BDD CH4 – Part2

The Vital Signs

• Vital Signs: 1.Blood pressure, 2.heart rate, 3.respiratory rate, and 4.temperature.
• Vital Signs provide initial information influencing evaluation tempo and direction.
• Review Vital Signs at the outset of the encounter (visit).
• If abnormal, retake them during the visit.
• Measure blood pressure and heart rate.
• Count heart rate for 1 minute using palpation or stethoscope.
• counting respiratory rate quietly.
• Take temperature at various sites based on patient and equipment.

Blood Pressure
• Accuracy of blood pressure measurements varies based on the method used.
• 1.Manual and 2.automated cuffs are common for office screening, but elevated readings require
confirmation with home and ambulatory monitoring.
• Ambulatory and home blood pressure monitoring are more predictive of cardiovascular disease and
end organ damage than manual office measurements.
• Automated ambulatory monitoring measures blood pressure at preset intervals over 24 to 48 hours,
considered the reference standard for confirming elevated office blood pressures.
• Errors in office readings can lead to misdiagnosis and unnecessary treatment.

Methods for Measuring Blood Pressure

1. Auscu-ltatory Office Blood Pressure Measurements
• Common, inexpensive, subject to patient anxiety.
• Requires multiple visits for measurements.
• Needs ambulatory or home monitoring for masked hypertension detection.
• Single measurements have 75% sensitivity and specificity compared to ambulatory monitoring.

2. Automated Osci-llometric Office Blood Pressure Measurement

• Requires optimal patient positioning and device calibration.
• Takes multiple measurements over short period.
• Requires confirmatory measurements to reduce misdiagnosis.
• Comparable sensitivity and specificity to manual measurements.

3. Home Blood Pressure Monitoring

• Accurate, easy-to-use, less expensive than ambulatory monitoring.
• More predictive of cardiovascular risk than office measurements.
• Requires patient education and repeated measurements.
• Detects white coat hypertension in 20% and masked hypertension in 10%.
• Has 85% sensitivity and 62% specificity compared to ambulatory monitoring.

4. Ambulatory Blood Pressure Monitoring

• Automated, clinical "gold standard."
• Provides 24-hour averages and averages of daytime, nighttime, systolic, and diastolic blood
pressures.
• Shows nocturnal blood pressure dips or stays elevated.
• More expensive and may not be covered by insurance.

Definitions of Hypertension
● Office manual or automated blood pressure based on the average of 2 readings on 2 separate
occasions: ≥140/90

● Home automated blood pressure: <135/85

● Ambulatory automated blood pressure:

● 24-hour average: ≥ of 130/80

● Daytime (awake) average: ≥135/85

● Nighttime (asleep) average: >120/70

Types of Hypertension: 1.White Coat (high blood pressure), 2.Masked (normal blood pressure but
when its monitoring at home appear elevated), and 3.nocturnal (elevated blood pressure at night)
• Ambulatory blood pressure monitoring is recommended for diagnosis and treatment evaluation.

■ White coat hypertension (isolated clinic hypertension):

• Defined as blood pressure ≥140/90 in medical settings and mean ambulatory readings <135/85.
• Carries normal to slightly increased cardiovascular risk and doesn't require treatment.
• Affects due to conditioned anxiety response.
• Poor measurement technique, presence of physician or nurse, and prior hypertension diagnosis can
alter readings.
• Automated device replacement can reduce "white coat effect."

■ Masked hypertension:
• Defined as office blood pressure <140/90, elevated daytime blood pressure >135/85.
• More serious than untreated hypertension.
• Increases risk of cardiovascular disease and end-organ damage in untreated adults.

■ Nocturnal hypertension:
• Physiologic blood pressure dips during night shifts.
• <10% nocturnal fall associated with poor cardiovascular outcomes.
• Identified through 24-hour ambulatory blood pressure monitoring.

Choosing the Correct Blood Pressure Cuff (Sphygmomanometer).

• 4 types of office blood pressure devices: 1. mercury, 2. aneroid, 3. electronic, and 4. hybrid.
• Hybrid devices combine electronic and ambulatory features.
• Blood pressure can be displayed as a simulated mercury column, aneroid reading, or digital readout.
• All measuring instruments should be routinely tested using international protocols.
• Some offices still use mercury cuffs, modified to minimize environmental spill risk, for routine office
measurements and nonmercury device accuracy evaluation.
Selecting the Correct Size Blood Pressure Cuff
• The inflatable bladder should fit the patient's arm.
• The width should be 40% of the upper arm circumference.
• The length should be 80% of the upper arm circumference.
• The standard cuff size is 12 × 23 cm, suitable for arm circumferences up to 28 cm.

Steps to Ensure Accurate Blood Pressure Measurement

1. Patient should avoid smoking, caffeine, or exercise for 30 minutes before measurement.
2. Examining room should be quiet and warm.
3. Patient should sit quietly for 5 minutes in a chair with feet on the floor.
4. Arm should be free of clothing, dialysis fistulas, brachial artery cutdown scars, or lymphedema.
5. Palpate the brachial artery to confirm a viable pulse.
• Position arm at heart level, near the fourth interspace.
6. Rest arm on a table or support at midchest level if seated or standing.

1. Positioning Cuff and Arm

• with the arm at the heart level
• Center inflatable bladder over brachial artery. Lower border of the cuff should be 2.5 cm above
antecubital.
• Secure cuff snugly.
• Flex patient's arm at elbow.

2. Estimate the Systolic Pressure and Add 30 mm Hg

• Estimate systolic pressure by palpation.
• Rapidly inflate cuff until radial pulse disappears.
• Read pressure on manometer and add 30 mm Hg.
• Use this sum for subsequent inflations to avoid discomfort and errors.
• Deflate cuff promptly and wait 15-30 seconds.

3. Position the Stethoscope Bell Over the Brachial

Artery
• Lightly place stethoscope bell over brachial artery.
• Make full air seal with rim because the sounds to be heard.
• Korotkoff sounds, low pitch, better heard with bell.

4. Identify the Systolic Blood Pressure

• Rapidly inflate cuff to target level.
• Slowly deflate cuff at 2 to 3 mm Hg per second.
• Note level when two consecutive beats sound.

5. Identify the Diastolic Blood Pressure.

• Slowly deflate cuff until muffled sounds disappear.
• Confirm disaprance point by listening as pressure falls another
10-20 mm Hg.
• Rapidly deflate cuff to zero.
• Disappearance point, a few mm Hg below muffling point, provides best diastolic pressure estimate.

6. Average Two or More Readings.

• Average 2 or more readings of systolic and diastolic levels to the nearest 2 mm Hg.
• Wait 2 or more minutes and repeat readings.
• If first two readings differ by more than 5 mm Hg, take additional readings.
• Hold dial directly when using an aneroid instrument.
• Avoid slow or repetitive inflations to avoid venous congestion.

7. Measure Blood Pressure in Both Arms At Least Once.

• Measure blood pressure in both arms at least once.
• Expect pressure difference of 5-10 mm Hg.
• Subsequent readings on arm with higher pressure.

Classification of Normal and Abnormal Blood Pressure.

• For patients with diabetes and chronic kidney disease, a higher treatment threshold is
recommended.

Orthostatic Hypotension.
• Common in older adults.
• Measure blood pressure and heart rate in 2 positions: supine after rest and standing up.
• Systolic pressure drops or remains unchanged as patient rises.
• Orthostatic hypotension: drop in systolic at least 20 mm Hg or diastolic blood pressure at least 10
mmHg within 3 minutes of standing.

Special Situations
1. Weak Korotkoff Sounds
• Technical issues like incorrect stethoscope placement, insufficient skin contact, and venous
 engorgement.
• Potential vascular disease or shock.
• Alternative methods: Doppler probe or direct arterial pressure tracings.
2. White Coat Hypertension
• Encourage relaxation.
• Remeasure blood pressure later.
• Consider automated office readings or ambulatory recordings.
3. The Obese or Very Thin Patient
• Use a 16 cm wide cuff for obese arm.
• For short upper arm, use a thigh cuff or very long cuff.
• For arm circumference >50 cm, wrap cuff around forearm, hold at heart level, and feel
for radial pulse.
• Use Doppler probe at radial artery or oscillometric device.
• For very thin arm, consider a pediatric cuff.
4. Arrhythmias
• Irregular rhythms cause pressure variations, unreliable measurements.
• Ignore occasional premature contractions.
• Monitor average of several observations.
• Ambulatory monitoring recommended for 2-24 hours.
5. The Hypertensive Patient with Systolic Blood Pressure Higher in the Arms
than in the Legs
Compare blood pressure in the arms and the legs and assess “femoral delay” at least once in
every hypertensive patient.

Coarctation of the Aorta and Blood Pressure Measurement

• Coarctation of the aorta results from narrowing of the thoracic aorta.
• Typically, it presents with systolic hypertension greater in the arms than the legs.
• In normal patients, systolic blood pressure should be 5-10 mm Hg higher in the lower
extremities than in the arms.
• Blood pressure in the leg can be determined using a wide, long thigh cuff with a bladder size
of 18 × 42 cm.
• Pulse palpation and comparison of volume and timing are crucial.
Heart Rate and Rhythm
- Examine the arterial pulses,
- the heart rate and rhythm,
- and the amplitude and
- contour of the pulse wave

Heart Rate.
• Uses radial pulse to measure heart rate.
• Compresses radial artery with index and middle fingers.
• Detects maximum pulsation.
• If rhythm is regular, count for 30 seconds and multiply by 2.
• If rate is fast or slow, count for 60 seconds.
• Normal range is 60 to 90 to 100 beats per minute.

Rhythm.
• Palpation of radial pulse.
• Assessment of rhythm at apex using stethoscope.
• Premature low amplitude beats may underestimate heart rate.
• Identification of regular or irregular rhythm.:

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 1.breathing rate, 2.rhythm, 3.depth, and 4.effort.
• Count respirations in 1 minute using visual inspection or stethoscope.
• Adults typically take 20 breaths per minute in a quiet, regular pattern.

Temperature
• Measured internally at 37°C (98.6°F).
• Lowest in early morning, highest in afternoon and evening.
• Women have a wider normal temperature range than men.
• Clinical practice uses noninvasive measurements: from 1.oral, 2.rectal, 3.axillary, 4.tympanic
membrane, and 5.temporal arteries.

■ Oral and Rectal Temperature Measurements

• Oral temperatures generally lower than core body temperature.
• Rectal temperatures lower by 0.4 to 0.5°C.
• Axillary temperatures higher by approximately 1°.
- take 5-10 minutes to register.

■ Tympanic Membrane Temperatures

• Variable compared to oral or rectal temperatures.
• Oral and temporal artery temperatures correlate with pulmonary artery.
• Lower by about 0.5°C in adults.

1. Oral Temperatures.
• Electronic thermometers are replacing glass thermometers due to breakage and
mercury exposure.
• Use 1.disposable cover over probe, 2.insert under tongue, 3.close both lips, and
watch for digital readout.
• Accurate temperature recording takes about 10 seconds.
• Glass thermometers: 1.shake to 35°C or below, 2.insert under tongue, 3.close
lips, 4.wait 3 to 5 minutes, 6.read, 7.reinsert, 8.read again.
• Note: Hot or cold liquids, smoking can alter reading, delay taking for 10 to 15
minutes.
2. Rectal Temperatures
• Patient lying on one side with hip flexed.
• Selecting a rectal thermometer with stubby tip.
• Inserting thermometer into anal canal.
• Reading after 3 minutes.
• Using electronic thermometer after lubricating probe cover.
• Waiting for 10 seconds for digital temperature recording.
3. Tympanic Membrane Temperatures
• Shares blood supply with hypothalamus, where temperature regulation occurs.
• Accurate temperature readings require access to the tympanic membrane.
• External auditory canal free of cerumen for accurate readings.
• Position probe in canal for infrared beam aimed at tympanic membrane.
• Wait for 2 to 3 seconds for digital temperature reading.
4. Temporal Artery Temperatures
• Utilizes temporal artery's location within a millimeter of forehead, cheek, and
ear lobes.
• Place probe against forehead center, depress infrared scanning button, brush
device across forehead, cheek, and earlobe.
• Display records highest temperature measurement.
• Industry suggests combined forehead and behind-ear contact for more accurate
results.

Acute and Chronic Pain

Assessing Acute and Chronic Pain
• Pain is defined as an unpleasant sensory and emotional experience linked to tissue damage.
• Chronic pain is defined as noncancer pain persisting for more than 3 to 6 months, lasting
more than 1 month beyond an acute illness or injury, or recurring at intervals of months or
years.
• Adopting a multidisciplinary, measurement-based approach to pain assessment is
recommended.

1. The Patient’s History

• Gather patient's complete history of pain.
• Discuss the origin and quality of pain.
• Evaluate the pain's pattern and intensity.
• Use 7 features of pain to understand it.
• Ask about treatments tried, including medications, physical therapy, and
alternative medicines.
• Identify drugs that interact with analgesics and reduce their efficacy.
• Explore comorbid conditions: like arthritis, diabetes, HIV/AIDS, substance
abuse, sickle cell disease, or psychiatric disorders.
• Understand the impact of chronic pain on daily activities, mood, sleep, work,
and sexual activity.
2. Assessing Severity of the Pain
• Use a consistent method for pain severity assessment.
• Common scales include: Visual Analog Scale, Numeric Rating Scale, and
Wong-Baker FACES Pain Rating Scale.
• Other multidimensional tools include Brief Pain Inventory and McGill Pain
Questionnaire.
• Wong-Baker FACES® Pain Raiting Scale suitable for 1.children, 2.language-
impaired patients, and 3.patients with cognitive impairment.

3. Health Disparities
• Lower use of analgesics in emergency rooms for African-American and
Hispanic patients.
• Disparities in use of analgesics for cancer, postoperative, and low back pain.
• Contributed by clinician: stereotypes, language barriers, and unconscious
biases.
• Steps to address include: 1.critiquing communication style, 2.seeking
information, and 3.improving patient education and 4.empowerment techniques.
4. Types of Pain
- [Noci-ceptive (somatic) Pain]
• Linked to tissue damage to skin, musculoskeletal system, or viscera.
• Mediated by: afferent A-delta and C-fibers of sensory system.
• Sensitized by: inflammatory mediators and modulated by psychological
processes and neurotransmitters.
• Can be acute or chronic.
- [Neuro-pathic Pain]
• Direct consequence of a lesion or disease affecting the somatos-ensory system.
• Over time, may become independent of the inciting injury, becoming burning,
lancinating, or shock-like.
• Persistent even after healing from the initial injury.
• Mechanisms to evoke neuropathic pain: include central nervous system brain or
spinal cord injury, peripheral nervous system disorders, and referred pain
syndromes.
• Triggers induce: changes in pain signal processing through "neuronal
plasticity," leading to pain persisting beyond initial injury healing.
 - [Central Sensitization Pain]
• Alters central nervous system processing of sensation, amplifying pain signals.
• Lowers pain threshold to nonpainful stimuli.
• Response to pain may be more severe than expected.
• Fibromyalgia, a condition with overlap with depression, anxiety, and
somatization, responds best to medications modifying neurotransmitters.
- [Psychogenic Pain]
• Influences patient's pain report.
• Includes: psychiatric conditions, personality, coping styles, cultural norms, and
social support systems.
- [Idio-pathic pain ]
is pain without an identifiable etiology.
Managing Chronic Pain: Steps for Measurement-Based Care
• Step1; Measure pain intensity and interference using validated
questionnaires.
• Step2; Measure mood with PHQ-4 and Primary Care-PTSD.
• Step3: Measure effect of pain on sleep using opioid doses.
• Step 4 :Measure opioid dose and calculate equivalency using web-
based calculators.

Chronic Pain Treatment and Overdose Risks

• Chronic pain treatment requires expertise in nono-pioid, opioid, and
adjuvant analgesics, as well as behavioral and physical therapy.
• Risk factors for fatal overdose include age 65 or older, depression,
substance abuse, and concurrent benzodiazepine treatment.
• To avoid hazards, acquiring skills in pain assessment and therapeutics
and using validated substance abuse screening and intervention
protocols are recommended.
Recording Your Findings
Physical Examination Write-up
• Starts with a general description of patient's appearance.
• Uses General Survey for findings.
• Transitions to using phrases for more detailed descriptions.

Physical Examination Recording Guidelines

• Use vivid, graphic adjectives to convey patient's unique features.
• Avoid clichés like "well-developed," "well-nourished," or "in no acute distress."
• Record vital signs taken at the time of the examination.
• Use abbreviations for blood pressure, heart rate, and respiratory rate.
• Example: "Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and cheerful. Height is
5′4″, weight 135 lbs, BMI 24, BP 120/80, right and left arms, HR 72 and regular, RR 16, temperature
37.5°C."
• Example: "Mr. Jones is an elderly man who looks pale and chronically ill. Alert, good eye contact,
unable to speak more than two or three words at a time due to shortness of breath. He has intercostal
muscle retraction when breathing and sits upright in bed. He is thin, with diffuse muscle wasting.