R MICHAEL RODRIGUEZ M D ASSOCIATE PROFESSOR OF

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

THE VITAL SIGNS • BLOOD PRESSURE • PULSE • RESPIRATORY RATE • TEMPERATURE

THE BLOOD PRESSURE

WHY DO WE MONITOR THE BLOOD PRESSURE? • NORMOTENSION • HYPERTENSION • HYPOTENSION

HOW DO WE MEASURE BLOOD PREESURE? • DIRECTLY - CATHETER IN THE ARTERY • INDIRECTLY – AUSCULTATORY OR PALPATORY

THE BLOOD PRESSURE CUFF BLADDER CUFF

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 39: 465 -474, 1969 DOCK W NEJM 302: 1264 -1267, 1980 PENNY J ET AL. AM J HYPERTENSION 9: 839, 1996

HOW TO MEASURE THE BLOOD PRESSURE NO CAFFEINE OR TOBACCO 30 MINUTES PRIOR TO MEASUREMENT SIT 5 MINUTES IN A QUIET ROOM NO CLOTHING, LYMPHEDEMA OR CUTDOWNS PLACE THE DISTAL EDGE OF THE SPHYGMOMANOMETER 1. 5 CM PROXIMAL TO THE BRACHIAL PULSE USE BELL OR DIAPHRAGM PALPATE THE BRACHIAL ARTERY TO MAKE SURE IT IS PRESENT PATIENT’S ARM SHOULD BE AT HEART LEVEL THE LENGTH OF THE BLOOD PRSSURE CUFF’S BLADDER SHOULD ENCIRCLE 80% OF THE ARM’S CIRCUMFERENCE CUSHMAN ET AL. AM J HYPERTENSION 3: 240241, 1990 REEVES RA JAMA 273: 1211 -1217, 1995 INFLATE THE CUFF TO A PRESSURE 20 MMHG ABOVE SYSTOLIC IDENTIFIED BY PALPATION RELEASE THE PRESSURE CUFF BY 2 MM/SEC OBTAIN TWO READINGS AT LEAST 30 SECONDS – 2 MINUTES APART FROM THE SAME ARM. THE READINGS SHOULD NOT DIFFER BY MORE THAN 5 MMHG DIASTOLIC.

THE BLOOD PRESSURE BATES: A GUIDE TO PHYSICAL EXAMINATION; 8 TH EDITION

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 124: 887 -883; 1996 BATES GUIDE TO THE PHYSICAL EXAMINATION 8 TH ED.

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 32: 223 -237, 1967 MAXWELL MH LANCET 2: 33 -35, 1982

CIRCADIAN PATTERNS OF BLOOD PRESSURE NORMALLY BLOOD PRESSURE FALLS AT NIGHT AND EARLY MORNING. NEJM 347: 778 -779; 2002

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 42: 311 -313, 1940 PUTT AM NURS RES 15: 311 -316, 1966

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. 8: 147 -153; 1986 NEUFELD PD CAN MED ASSOC J. 135: 633 -637; 1986

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+2 D)/3 • PULSE PRESSURE – THE DIFFERENCE BETWEEN THE SYSTOLIC AND DIASTOLIC BP

WHAT IS CONSIDERED TO BE A NORMAL AND HIGH BLOOD PRESSURE? NORMAL < 120 MMHG SYSTOLIC < 80 MMHG DIASTOLIC HIGH NORMAL 130 – 139 MMHG SYSTOLIC 85 -89 MMHG DIASTOLIC HIGH > 140 MMHG SYSTOLIC > 90 MMHG DIASTOLIC JAMA 273: 1211 -1217; 1995

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. SINGER AJ ARCH INTERN MED 156: 2005 -2006; 1996 FISHER CM NEJM 265: 912 -913; 1961

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. JAMA 273: 1211 – 1217, 1995

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. 106: 316 -320; 1983

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. WIDE NARROW AORTIC REGURGITATION DECREASE IN LV STROKE VOLUME FEVER TAMPONADE ANEMIA PERICARDIAL CONSTRICTION AV FISTULA AORTIC STENOSIS BERI PAGET’S DISEASE CIRRHOSIS THYROTOXICOSIS PREGNANCY EXCERCISE

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.

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.

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. MESSERLI FH NEJM 271: 1548 -1551; 1985 TSAPATASARIS NP ARCH INTERN MED 151: 2209 – 2211; 1991

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.

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.

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.

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. JAMA 281: 1022 – 1029, 1999

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. GROSS CR J EMERG MED 10: 267 -274; 1992

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 - > 20 MMHG 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 61: 125 -130; 1971

THE PULSE

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

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. SNEED NV ET AL. HEART LUNG 21: 427 -433; 1992 SPODICK DH SOUTH MED J 89: 666 -667; 1996

THE NORMAL ARTERIAL PULSE

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

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 27: 1407 -1412; 1993 SAUNDERS DE ET AL. AM J CARDIOL 9: 223 -226; 1962

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 19: 519 -524; 1957 CIESIELSKI J ET AL. JAMA 175: 475 -477; 1961

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 27: 708 -709; 1971

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 39: 655 -661; 1969

ABNORMALITIES OF THE ARTERIAL PULSE AORTIC STENOSIS AORTIC REGURGITATION CONGESTIVE HEART FAILURE CARDIAC TAMPONADE

THE PULSE IN VARIOUS CLINICAL STATES LV OUTFLOW OBSTUCTION PULSUS BISFERIENS - AI NORMAL DICROTIC PULSE BRAUNWALD A TEXTBOOK OF CARDIOVASCULAR MEDICINE 5 TH ED.

THE TEMPERATURE

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

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.

TECHNIQUE OF MEASURING AN ORAL TEMPERATURE • GLASS OR ELECTRONIC THERMOMETER. • GLASS – SHAKE THERMOMETER DOWN TO 35˚C (96˚F) OR BELOW. • INSERT 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.

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. RABINOWITZ RP ET AL. ARCH INT MED 156: 777 -780; 1996 HORVATH SM ET AL. JAMA 144: 1562 -1565; 1950 NICHOLS GA ET AL. NURS RES 15: 307 -310; 1966

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 22: 435 -441; 1993 CHU A ET AL. PARAPLEGIA 33: 476 -479; 1995

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. • O 2 BY NASAL CANNULA – NO CHANGE • CERUMEN – DECREASES TEMPERATURE TANDBERG D ET AL. NEJM 308: 945 -946; 1983 LIM-LEVY F NURS RES 31: 150 -152; 1982 MARON MB NEJM 309: 612 -613; 1983(LETTER) TENDRUP DE ET AL. AM J EMERG MED 7: 150 -154; 1989

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 10: 33 -41; 1996

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. INF DIS CLIN N AM 10: 33 -41; 1996

DOUBLE QUOTIDIAN FEVER ADULT STILL’S DISEASE RIGHT SIDED GONOCOCCAL ENDOCARDITIS VISCERAL LEISHMANIASIS INF DIS CLIN N AM 10: 33 -41; 1996

FEVER PATTERNS INTERMITTENT FEVER SEPSIS ABCESS REMITTENT FEVER VIRAL URI MYCOPLASMA CONTINUOUS FEVER BRUCELLOSIS RMSF INF DIS CLIN N AM 10: 33 -41; 1996

RELAPSING FEVER INFECTIOUS NON - INFECTIOUS BORRELIA RECURRENTIS BECHET’S DISEASE TUBERCULOSIS CHRON’S DISEASE HISTOPLASMOSIS INF DIS CLIN N AM 10: 33 -41; 1996

PNEUMOCOCCAL PNEUMONIA

QUOTIDIAN FEVER - MALARIA SALTHI DIAGNOSTIC METHODS 4 TH EDITION 1905

PULSE – TEMPERATURE RELATIONSHIPS 1˚/ 10 BPM LEGIONNAIRE’S DISEASE DRUG FEVER SALMONELLA INF DIS CLIN N AM 10: 33 -41; 1996

PEL-EBSTEIN FEVER HODGKINS DISEASE 16% OF PATIENTS

HYPOTHERMIA - <97˚F • • • COLD EXPOSURE HYPOTHYROIDISM SEPSIS MEDICATIONS ELDERLY POSTGRAD MED 85(5): 188 -200; 1989

RESPIRATORY RATE

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

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 165: 448 -450; 1957

ABNORMAL BREATHING PATTERNS APNEA - CARDIAC ARREST BIOTS – INCREASED INTRACRANIAL PRESSURE – DRUGS- MEDULLA CHEYNE STOKES – CONGESTIVE HEART FAILURE – DRUGS – CEREBRAL KUSSMAULS – METABOLIC ACIDOSIS

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

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