THE GENERAL EXAM R. MICHAEL RODRIGUEZ, M.D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE

8. THE VITAL SIGNS BLOOD PRESSURE PULSE RESPIRATORY RATE TEMPERATURE

10. WHY DO WE MONITOR THE BLOOD PRESSURE? NORMOTENSION HYPERTENSION HYPOTENSION

11. HOW DO WE MEASURE BLOOD PREESURE? DIRECTLY - CATHETER IN THE ARTERY INDIRECTLY � AUSCULTATORY OR PALPATORY

14. KOROTKOFF SOUNDS THESE SOUNDS ARE PRODUCED BENEATH THE DISTAL THIRD OF THE BP CUFF. THE SOUNDS ARE GENERATED BETWEEN THE SYSTOLIC AND DIASTOLIC BP, BECAUSE THE ARTERY IS COLLAPSING COMPLETELY AND REOPENING WITH EACH HEART BEAT. THE ARTERY OPENS BECAUSE SYSTOLIC PRESSURE IS GREATER THAN THE CUFF PRESSURE AND THE ARTERY COLLAPSES BECAUSE THE DIASTOLIC PRESSURE IS LESS THAN THE CUFF PRESSURE. THE SOUND REPRESENTS THE DECELERATION OF THE RAPIDLY OPENING ARTERIAL WALLS. ONCE CUFF PRESURE FALLS BELOW DIASTOLIC PRESSURE THE SOUNDS DISAPPEAR. PHASE I � FIRST AUDIBLE SOUND AS CUFF DEFLATED - SBP PHASE 4 � MUFFLING - ? DIASTOLE PHASE 5 � DISAPPEARANCE - DIASTOLE

20. CAN WE PALPATE THE BP? YES WE CAN. USE IN PATIENTS WITH HYPOTENSION OR DISTAL KOROTKOFF SOUNDS. PALPATE THE BRACHIAL ARTERY. DEFLATE THE CUFF, THE FIRST SENSATION OF A PULSE REPRESENTS THE SYSTOLIC PRESSURE. AS THE CUFF PRESSURE FALLS BELOW DIASTOLIC PRESSURE THE SENSATION BECOMES MUCH SOFTER, THIS IS THE DIASTOLIC PRESSURE. THERE IS A 6-8 MMHG DIFFERENCE BETWEEN THE SBP AND DBP WHEN COMPARING THE TWO METHODS. THE PALPATED PRESSURE IS USUALLY LOWER THAN THE AUSCULTATED.

21. WHAT ACCOUNTS FOR THE VARIABLITY IN BLOOD PRSSURE MEASUREMENTS? PATIENT � SYSTOLIC AND DIASTOLIC PRESSURES MAY VARY BEAT TO BEAT OR WITH RESPIRATORY VARIATION. BP MAY VARY MIN TO MIN OR DAY TO DAY WITH SD OF 4 MMHG SYS AND 2 MMHG DIASTOLIC . THESE VALUES MAY EVEN BE GREATER DAY TO DAY 5-12 MMHG SYS AND 6-8 MMHG DIASTOLIC. EQUIPMENT � SIZE OF THE CUFF OR PRESSING TO HARD WITH THE STETHOSCOPE. EXAMINER � POOR TECHNIQUE. ENVIROMENTAL � NOISE ETC.

22. THE BLOOD PRESSURE SYSTOLIC BP � THE MAXIMAL PRESSURE WITHIN THE ARTERY DURING VENTRICULAR SYSTOLE. DIASTOLIC BP � THE LOWEST PRESSURE WITHIN THE ARTERY PRIOR TO THE NEXT SYSTOLE. MEAN ARTERIAL PRESSURE � (S+2D)/3 PULSE PRESSURE � THE DIFFERENCE BETWEEN THE SYSTOLIC AND DIASTOLIC BP

23. WHO SHOULD HAVE THEIR BLOOD PRESSURE CHECKED? EVERYONE � EVERY VISIT CHECK BOTH ARMS � THE AVERAGE SYSTOLIC DIFFERENCE BETWEEN ARMS IS 10 MMHG. A DIFFERENCE OF > 20 MMHG IS SIGNIFICANT. (SUBCLAVIAN STEAL SYNDROME, AORTIC DISSECTION). AT THE FIRST VISIT CHECK BOTH ARMS. THE ARM WITH THE HIGHEST PRESURE SHOULD BE USED DURING SUBSEQUENT VISITS.

25. SUBCLAVIAN STEAL SYNDROME MECHANISM ONE SUBCLAVIAN ARTERY IS OBSTRUCTED PROXIMAL TO THE ORIGIN OF THE VERTEBRAL ARTERY. THE PRESSURE IN THE SUBCLAVIAN ARTERY IS DECREASED RESULTING IN DIMINISHED FLOW IN THE IPSILATERAL VERTEBRAL ARTERY. BLOOD FLOWS FROM THE CONTRALATERAL VERTEBRAL ARTERY TO THE BASILAR ARTERY AND THEN DOWN THE IPSILATERAL VERTEBRAL ARTERY RESULTING IN INCREASED BLOOD FLOW TO THE ARM AT THE EXPENSE OF DECREASED BLOOD FLOW TO THE BRAIN.

26. SUBCLAVIAN STEAL SYNDROME SYMPTOMS VERTEBROBASILAR INSUFFICIENCY VERTIGO, DIPLOPLIA, ATAXIA. SIGNS SYSTOLIC BP < 20 MMHG ON AFFECTED SIDE COMPARED TO THE OPPOSITE SIDE. IPSILATERAL DIMINISHED RADIAL PULSE. SUBCLAVIAN BRUIT.

27. WHITE COAT HYPERTENSION INCREASED BP IN THE PHYSICIAN�S OFFICE COMPARED TO AMBULATORY VALUES. 10 � 40% OF PATIENTS WITH BORDERLINE HYPERTENSION DIFFERENCE IN MEASUREMENTS MAY BE > 20/10 MMHG. WHITE COATS ON NURSES OR TECHNICIANS DO NOT EVOKE THE SAME BP CHANGE AS DO PHYSICIANS WITH A WHITE COAT.

28. WHAT IS THE EFFECT OF EXERCISE ON THE BP? SYSTOLIC BP WILL INCREASE. DIASTOLIC BP CHANGES MINIMALLY. THEREFORE, IF BP LEVELS RETURN TO NORMAL AFTER EXERCISE THE PATIENT IS NOT HYPERTENSIVE.

29. THE PULSE PRESSURE SYSTOLIC � DIASTOLIC PRESSURE ABNORMALLY WIDE PP � PULSE PRESSURE IS > 50% OF THE SBP. NARROW PP � PULSE PRESSURE IS < 25% OF THE SBP.

30. PULSUS PARADOXUS SBP DECREASES WITH INSPIRATION AND INCREASES WITH EXPIRATION. ABNORMAL > 10 MMHG INSPIRATORY FALL. THE PARADOX � KUSSMAUL NOTED THAT A PATIENT HE EXAMINED MAINTAINED A HEARTBEAT WITHOUT A PULSE. NORMALLY INSPIRATION LEADS TO INCREASED VENOUS RETURN TO THE RIGHT HEART AND POOLING OF BLOOD IN THE LUNGS WHICH RESULTS IN DECRESED LV VOLUME AND THEREFORE DECREASED STROKE VOLUME. A PULSUS PARADOXUS IS ABNORMAL VARIATION OF THE NORMAL PHYSIOLOGY. PERICARDIAL TAMPONADE, COPD, ASTHMA. FALSE NEGATIVE IN PATIENTS WITH SEVERE LV FAILURE, AI, ASD.

31. HOW TO MEASURE THE PULSUS PARADOXUS INFLATE THE CUFF SO THAT THE SYSTOLIC PRESSURE HAS BEEN EXCEEDED. DEFLATE THE CUFF UNTIL YOU HEAR THE FIRST KOROTKOFF SOUND. STOP DEFLATING AND RECORD THE PRESSURE. THIS WILL BE IN EXHALATION. BEGIN DEFLATION AGAIN UNTIL YOU HEAR THE KOROTKOFF SOUNDS DURING INSPIRATION AND EXPIRATION. AGAIN RECORD THE PRESSURE. THE DIFFERENCE IS THE PULSUS PARADOXUS.

32. PSEUDOHYPERTENSION AND OSLER�S SIGN ELEVATED INDIRECT BP IN PATIENT�S WITH NORMAL INTRAARTERIAL PRESSURE. UNCOMMON < 2% OF HEALTHY ELDERLY PATIENTS CALCIFIED VESSELS? OSLER�S SIGN � CONSIDERED POSITIVE IF BRACHIAL OR RADIAL ARTERY IS PALPABLE AFTER CUFF IS INFLATED ABOVE THE SYSTOLIC PRESSURE. MINIMAL CLINICAL VALUE. OCCURS IN 11% OF PATIENTS 75 Y.O. OR OLDER AND 44% OF PATIENTS 85 Y.O. OR OLDER, WITH OR WITHOUT HYPERTENSION. SOME INVESTIGATORS HAVE SHOWN THAT PATIENTS WITH PSEUDOHYPERTENSION ACTUALLY HAVE DIRECT BP MEASUREMENTS WHICH ARE > THAN THE INDIRECT MEASUREMENTS.

33. HYPOVOLEMIA AND HYPOTENSION DEFINITION - HYPOVOLEMIA IS USED TO REFER TO PATIENTS WITH VOLUME DEPLETION AND DEHYDRATION, WHEN IN FACT VOLUME DEPLETION REFERS TO LOSS OF SODIUM FROM THE EXTRAVACULAR SPACE AND DEHYDRATION REFERS TO LOSS OF INTRACELLULAR WATER. CLINICALLY - IS HYPOVOLEMIA PRESENT AND HOW SEVERE IS IT? THE TILT TEST IS USED TO DETERMINE IF A PATIENT IS HYPOVOLEMIC.

34. NORMAL PHYSIOLOGY SUPINE STANDING HEART 10 BEATS/MIN CONSTANT 45-60 SECONDS. SBP 3.5 MMHG CONSTANT 1-2 MINUTES. DBP 5.2 MMHG CONSTANT 1-2 MINUTES.

35. HOW TO PERFORM THE TILT TEST HAVE THE PATIENT LIE IN A SUPINE POSITION FOR 2 MINUTES. RECORD HR AND BP IN THE SUPINE POSITION. HAVE THE PATIENT STAND, WAIT I MINUTE. RECORD HR AND BP IN THE STANDING POSITION. SITTING DECREASES THE SENSITIVITY OF THE TEST.

36. FINDINGS OF THE TILT TEST IN A PATIENT WITH HYPOVOLEMIA MOST HELPFUL - INCREASE IN HR OF 30 BEATS/MIN. 97%SENS AND 96% SPEC FOR BLOOD LOSS > 630 ML. SECOND MOST HELPFUL IS DIZZINESS. SAME SENS AND SPEC AS TACHYCARDIA. HYPOTENSION OF MINIMAL VALUE. A SBP DECREASE OF 20 MMHG UPON STANDING MAY BE SEEN IN 10% OF NORMOVOLEMIC PATIENTS YOUNGER THAN 65 YO AND 11-30% OF NORMALS OLDER THAN 65 YO.

37. OTHER PHYSICAL FINDINGS IN PATIENTS WITH HYPOVOLEMIA SUPINE TACHYCARDIA � HR > 100 BEATS/MIN. SUPINE HYPOTENSION � BP < 95 MM HG. BOTH ARE SPECIFIC BUT NOT SENSITVE TO THE VOLUME OF BLOOD LOST. CAPILLARY REFILL TIME OF LITTLE VALUE DRY AXILLA SUPPORTS DX OF HYPOVOLEMIA SKIN TURGOR OF ? VALUE WEAKNESS, NONFLUENT SPEECH, DRY MUCOUS MEMBRANES, DRY TONGUE, SUNKEN EYES CORRELATE WITH SERUM SODIUM AND BUN/CREATININE RATIO. INDIVIDUALLY EACH FINDING IS NOT OF SIGNIFICANT VALUE.

38. WHAT IS THE RELATIONSHIP BETWEEN THE BLOOD PRESSURE IN THE LEGS AND ARMS? TO MEASURE THE BLOOD PRESURE IN THE LEGS, PLACE THE CUFF AROUND THE THIGH AND LISTEN OR PALPATE OVER THE POPLITEAL ARTERY. INDIRECT MEASUREMENT � THE SBP IN THE LEGS IS 10 � 15 MMHG HIGHER THAN IN THE ARMS. DIRECT MEASUREMENT � NO DIFFERENCE HILL�S SIGN - > 20MMHG DIFFERENCE BETWEEN THE ARMS AND THE LEGS (AI). COARCTATION OF THE AORTA � BP IN LEGS IS MUCH LESS THAN IN THE ARMS.

40. THE ARTERIAL PULSE EGYPTIAN PHYSICIANS � 3500 B.C. GALEN (ca. 129 -200) STOKES/ADAMS (1827 � 1846) NOTED A WEAK PULSE OR HEART BLOCK COULD ACCOUNT FOR SEIZURES. THEREFORE, ALL SEIZURES AND FAINTING SPELLS WERE NOT NECESSARILY RELATED TO THE BRAIN.

41. HISTORY OF THE ARTERIAL PULSE PTOLEMAIC ALEXANDRIA 3-4TH CENTURY B.C. HEROPHILUS FIRST TO SUGGEST THE VALUE OF THE PULSE. CHINESE 1000 YEARS LATER - FOUR PULSATIONS PER RESPIRATION. JOHN FLOYER 18TH CENTURY USED SECOND HAND ON A WATCH TO COUNT THE PULSE FOR ONE MINUTE, PUBLISHED THE PHYSICIANS PULSE WATCH 1707. NOT UNTIL 19TH CENTURY DID TIMING THE PULSE BECOME THE STANDARD OF CARE.

42. HOW TO DETERMINE THE PULSE RATE PALPATION OF THE RADIAL PULSE (ARTERIAL). LISTEN TO THE HEART. COUNT THE PULSE FOR 30 SECONDS AND DOUBLE THE VALUE. MORE ACCURATE THAN COUNTING FOR 15 SECS. FASTER HEART RATES COUNT FOR 60 SECS. PULSE DEFICIT � THE DIFFERENCE BETWEEN RADIAL PULSE RATE AND APICAL RATE (AF). NORMAL � 60 � 100 BEATS/MIN. BRADYCARDIA - < 60 BEATS/MIN. TACHYCARDIA - > 100 BEATS/MIN.

45. PULSUS ALTERNANS THE FINDING OF PULSUS ALTERNANS IN PATIENTS WITH NORMAL HEART RATES SUGGESTS SEVERE LEFT VENTRICULAR DYSFUNCTION. THIS FINDING IN PATIENTS WITH TACHYCARDIAS HAS LESS CLINICAL SIGNIFICANCE.

46. PULSUS BISFERIENS BIS � TWICE FERIRE � TO BEAT TWO BEATS PER CARDIAC CYCLE BOTH OCCURRING IN SYSTOLE. PALPATE CENTRAL ARTERY (CAROTID). AORTIC REGURGITATION OCCASIONALLY IN HOCUM.

47. HYPERKINETIC PULSE THE FORCE OF THE PULSE IS STRONG. ASSOCIATED WITH EITHER A NORMAL PULSE PRESURE (MR) OR WIDE PULSE PRESSURE(AI). IN MR BLOOD IS EJECTED RAPIDLY AND IN THE PRESENCE OF A NORMAL AORTIC VALVE THE PULSE PRESSURE IS PRESERVED. PATIENTS WITH AI ALSO HAVE RAPID EJECTION OF BLOOD BUT THE INCOMPETENT AORTIC VALVE ALLOWS A LOW DIASTOLIC PRESSURE AND A WIDE PULSE PRESSURE.

48. DICROTIC PULSE SIMILAR TO PULSUS BISFERIENS WITH 2 BEATS/CARDIAC CYCLE, EXCEPT ONE PEAK IS IN SYSTOLE AND THE OTHER IN DIASTOLE. REBOUND OF BLOOD AGAINST A CLOSED AORTIC VALVE? SEPSIS, CHF, LOW STROKE VOLUMES.

52. WHAT SITES CAN WE USE TO MEASURE THE TEMPERATURE? ORAL CAVITY RECTUM AXILLA TYMPANIC MEMBRANE CENTRALLY

53. WHAT IS THE NORMAL TEMPERATURE? ORAL - ON AVERAGE 37�C (98.6�F). FLUCTUATES WITH THE TIME OF DAY. A.M. AS LOW AS 35.8�C (96.4�F) OR AS HIGH AS 37.3�C (99.1�F) IN THE P.M. MOST PATIENTS PREFER ORAL TEMPERATURES WHEN PATIENTS ARE UNCONCIOUS OR UNCOOPERATIVE ORAL TEMPERATURES SHOULD BE AVOIDED.

54. TECHNIQUE OF MEASURING AN ORAL TEMPERATURE GLASS OR ELECTRONIC THERMOMETER. GLASS � SHAKE THE THERMOMETER DOWN TO 35�C (96�F) OR BELOW. INSERT THE THERMOMETER UNDER THE TONGUE. TELL THE PATIENT TO CLOSE HIS/HER LIPS. WAIT 3-5 MINUTES. READ THE TEMPERATURE AND REINSERT FOR A MINUTE AND REREAD. IF TEMPERATURE IS STILL RISING REPEAT THE PROCEDURE UNTIL THE TEMPERATURE IS STABLE.

55. TEMPERATURE RELATIONSHIPS BETWEEN DIFFERENT SITES RECTAL 0.4 � 0.5�C (0.7 � 1.0� F) > ORAL ORAL 0.4 � 0.7�C (0.7 -1.3� F) > AXILLARY AND 0.4�C (0.7�F) > TYMPANIC. NOTE THESE ARE AVERAGE VALUES. IN A PARTICULAR PATIENT THE DIFFERENCE BETWEEN ORAL AND RECTAL TEMPERATURES MAY VARY -0.4 -1.3�C (-0.8 -2.4�F) ON SUCCESIVE DAYS.

56. THE TYMPANIC TEMPERATURE CONVENIENT HYPOTHALMUS IS SUPPLIED BY THE SAME ARTERY AS THE TYMPANIC MEMBRANE. DESPITE BEING AN IDEAL LOCATION THE TEMPERATURE VARIES MUCH MORE IN THE SAME PERSON OVER TIME THAN DOES THE RECTAL OR ORAL TEMPERATURE. SOME STUDIES SUGGEST THAT THE CORRELATION BETWEEN THE RIGHT AND LEFT TYMPANIC MEMBRANE IS POOR.

57. THE EFFECTS OF DIFFERENT VARIABLES ON THE TEMPERATURE CHEWING � INCREASES ORAL TEMPERATURE BY 0.3�C FOR APPROXIMATELY 20 MINUTES. ICE WATER � DECREASES ORAL TEMPERATURE BY 0.3-1.2�C FOR APPROXIMATELY 15 MINUTES. HOT LIQUIDS � INCREASES ORALTEMPERATURE BY 0.9�C FOR APPROXIMATELY 15 MINUTES. SMOKING � INCREASES ORAL TEMPERATURE BY 0.2�C FOR APPROXIMATELY 30 MINUTES. TACHYPNEA � DECREASES ORAL TEMPERATURE BY 0.5� FOR EVERY INCREASE IN 10 BR/MIIN. O2 BY NASAL CANNULA � NO CHANGE CERUMEN � DECREASES TEMPERATURE

58. FEVER PATTERNS AT ONE TIME AN IMPORTANT DIAGNOSTIC SIGN. NOT AS MUCH ANYMORE EXCEPT IN SOME AREAS OF THE WORLD. FEVER MAY BE DUE TO INFECTIOUS, INFLAMATORY OR NEOPLASTIC PROCESS. ACUTE, SUBACUTE OR CHRONIC. CLINICALLY USEFUL.

59. FEVER PATTERNS INTERMITTENT FEVER � TEMPERATURE ELEVATIONS WHICH RETURN TO NORMAL AT LEAST DURING MOST DAYS. REMITTENT FEVER � DOES NOT RETURN TO NORMAL EACH DAY. CONTINUING FEVER � DOES NOT VARY MORE THAN 1�F PER DAY. RELAPSING FEVER � RECURRENT OVER DAYS OR WEEKS AND MAY HAVE ANY OF THE ABOVE PATTERNS.

67. HYPOTHERMIA - <97�F COLD EXPOSURE HYPOTHYROIDISM SEPSIS MEDICATIONS ELDERLY

69. RESPIRATORY RATE NORMAL � 16-25 BR/MIN (AVG 20 BR/MIN) TACHYPNEA � VARIES BUT USUALLY > 25 BR/MIN CARDIO � PULMONARY DISEASE MAY BE NORMAL AT TIMES BRADYPNEA - <8 BR/MIN MEDICATIONS � NARCOTICS,SEDATIVES HYPOTHYROIDISM CNS DISEASE

70. THE RESPIRATORY RATE UNDER VOLUNTARY CONTROL - THIS IS CLINICALLY IMPORTANT, MEASURE THE RATE WHILE CHECKING THE PULSE OR WHEN LISTENING OVER THE TRACHEA. OFTEN INACCURATE. OBSERVE THE RHYTHM, DEPTH AND RATE. COUNTING THE RATE FOR 10 SECONDS AND MULTIPLYING BY 6 IS OFTEN INACCURATE. COUNT THE NUMBER OF BREATHS FOR 30 SECONDS AND MULTIPLY BY 2 OR COUNT THE NUMBER OF BREATHS FOR 1 MINUTE.

72. THE PNEA�S DYSPNEA � SOB - IS NOT THE SAME AS TACHYPNEA - RR > 25 BR/MIN BRADYPNEA - RR< 8 BR/MIN PND - PAROXYSMAL NOCTURNAL DYSPNEA SUDDEN ONSET OF SOB DURING SLEEP ORTHOPNEA � SOB LYING FLAT PLATYPNEA � SOB SITTING UP AND BETTER LYING FLAT TREPOPNEA � SHORTNESS OF BREATH IN ONE LATERAL DECUBITUS POSITION WHICH IS IMPROVED BY TURNING ON THE OPPOSITE SIDE

73. RESPIRATORY ALTERNANS NORMALLY BOTH CHEST AND ABDOMEN RISE DURING INSPIRATION PARADOXICAL RESPIRATION IMPLIES THAT DURING INSPIRATION THE CHEST RISES AND THE ABDOMEN COLLAPSES IMPENDING MUSCLE FATIGUE