison’s Internal Medicine, 17 th Ed

19 19 Evidence of secondary hypertension: hx of renal dse, change in appearance, muscle weakness, spells of sweating, palpitations, tremor, erratic sleep, snoring, daytime somnolence, symptoms of hypo/hyperthyroidism, use of agents that may inc bp Evidence of target organ damage – stroke, transient ischemic attack, angina, transient blindness, MI, CHF **notes from history needed Harrison’s Internal Medicine, 17 th Ed


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