From supine to standing, a normal patient will exhibit an increase in the heart rate by 10.9 beats per minute which stabilises after 45 - 60 seconds. The systolic blood pressure decreases only by 3.5 mmHg.It will be stabilised by 1-2 minutes. The diastolic blood pressure increase by 5.2mmHg which stabilises within 1-2 minutes.
Physical Diagnosis - The normal response to tilt test
From supine to standing, a normal patient will exhibit an increase in the heart rate by 10.9 beats per minute which stabilises after 45 - 60 seconds. The systolic blood pressure decreases only by 3.5 mmHg.It will be stabilised by 1-2 minutes. The diastolic blood pressure increase by 5.2mmHg which stabilises within 1-2 minutes.
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Physical Diagnosis - Physiological changes on standing
7-8 ml/kg of blood ( 350-600 ml) will shift to the lower body within 1-2 minutes. This will decrease the stroke volume, intra thoracic volume and cardiac output and will increase the circulating catecholamines.This will increase systemic vascular resistance and heart rates. The blood will also shift from pulmonary to systemic circulation. The compensatory changes directed towards normalising blood pressure.Orthostatic changes will occur due to the loss of blood or autonomic dysregulation. Physical Diagnosis - How to detect the present of hypovolemia ?
Hypovolemia is detected through the tilt test. The tilt test measures postural changes in blood pressure and heart rate. To perform this procedure asks the patient to lie supine.2 minutes in the supine position is important to cause maximum leg pooling of blood. This results in maximal drop in cardiac output and maximal increase in heart rates upon re standing. Therefore 2 minutes in supine position increases the sensitivity of tilt test. Patient should not lie supine more than 2 minutes. Wait at least 2 minutes then measure the blood pressure and heart rate in this position. Patient is asked to stand. Wait for 1 minute. Blood pressure and heart are measured while the patient is standing. Heart rate is measured by counting over 30 minutes and multiple by 2. Physical Diagnosis - How to treat volume depletion and dehydration ?
Volume depletion leads to hemodynamical unstability and should be treated with rapid saline infusion. Dehydration is treated with 5% dextrose infusion. Physical Diagnosis - Volume depletion or dehydration commonly leads to hypovolemia ?
It depends on the age of the patient. Children younger than 5 years old suffer from hypovolemia due to volume depletion without dehydration.Occurs due to excessive extrinsic loss of fluids from diarrhea, vomiting and increase in sensible losses of water. Intravascular sodium levels are within the reference range. Indicating isonatremic volume depletion. The entire plasma pool is contained with solute such as sodium.Water / solvent is lost in proportionate amount. This happens, as children younger than 5 years old, will loss fluid more significantly and rapidly since the turnover of fluids and solutes can be three times of that adults. Physical Diagnosis - What is hypovolemia ?
Hypovolemia is characterized by volume depletion or dehydration. It is a loss of the extracellular salt. The loss is through the gastrointestinal tract ( hemorrhage, diarrhea, vomiting) or kidney ( diuresis). This leads to circulatory collapse /instability and an increase in the serum urea nitrogen to creatinine ratio as a results of contraction of the total intravascular pool of plasma. Dehydration It is a loss of intracellular water.Leads to cellular desiccation. Increase in serum solution and plasma osmolality. Volume Depletion However, volume depletion and hypovolemia do not depend on each other.Volume depletion occurs with / without hypovolemia so does hypovolemia. Physical Diagnosis - Posture of Patient with Dyspnea
Orthopnea, paroxysmal nocturnal dyspnea, nocturnal dyspnea, orthodeoxia, platypnea, abdominal paradox and respiratory alternans. Physical Diagnosis - Posture as indication of diseases
Pancreatitis - Patients with pancreatitis will lie on one side with the legs and knees bent over. In other words, lie in fetal position. Peritonitis - Patients with peritonitis lie very still. They try to avoid any movement that worsen the pain. Intestinal Obstruction - Patients are quite restless in case of intestinal obstruction. Renal abscess / perirenal abscess - Patients bend towards the site of the lesions Meningitis - Patients lie on the side.Thighs flexed at the hips and neck extended.Leg bent at the knees. Large pleural effusion - lie on the affected side with the purpose to maximize excursions of the affected side. Small pleural effusion - lie on the unaffected side ( as direct pressure would otherwise worsen on the pleuritic pain. Pericardial effusion - Patients sit up in bed and lean forward.Distention of the neck. Tetralogy of Fallot - Patients assume a squatting position in order to resolve the cyanotic spells such as after exercise. Psoas sign - Patient lie in supine.One knee flexed. Hip externally rotated.Indicate abnormality around the iliopsoas muscle. These include inflammed appendix, inflamed diverticulum and inflamed terminal ileum or muscle inflammation itself. Physical Diagnosis - The Aspects of Patient that should be assessed
Sex, race, age, posture, state of hydration, state of nutrition, body proportions, body habitus, facies, alertness, state of consciousness, degree of illness. acute or chronic illnesses, degree of comfort, state of mind, mood and gait. |