History & Physical 1. Info gathered determines: Level of health Need for testing or exams Tentative diagnosis Preventive measures needed Type of treatment

History & Physical 2. Length & detail: For primary physician Simple history gives good idea about what’s going on For specialist Greater detail about past problems to indicate a pattern

History & Physical 3. Common components: Chief Complaint (CC): signs and symptoms; duration of symptoms History of present illness (HPI): symptom detail, order of occurrence & length of each Past History (PH): prior illnesses & dates of occurrence Operations Hospital admissions Serious injuries Shot record Allergies # of pregnancies

History & Physical Family history (FH): health status of immediate family looking for hereditary tendencies Social & occupational history (SH): job, living environment, travel, personal habits, lifestyle Review of systems (ROS): history of symptoms patient forgot to mention franciscanpainandneurology.com/forms

Vital Signs

Vital Signs Various determinations which provide information about basic condition of the patients When the signs with in normal limits, body in homeostasis, a state of equilibrium Abnormal vital signs are often first indication of something wrong- ACCURACY is essential

Vital Signs MAIN VITAL SIGNS: Temperature (T) Pulse (P) Respiration (R) Blood pressure (B/P)

TEMPERATURE Measurement of balance between heat lost & heat produced in body Heat Loss: perspiration, respiration, excretion Heat production: metabolism, muscle activity

TEMPERATURE Factors affecting body Temperature: Eating hot food Drinking hot or cold liquids Time of Day Smoking Temperature of environment Body metabolism

TEMPERATURE Parts of the body where temperature is measured Oral Temperature: - normal range: 97.6-99.6F (98.6 F) - most common, convenient, comfortable method

TEMPERATURE - Rectal: - Normal range: 98.6-100.6F (99.6F) - Most accurate because a core measurement

TEMPERATURE Axillary or groin: - Normal range:96.6-98.6 F (97.6F) - Least accurate because external Aural or Tympanic: Temperature of blood flowing through tympanic membrane Accurate-core temp

TERMS Afebrile- without fever Febrile- having fever

TEMPERATURE Conversion between Fahrenheit & Celsius - To convert Fahrenheit (F) to Celsius (C): C= (F-32) x 5/9\ To Convert Celsius (C) to Fahrenheit (F): F= (C x 9/5) + 32

Practice Temperatures

PULSE

PULSE - The wave of blood created by the heart pumping as it travels along the arteries. - Most easily felt in arteries which lie close to the skin & can be pressed against the bone

PULSE Eight Locations: Temporal (temple) Carotid (neck) Apical (apex of heart) Brachial ( inner aspect of elbow) Radial (wrist) Femoral (groin) Popliteal (behind the knee) Pedal (Top of foot)

PULSE Radial artery most common sight to take pulse

PULSE Pulse rate: Noted as the number of beats per minute (BPM) -Rates vary depending of age, sex, body size

PULSE Normal adults rates: 60-80 BPM -men: 60-79 -women: 65-80 Children - over 7: 72-90 1-7 : 80-120 Infants: 90-140

PULSE Terms associated with pulse rate: Bradycardia: under 60 BPM Tachycardia: over 100 BPM Arrhythmia: uneven interval between heartbeats

PULSE Factors increasing pulse rates: Exercise, excitement, nervous tension Stimulant drugs Shock fever

PULSE Factors decrease pulse rates: Sleep Coma Depressant drugs

Respiration Breathing rate Begins when level of CO2 increases One inspiration & one expiration=one respiratory cycle Do not allow patient to know rate is being counted

Respiration Normal rates Adults: 14-18 Children: 16-25 Infants: 30-50

Factors Affecting Respiratory Rate Exercise Strong emotions Trauma Chronic/acute lung diseases Cardiovascular diseases

Abnormal Respirations Dyspnea Difficult or labored breathing Apnea Absence of respirations Cheyne-Stokes Periods of dyspnea followed by periods of apnea Frequently noted in dying patients Rales Bubbling or noisy sounds caused by fluids or mucus in air passages Wheezing High-pitched musical squeak

Blood Pressure

Blood Pressure Measurement of pressure of the blood exerted against walls of arteries Two measures: Systolic: heart contracts 100-140 Diastolic: heart relaxes 60-90 Written as a fraction: 120/80 Units of measure: mm Hg

Blood Pressure Factors increasing B/P Factors decreasing B/P Excitement, anxiety, nervous tension Stimulant drugs Exercise Eating Factors decreasing B/P Rest or sleep Fasting Depressant drugs Excessive loss of blood

Blood Pressure Instrument of measure: sphygmomanometer Types: Sphygmo-: pulse Man: pressure Meter: measure of Types: Mercury-long column of mercury Aneroid-a round gauge Digital

Blood Pressure Reading the gauge Long marks: units of 10 mm Hg Short marks: units of 2 mm Hg

TIME Why is time important? Indicates: When treatment is to be done When medication to be given How long procedures last

TIME Military time Expressed in 4 digits No colons between hours/minutes Use 0 to complete 4-digit number 0300 rather than 300 Stated in hundreds Zeros three hundred=3:00 AM Twenty-two hundred hours=10:00 PM Use 24 hour clock AM=0100 to 1200 PM=1201-2400

Comparison of Greenwich to Military Time 1:00 AM 0100 2:00 AM 0200 3:00 AM 0300 4:00 AM 0400 5:00 AM 0500 6:00 AM 0600 7:00 AM 0700 8:00 AM 0800 9:00 AM 0900 10:00 AM 1000 11:00 AM 1100 12:00 noon 1200 1:00 PM 1300 2:00 PM 1400 3:00 PM 1500 4:00 PM 1600 5:00 PM 1700 6:00 PM 1800 7:00 PM 1900 8:00 PM 2000 9:00 PM 2100 10:00 PM 2200 11:00 PM 2300 12:00 PM 2400

Convert the following to Military.24-hour time 10:43 a.m. 10:27 p.m. 11:21 a.m. 8:16 p.m. 9:32 p.m. 3:19 p.m. 9:10 a.m. 12:22 a.m. 12:22 p.m.

Write these 24-hour clock times in 12-hour clock times, using a. m Write these 24-hour clock times in 12-hour clock times, using a.m. or p.m. 1213 1705 0622 1635 1942 2205 1340 1445