THE GENERAL EXAM

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THE GENERAL EXAM R. MICHAEL RODRIGUEZ,
M.D. ASSOCIATE PROFESSOR OF MEDICINE VANDERBILT
UNIVERSITY SCHOOL OF MEDICINE
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(No Transcript)
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INSPECTION
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• The patient is a 56 year-old male. You would
  expect this patient to have which of the
  following
• Hypertension
• (B) Sleep Apnea
• (C) Diabetes
• (D) Heart Disease

Obesity
CAD DIABETES HYPERTENSION SLEEP
APNEA CHOLELITHIASIS
SAHLI DIAGNOSTIC METHODS 1907
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MALNOURISHED
NUTRITION MALIGNANCY INFECTIOUS OTHER
SAHLI DIAGNOSTIC METHODS 1907
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• The patient is a 70 year-old male who walks
  into your office SOB. Appropriate questions would
  include which of the following
• Do you smoke
• Have you lost weight
• Are you SOB with exercise
• Do you wheeze
• Do you have a cough

TOBACCO EXPOSURES SYMPTOMS MALIGNANCY
SAHLI DIAGNOSTIC METHODS 1907
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SYMMETRY
SAHLI DIAGNOSTIC METHODS 1907
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THE VITAL SIGNS

• BLOOD PRESSURE
• PULSE
• RESPIRATORY RATE
• TEMPERATURE

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THE BLOOD PRESSURE
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WHY DO WE MONITOR THE BLOOD PRESSURE?

• NORMOTENSION
• HYPERTENSION
• HYPOTENSION

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HOW DO WE MEASURE BLOOD PREESURE?

• DIRECTLY - CATHETER IN THE ARTERY
• INDIRECTLY AUSCULTATORY OR PALPATORY

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THE BLOOD PRESSURE CUFF
CUFF
BLADDER
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DOES CUFF SIZE MATTER?

• YES, IT DOES.
• BLADDER WIDTH AND LENGTH MATTER.
• BLADDER 12 X 23 CM
• THE BLADDER IN THE CUFF SHOULD ENCIRCLE 80 OF
  THE ARM IN ADULTS. IN CHILDREN YOUNGER THAN 13
  YEARS THE BLADDER IN THE CUFF SHOULD ENCIRCLE
  100 OF THE ARM.
• CUFF SHOULD BE 20 WIDER THAN THE DIAMETER OF THE
  EXTREMITY.
• A CUFF THAT IS TO SMALL WILL OVERESTIMATE THE BP.

KING GE. CLIN SCI 32223-237, 1967 MAXWELL MH
LANCET 233-35, 1982 JAMA 289 2560-2575, 2003
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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

TAVEL ME ET AL. CIRCULATION 39465-474,1969 DOCK
W NEJM 302 1264-1267,1980 PENNY J ET AL. AM J
HYPERTENSION 9839,1996
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THE AUSCULTATORY GAP
THE DISAPPERANCE OF THE PHASE 1 KOROTKOFF SOUNDS
IN SYSTOLE WITH REAPPEARANCE ABOVE THE DIASTOLIC
PRESSURE. AVOID BY PALPATING THE DISTAL PULSE
UNTIL IT DISAPPEARS DURING CUFF
INFLATION. MECHANISM UNKNOWN ?ATHEROSCLEROTIC
PLAQUE. 20 OF ELDERLY PATIENTS. MAY LEAD TO
INACCURATE SYSTOLIC AND DIASTOLIC READING.
FALSELY LOW SBP OR FALSELY HIGH DBP.
150/98 200/98 WITH AN AUSCULTATORY GAP BETWEEN
170 - 150
CAVALLINI MC ANN INTERN MED 124887-8831996 BATES
GUIDE TO THE PHYSICAL EXAMINATION 8TH ED.
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THE BLOOD PRESSURE
BATESA GUIDE TO PHYSICAL EXAMINATION8TH EDITION
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(No Transcript)
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JAMA 2892560-25752003
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CIRCADIAN PATTERNS OF BLOOD PRESSURE
NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY
MORNING.
NEJM 347778-7792002
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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.

SEGALL HN CAN MED ASSOC J 42311-313,1940 PUTT AM
NURS RES 15311-316,1966
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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.

MANCIA G HYPERTENSIION. 8147-1531986 NEUFELD PD
CAN MED ASSOC J. 135633-6371986
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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 (S2D)/3
• PULSE PRESSURE THE DIFFERENCE BETWEEN THE
  SYSTOLIC AND DIASTOLIC BP

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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 gt 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.

SINGER AJ ARCH INTERN MED 1562005-20061996 FISHE
R CM NEJM 265912-9131961
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SUBCLAVIAN STEAL SYNDROME
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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.

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SUBCLAVIAN STEAL SYNDROME

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

NEJM 1961265912-913 JAMA 19722221139-1143
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WHITE COAT HYPERTENSION

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

JAMA 273 1211 1217,1995
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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.

DLIN RA ET AL. AM HEART J. 106316-3201983
29
THE PULSE PRESSURE

• SYSTOLIC DIASTOLIC PRESSURE
• ABNORMALLY WIDE PP PULSE PRESSURE IS gt 50 OF
  THE SBP.
• NARROW PP PULSE PRESSURE IS lt 25 OF THE SBP.

WIDE
NARROW
AORTIC REGURGITATION FEVER ANEMIA AV FISTULA BERI
BERI PAGETS DISEASE CIRRHOSIS THYROTOXICOSIS PREG
NANCY EXCERCISE
DECREASE IN LV STROKE VOLUME TAMPONADE PERICARDIAL
CONSTRICTION AORTIC STENOSIS
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PULSUS PARADOXUS

• SBP DECREASES WITH INSPIRATION AND INCREASES WITH
  EXPIRATION.
• ABNORMAL gt 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.

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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.

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PSEUDOHYPERTENSION AND OSLERS SIGN

• ELEVATED INDIRECT BP IN PATIENTS WITH NORMAL
  INTRAARTERIAL PRESSURE.
• UNCOMMON lt 2 OF HEALTHY ELDERLY PATIENTS
• CALCIFIED VESSELS?
• OSLERS 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 gt THAN THE INDIRECT
  MEASUREMENTS.

MESSERLI FH NEJM 2711548-15511985 TSAPATASARIS
NP ARCH INTERN MED 1512209 22111991
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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.

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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.
  
  
  
  
  
  
  
  
  

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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.

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FINDINGS OF THE TILT TEST IN A PATIENT WITH
HYPOVOLEMIA

• MOST HELPFUL - INCREASE IN HR OF 30 BEATS/MIN.
  97SENS AND 96 SPEC FOR BLOOD LOSS gt 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.

JAMA 2811022 1029, 1999
37
OTHER PHYSICAL FINDINGS IN PATIENTS WITH
HYPOVOLEMIA

• SUPINE TACHYCARDIA HR gt 100 BEATS/MIN.
• SUPINE HYPOTENSION BP lt 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.

GROSS CR J EMERG MED 10267-2741992
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
• HILLS SIGN - gt 20MMHG DIFFERENCE BETWEEN THE
  ARMS AND THE LEGS (AI).
• COARCTATION OF THE AORTA BP IN LEGS IS MUCH
  LESS THAN IN THE ARMS.

OSTERMILLER WE J THOR CARDIOVASC SURG
61125-1301971
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THE PULSE
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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.

SCHECTHER DC ET AL. DIS CHEST55535-579,1969
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.

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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 - lt 60 BEATS/MIN.
• TACHYCARDIA - gt 100 BEATS/MIN.

SNEED NV ET AL. HEART LUNG 21427-4331992 SPODICK
DH SOUTH MED J 89666-6671996
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THE NORMAL ARTERIAL PULSE
44
THE ARTERIAL PULSE
NOTE STEEPER UPSTROKE, HIGHER SYSTOLIC PEAK AS
PULSE IS TRANSMITTED TO THE PERIPHERY USE CENTRAL
VESSELS TO FEEL FOR THE CONTOUR OF THE PULSE
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.

LAB MJ ET AL. CARDIOVASC RES 271407-14121993 SAU
NDERS DE ET AL. AM J CARDIOL 9223-2261962
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.

FLEMING PR BR HEART J 19519-5241957 CIESIELSKI
J ET AL. JAMA 175475-4771961
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.

FEINSTEN AR ET AL. AM J CARD 27708-7091971
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.

EWY GA ET AL. CIRCULATION 39655-6611969
49
ABNORMALITIES OF THE ARTERIAL PULSE
AORTIC STENOSIS
AORTIC REGURGITATION
AORTIC REGURGITATION
CONGESTIVE HEART FAILURE
CARDIAC TAMPONADE
50
THE PULSE IN VARIOUS CLINICAL STATES
LV OUTFLOW OBSTUCTION
NORMAL
PULSUS BISFERIENS - AI
DICROTIC PULSE
BRAUNWALD A TEXTBOOK OF CARDIOVASCULAR MEDICINE
5TH ED.
51
THE TEMPERATURE
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WHAT SITES CAN WE USE TO MEASURE THE TEMPERATURE?

• ORAL CAVITY
• RECTUM
• AXILLA
• TYMPANIC MEMBRANE
• CENTRALLY

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WHAT IS THE NORMAL TEMPERATURE?

• ORAL - ON AVERAGE 37C (98.6F).
• FLUCTUATES WITH THE TIME OF DAY. A.M. AS LOW AS
  35.8C (96.4F) OR AS HIGH AS 37.3C (99.1F) 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 35C (96F)
  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 0.5C (0.7 1.0 F) gt ORAL
• ORAL 0.4 0.7C (0.7 -1.3 F) gt AXILLARY AND
  0.4C (0.7F) gt TYMPANIC. NOTE THESE ARE AVERAGE
  VALUES.
• IN A PARTICULAR PATIENT THE DIFFERENCE BETWEEN
  ORAL AND RECTAL TEMPERATURES MAY VARY -0.4 -1.3C
  (-0.8 -2.4F) ON SUCCESIVE DAYS.

RABINOWITZ RP ET AL. ARCH INT MED
156777-7801996 HORVATH SM ET AL. JAMA
1441562-15651950 NICHOLS GA ET AL. NURS RES
15307-3101966
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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.

KLEIN DG ET AL. HEART LUNG 22435-4411993 CHU A
ET AL. PARAPLEGIA 33 476-4791995
57
THE EFFECTS OF DIFFERENT VARIABLES ON THE
TEMPERATURE

• CHEWING INCREASES ORAL TEMPERATURE BY 0.3C FOR
  APPROXIMATELY 20 MINUTES.
• ICE WATER DECREASES ORAL TEMPERATURE BY
  0.3-1.2C FOR APPROXIMATELY 15 MINUTES.
• HOT LIQUIDS INCREASES ORALTEMPERATURE BY 0.9C
  FOR APPROXIMATELY 15 MINUTES.
• SMOKING INCREASES ORAL TEMPERATURE BY 0.2C 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

TANDBERG D ET AL. NEJM 308945-9461983 LIM-LEVY
F NURS RES 31150-1521982 MARON MB NEJM
309612-6131983(LETTER) TENDRUP DE ET AL. AM J
EMERG MED 7150-1541989
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.

INF DIS CLIN N AM 1033-411996
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 1F
  PER DAY.
• RELAPSING FEVER RECURRENT OVER DAYS OR WEEKS
  AND MAY HAVE ANY OF THE ABOVE PATTERNS.

INF DIS CLIN N AM 1033-411996
60
DOUBLE QUOTIDIAN FEVER
ADULT STILLS DISEASE RIGHT SIDED GONOCOCCAL
ENDOCARDITIS VISCERAL LEISHMANIASIS
INF DIS CLIN N AM 1033-411996
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FEVER PATTERNS
INTERMITTENT FEVER
SEPSIS ABCESS
REMITTENT FEVER
VIRAL URI MYCOPLASMA
CONTINUOUS FEVER
BRUCELLOSIS RMSF
INF DIS CLIN N AM 1033-411996
62
RELAPSING FEVER
INFECTIOUS
NON - INFECTIOUS
BORRELIA RECURRENTIS TUBERCULOSIS HISTOPLASMOSIS
BECHETS DISEASE CHRONS DISEASE
INF DIS CLIN N AM 1033-411996
63
PNEUMOCOCCAL PNEUMONIA
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QUOTIDIAN FEVER - MALARIA
SALTHI DIAGNOSTIC METHODS 4TH EDITION 1905
65
PULSE TEMPERATURE RELATIONSHIPS
1/ 10 BPM
LEGIONNAIRES DISEASE DRUG FEVER SALMONELLA
INF DIS CLIN N AM 1033-411996
66
PEL-EBSTEIN FEVER
HODGKINS DISEASE 16 OF PATIENTS
67
HYPOTHERMIA - lt97F

• COLD EXPOSURE
• HYPOTHYROIDISM
• SEPSIS
• MEDICATIONS
• ELDERLY

POSTGRAD MED 85(5)188-2001989
68
RESPIRATORY RATE
69
RESPIRATORY RATE

• NORMAL 16-25 BR/MIN (AVG 20 BR/MIN)
• TACHYPNEA VARIES BUT USUALLY gt 25 BR/MIN
• CARDIO PULMONARY DISEASE
• MAY BE NORMAL AT TIMES
• BRADYPNEA - lt8 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.

KORY RC JAMA 165448-4501957
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ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST BIOTS INCREASED
INTRACRANIAL PRESSURE DRUGS- MEDULLA CHEYNE
STOKES CONGESTIVE HEART FAILURE DRUGS
CEREBRAL KUSSMAULS METABOLIC ACIDOSIS
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THE PNEAS

• DYSPNEA SOB - IS NOT THE SAME AS TACHYPNEA - RR
  gt 25 BR/MIN
• BRADYPNEA - RRlt 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

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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

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