Patient Scenario Components of the Physical Examination

Patient Scenario

Components of the Physical Examination -- The basic components of the physical exam can be delineated into four major pars: 1) Inspection, 2) Palpation, 3) Percussion, 4) Auscultation:

Inspection -- assess breathing abnormalities, cough, patient color, stained fingers, neck, thorax; focus on abnormal reactions, color, movement, or sound.

Palpation -- indicates tender areas, observed abnormalities, respiratory expansion, vibration

Percussion -- audible sounds when chest wall is percussed; dull or flat or resonant; sound and quality

Auscultation -- lung sounds and vibrations, intensity of breath sounds, absence of fluid, presence of consolidation (Introduction to Full Medical Examinations, 2010).

Part 2 -- a. Blood pressure is the pressure exerted by blood circulating through the vessels. It is usually measured with a sphygmomanometer which uses the height of a column of mercury to reflect the pressure. Modern devices measure output electronically or digitally. Patients are fitted with a cuff over their upper arm, air pressure is applied, and then listening with a stethoscope to the brachial artery at the elbow, the examiner releases the pressure into the cuff creating a "whooshing" or "pounding" sound. The pressure at which this first occurs is the systolic pressure; the cuff is further released until no sound can be heard, this is the diastolic pressure.

b. The top measure is the systolic (maximum) and diastolic (minimum) pressure based on the speed and pumping actions of the heart.

c. Ranges of the two numbers, particularly compared over time, give a mean average of pressure. Hypo- and Hyper-tension occur based on measurements. For instance 90-110/60-79 is considered desired, depending on age and condition of patient. >180/>110 is hypertensive crisis.

d. Mr. Smith's BP is 165/100; he is 60, but likely in pain from headache and intestinal blockage. According to tables dealing with classification of BP for adults, Mr. Smith is in the initial part of Stage II hypertension, or the ranges of 160-170/100-109.

e. The higher the pressure, the more stress on the heart and higher the chance of unhealthy tissue growth in the arteries. Persistent hypertension increases the risk for stroke, heart attacks, heart and renal failure, particularly in older adults. Mr. Smith should be stabilized and continually monitored to see if his pressure decreases once the pain has abated (American Heart Association, 2012; How to measure blood presure, 2011; What is blood pressure?, 2012).

Part 3 -- Mr. Smith was given a CBC (Complete Blood Count) to measure features of red blood cells (which carry oxygen), infection fighting white blood cells, hemoglobin, hematocrit, and platelets. He was also given a blood glucose test, a urinary aldosterone and potassium test; a Synachtehn (ACTH) test, and a cortisol test. This was done via drawing blood and collecting a urine sample (Blood and Urine Tests, 2012).

a. Urinary K+ is a spot or 24-hour test to check the levels of potassium in the urine. Potassium is an electrolyte and mineral, helping to keep the amount of water inside and outside cells balanced. Potassium levels often change with sodium levels -- when sodium is up, potassium is down, etc. Potassium levels also indicate how well the kidneys are working, and abnormal potassium may cause cramps, weakness, confusion, nausea, and changes in heart rhythm. For Mr. Smith, it is likely the test was ordered to see how well his kidneys were working and to check if the adrenal glands are in good shape (Potassium (K) in Urine, 2010)

Part 4 - Mr. Smith's Test Values (Red indicates out of range -- high, green out of range low):

Mr. Smith

Reference Values

K+

2.6 mmol/L

3.8-4.9mmol/L

Hb

7.3 g/dl

13.8 to 18.2 g/dL

Hct

20.4%

45-52%

Platelet Count

20x109/L

150-400x109/L

HCO3

38 mmol/l

22-26 mmol/L

Urinary K+

70 mmol/L/24 hr

25-120 mmol/L/24 hr

Blood Glucose

460 mg/dl

64.8-104.4 mg/dL

Serum Aldosterone

1 ng/dl

24-hour Urinary Aldosterone

8.4 mcg/24 hr

2.3-21.0 mcg/24 hr

Renin

2.1 ng/ml/hr

0.65-5.0 ng/ml/hr