UNIT I: GENERAL SURVEY, VITAL SIGNS, AND PAIN
Chapter 10 General Survey The general survey begins immediately when the patient encounter starts. It provides an overall impression of:
Physical condition
Emotional state
Mobility
Nutritional status
Hygiene
Mental status
Components of the General Survey
Appearanc Assess:
Apparent age
Sex characteristics
Body habitus
Facial expression
Skin color
Distress level
Behavior Observe:
Eye contact
Mood
Speech
Motor activity
Cooperation
Dress/Grooming Poor grooming may suggest:
Depression
Dementia
Substance use
Psychosis
Constitutional Symptoms Common Symptoms
Fatigue
Weakness
Fever
Night sweats
Weight changes
Pain
Symptom Possible Causes
Fever Infection, inflammatory disease
Night sweats TB, lymphoma
Weight loss Cancer, hyperthyroidism
Fatigue Depression, anemia
Body Mass Index (BMI)
BMI Classification
<18.5 Underweight
18.5–24.9 Normal
25–29.9 Overweight
≥30 Obesity
Vital Signs
Blood Pressure Proper Technique
Patient seated quietly
Back supported
Feet flat
Arm at heart level
Correct cuff size
No talking
, Category BP
Normal <120/<80
Elevated 120–129/<80
Stage 1 HTN 130–139 or 80–89
Stage 2 HTN ≥140 or ≥90
Orthostatic Hypotension Defined as:
SBP drop ≥20 mmHg OR
DBP drop ≥10 mmHg after standing
Causes
Dehydration
Antihypertensives
Autonomic dysfunction
Blood loss
Heart Rate Normal adult: 60–100 bpm Assess:
Rate
Rhythm
Strength
Respiratory Rate Normal: 12–20 breaths/minute Assess:
Rhythm
Effort
Accessory muscle use
Temperature Fever: ≥100.4°F (38°C)
Pain Assessment OLDCARTS
Letter Meaning
O Onset
L Location
D Duration
C Character
A Aggravating factors
R Relieving factors
T Timing
S Severity
Types of Pain
Type Description
Acute Sudden onset
Chronic >3 months
Neuropathic Nerve damage
Nociceptive Tissue injury
Referred Felt elsewhere
UNIT II: COGNITION, BEHAVIOR, AND MENTAL STATUS Chapter 11 Mental Status Examination (MSE) Components
Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight
Judgment
Level of Consciousness
Level Description
Alert Fully awake
Lethargic Drowsy
Obtunded Difficult to arouse
Stupor Requires vigorous stimulation
Chapter 10 General Survey The general survey begins immediately when the patient encounter starts. It provides an overall impression of:
Physical condition
Emotional state
Mobility
Nutritional status
Hygiene
Mental status
Components of the General Survey
Appearanc Assess:
Apparent age
Sex characteristics
Body habitus
Facial expression
Skin color
Distress level
Behavior Observe:
Eye contact
Mood
Speech
Motor activity
Cooperation
Dress/Grooming Poor grooming may suggest:
Depression
Dementia
Substance use
Psychosis
Constitutional Symptoms Common Symptoms
Fatigue
Weakness
Fever
Night sweats
Weight changes
Pain
Symptom Possible Causes
Fever Infection, inflammatory disease
Night sweats TB, lymphoma
Weight loss Cancer, hyperthyroidism
Fatigue Depression, anemia
Body Mass Index (BMI)
BMI Classification
<18.5 Underweight
18.5–24.9 Normal
25–29.9 Overweight
≥30 Obesity
Vital Signs
Blood Pressure Proper Technique
Patient seated quietly
Back supported
Feet flat
Arm at heart level
Correct cuff size
No talking
, Category BP
Normal <120/<80
Elevated 120–129/<80
Stage 1 HTN 130–139 or 80–89
Stage 2 HTN ≥140 or ≥90
Orthostatic Hypotension Defined as:
SBP drop ≥20 mmHg OR
DBP drop ≥10 mmHg after standing
Causes
Dehydration
Antihypertensives
Autonomic dysfunction
Blood loss
Heart Rate Normal adult: 60–100 bpm Assess:
Rate
Rhythm
Strength
Respiratory Rate Normal: 12–20 breaths/minute Assess:
Rhythm
Effort
Accessory muscle use
Temperature Fever: ≥100.4°F (38°C)
Pain Assessment OLDCARTS
Letter Meaning
O Onset
L Location
D Duration
C Character
A Aggravating factors
R Relieving factors
T Timing
S Severity
Types of Pain
Type Description
Acute Sudden onset
Chronic >3 months
Neuropathic Nerve damage
Nociceptive Tissue injury
Referred Felt elsewhere
UNIT II: COGNITION, BEHAVIOR, AND MENTAL STATUS Chapter 11 Mental Status Examination (MSE) Components
Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight
Judgment
Level of Consciousness
Level Description
Alert Fully awake
Lethargic Drowsy
Obtunded Difficult to arouse
Stupor Requires vigorous stimulation
