The Vital Signs, pain,BMI
Based on- Bate’s Guide to Physical Examination and History Taking
Giorgi Antadze
introduction
• The Vital Signs—blood pressure, heart rate, respiratory rate, and
temperature— provide critical initial information that often
influences the tempo and direction of your evaluation.
• If already recorded by office staff, review the Vital Signs promptly at
the outset of the encounter. If the Vital Signs are abnormal, you will
often retake them yourself during the visit
Blood Pressure
• The accuracy of blood
pressure measurements
varies according to how
these measurements are
taken. Office screening with
manual and automated cuffs
remains common, but
elevated readings
increasingly require
confirmation with home and
ambulatory monitoring
Methods for Measuring Blood Pressure
• Auscultatory office blood pressure
with aneroid or mercury blood
pressure cuff
• Common, inexpensive Subject to
patient anxiety (“white coat
hypertension”), observer technique,
cuff recalibration every 6 months
Requires measurements over several
visits Ambulatory or home monitoring
needed to detect masked hypertension
Single measurements with sensitivity
and specificity of 75% compared to
ambulatory monitoring
Blood Pressure
• Automated oscillometric office
blood pressure
• Requires optimal patient positioning,
cuff size and placement, and device
calibration Takes multiple
measurements over short period
Requires confirmatory measurements
to reduce misdiagnosis Comparable
sensitivity and specificity to manual
measurements
Blood Pressure
• Home blood pressure monitoring
• Accurate automated device applied by patient, easy to use, less expensive
than ambulatory monitoring
• Acceptable alternative if ambulatory monitoring not feasible; more predictive
of cardiovascular risk than office measurements
• Requires patient education for accurate technique, repeated measurements
(two morning, two evening readings daily for 1 week); nighttime readings not
recorded
• Detects white coat hypertension—present in 20%
• Detects masked hypertension—present in 10% (blood pressure is higher than
office readings)
• Sensitivity 85%, specificity 62% compared to ambulatory monitoring
Blood Pressure
• Ambulatory blood pressure monitoring
• Automated; clinical and research “gold standard”
• Provides 24-hour average blood pressures and averages of daytime (awake),
nighttime (asleep), systolic, and diastolic blood pressures
• Shows whether nocturnal blood pressure “dips” (normal) or stays elevated ( =
cardiovascular disease risk factor)
• More expensive; may not be covered by insurance
Definitions of Hypertension
• Hypertension (high blood pressure) is when the pressure in your
blood vessels is too high (140/90 mmHg or higher).
There are two types of hypertension
• Primary: High blood pressure that is not related to another medical
condition.
• Secondary: Another medical condition that causes high blood
pressure, usually occurring in the kidneys, arteries, heart, or
endocrine system. Examples include: Sleep problems like sleep apnea.
Three types of hypertension are especially
important to recognize
Three types of hypertension are especially
important to recognize
• White coat hypertension (isolated
clinic hypertension)
• occurs when blood pressure readings
at a health care provider's office are
higher than they are in other settings,
such as at home
• White coat hypertension is defined as
blood pressure ≥140/90 in medical
settings and mean awake ambulatory
readings <135/85. This phenomenon,
reported in up to 20% of patients with
elevated office blood pressure, is
important to identify since it carries
normal to slightly increased cardiovascular
risk and does not require treatment
Three types of hypertension are especially
important to recognize
• Masked hypertension: Masked hypertension is diagnosed if the office
blood pressure reading is not increased but the out-of-office-blood
pressure reading by either home blood pressure monitoring or by
ambulatory blood pressure monitoring is increased . Untreated adults
with masked hypertension, an estimated 10% to 30% of the general
population, have increased risk of cardiovascular disease and endorgan damage.
Three types of hypertension are especially
important to recognize
• Nocturnal hypertension is elevated blood pressure that occurs at
night
• Physiologic blood pressure “dipping” occurs inmost patients at night
as they shift from wakefulness to sleep. A nocturnal fall of <10% of
daytime values is associated with poor cardiovascular outcomes and
can only be identified on 24-hour ambulatory blood pressure
monitoring. Two other patterns have poor cardiovascular outcomes, a
nocturnal rising pattern and a marked nocturnal fall of >20% of
daytime values
Making Accurate Blood Pressure
Measurements.
steps
• Position the Cuff and Arm
• Estimate the Systolic Pressure and Add 30 mm
Hg
• Position the Stethoscope Bell Over the Brachial
Artery
• Identify the Systolic Blood Pressure
• Identify the Diastolic Blood Pressure
Heart Rate and Rhythm
• Examine the arterial pulses, the heart rate and
rhythm, and the amplitude and contour of the pulse
wave.
• Heart Rate. The radial pulse is commonly used to
assess the heart rate . With the pads of your index
and middle fingers, compress the radial artery until
a maximal pulsation is detected. If the rhythm is
regular and the rate seems normal, count the rate
for 30 seconds and multiply by 2. If the rate is
unusually fast or slow, count for 60 seconds. The
usual range of normal is 60 to 90 to 100 beats per
minute.
Heart Rate and Rhythm
• Begin by palpating the radial pulse. If there are any irregularities,
assess the rhythm at the apex by listening with your stethoscope.
Premature beats of low amplitude may not be transmitted to the
peripheral pulses, leading to underestimates of the heart rate.
• Is the rhythm regular or irregular?
• If irregular, try to identify a pattern:
• (1) Do early beats appear in a basically regular rhythm?
• (2) Does the irregularity vary consistently with respiration?
• (3) Is the rhythm totally irregular?
Respiratory Rate and Rhythm
• Observe the rate, rhythm, depth, and effort of breathing.
• Count the number of respirations in 1 minute either by visual
inspection or by subtly listening over the patient’s trachea with your
stethoscope during your examination of the head and neck or chest.
• Normally, adults take approximately 20 breaths per minute in a quiet,
regular pattern. An occasional sigh is normal. Check to see if
expiration is prolonged
Temperature
Causes of fever include infection, trauma such as surgery or
crush injuries, malignancy, drug reactions, and immune
disorders such as collagen vascular disease.
The chief cause of hypothermia is exposure to cold. Other
causes include reduced movement as in paralysis, interference
with vasoconstriction from sepsis or excess alcohol, starvation,
hypothyroidism, and hypoglycemia. Older adults are especially
susceptible to hypothermia and also less likely to develop fever.
Assessing body temperature
• The most common sites for measuring body temperature are
• Oral
• Rectal
• Axillary
• Tympanic membrane
• Skin/temporal artery
• Tympanic Membrane Temperatures. The tympanic membrane shares
the same blood supply as the hypothalamus, where temperature
regulation occurs in the brain. Accurate temperature readings require
access to the tympanic membrane
• Temporal Artery Temperatures. This method takes advantage of the
location of the temporal artery, which branches off the external
carotid artery and lies within a millimeter of the skin surface of the
forehead, cheek, and behind the ear lobes
Assessing Acute and Chronic Pain
• The International Association for the Study of Pain defines pain as “an
unpleasant sensory and emotional experience” associated with tissue
damage. The experience of pain is complex and multifactorial. Pain
involves sensory, emotional, and cognitive processing, but may lack a
specific physical etiology
What is Chronic pain
• Chronic pain is defined in several ways: pain not associated with
cancer or other medical conditions that persists for more than 3 to 6
months; pain lasting more than 1 month beyond the course of an
acute illness or injury; or pain recurring at intervals of months or
years
Assessing Severity of the Pain
• Use a consistent method to assess pain severity. Three scales are
common: the Visual Analog Scale and two scales using ratings from 1
to 10—the Numeric Rating Scale and the WongBaker FACES Pain
Rating Scale. Numerous more detailed multidimensional tools like the
Brief Pain Inventory and the McGill Pain Questionnaire are also
available, but take longer to administer. The Wong-Baker FACES® Pain
Raiting Scale can be used by children as well as patients with
language barriers or cognitive impairment.
Types of pain
• Nociceptive (somatic) is linked to tissue damage to the skin,
musculoskeletal system, or viscera (visceral pain), but the sensory
nervous system is intact, as in arthritis or spinal stenosis. It can be
acute or chronic. The involved afferent nociceptors can be sensitized
by inflammatory mediators and modulated by both psychological
processes and neurotransmitters like endorphins, histamines,
acetylcholine, serotonin, norepinephrine, and dopamine.
Types of pain
• Neuropathic pain Neuropathic pain is a direct consequence of a lesion or
disease affecting the somatosensory system. Over time, neuropathic pain
may become independent of the inciting injury, becoming burning,
lancinating, or shock-like in quality, It may persist even after healing from
the initial injury has occurred. Mechanisms postulated to evoke
neuropathic pain include central nervous system brain or spinal cord injury
from stroke or trauma; peripheral nervous system disorders causing
entrapment or pressure on spinal nerves, plexuses, or peripheral nerves;
and referred pain syndromes with increased or prolonged pain responses
to inciting stimuli. These triggers appear to induce changes in pain signal
processing through “neuronal plasticity,” leading to pain that persists
beyond healing from the initial injury.
Types of pain
• central sensitization pain, there is alteration of central nervous system
processing of sensation, leading to amplification of pain signals. There
is a lower pain threshold to nonpainful stimuli, and the response to
pain may be more severe than expected. Mechanisms are the subject
of ongoing research. An example is fibromyalgia, which has a strong
overlap with depression, anxiety, and somatization disorders and
responds best to medications that modify neurotransmitters like
serotonin and dopamine.
Types of pain
• Psychogenic pain involves the many factors that influence the
patient’s report of pain—psychiatric conditions like anxiety or
depression, personality and coping style, cultural norms, and social
support systems.
• idiopathic pain is pain without an identifiable etiology
Waist Circumference. If the BMI is ≥35 kg/m2 , measure the
patient’s waist circumference just above the hips. Risk for
diabetes, hypertension, and cardiovascular disease increases
significantly if the waist circumference is 35 inches or more in
women and 40 inches or more in men