Bates Reading: Vital Signs (pages 114-125, 134)

  • The blood pressure cuff should be:
    • Width = 40% of upper arm circumference
    • Length = 80% of upper arm circumference
  • If the wrong sized cuff is used:
    • If too small, blood pressure will read too high
    • If too large, blood pressure will read too low on a small arm, but high on a large.
  • To ensure an accurate blood pressure reading:
    • Avoid smoking, don’t drink caffeine for 30 min.
    • Have arm at heart level, preferably seated for at least 5 min
    • Be in quiet place. Have patient’s arm free of clothing.
  • What is an auscultatory gap? What kind of errors can they cause?
    • A gap of silence sometimes heard between systolic and diastolic pressures, which can lead to overestimation or underesteimation of blood pressure. It is associated with arterial stiffness.
  • How do you classify blood pressure according to JNCVII?
    • Less than 120/80 is normal
    • Prehypertension is through 140/90
    • Hypertension I is through 160/100
    • Hypertension II is above 160/100
  • Physically you’d expect someone with coarctation of the aorta to have:
    • Hypertension in the upper extremities, low blood pressure in the lower extremities. Delayed femoral pulse.
  • Orthostatic hypotension is:
    • The drop of systolic by 20 points and diastolic by 10 within 3 minutes of standing.
  • Normal heart rate is:
    • 50-90 beats/min
  • Hyperpyrexia and hypothermia are:
    • Hyperpyrexia = extreme elevation in body temperature (“fever”) above 106 (41)
    • Hypothermia = drop in body temperature below 95 (35)
  • Oral vs. rectal vs. tympanic temperatures
    • Rectal is higher than oral (axillary → oral → rectal → tympanic)
    • Axillary is lower than oral
    • Tympanic membrane temperature measures core body temperature, which is higher than oral temperature.
  • Normal respiratory rates:
    • 14-20 per minute
  • Abnormal breathing rhythms:
    • Tachypnea – rapid shallow breathing
    • Bradypnea – slow breathing
    • Hyperpnea – “Cheyne-Stokes breathing” – periods of breathing alternating with periods of apnea.
  • What’s the significance of an irregularly irregular pulse?
    • Atrial fibrillation

Bate’s Reading: Peripheral Vascular System (pages 471-499)

  • Common signs of peripheral vascular disease:
    • Pain in arms and or legs
    • Cold, numbness in legs
    • Color changes in fingertips or toes in cold weather
    • Swelling in calves, legs or feet
    • Intermittent claudication (cramping)
  • Raynauds phenomena:
    • Wrist pulses normal, but distal arteries have spasms.
  • Risk factors for PAD:
    • Younger than 50: diabetes, atherosclerosis, smoking, dyslipidemia, hypertension, hyperhomocysteinemia
    • 50-69 years old: smoking, diabetes
    • 70 years or older
  • Ankle-brachial Index to screen for PAD:
    • Take measurements in ankle and brachium and compare with ABI to assess Peripheral Arterial Disease (PAD).
    • Below 0.39 = severe PAD
    • 0.59-0.40 = moderate PAD
    • 0.89 to 0.60 = Mild PAD
    • Above 0.90 = normal.
  • Current recommendation for screening of aortic aneurysm:
    • Do ultrasound to men between 65 and 75 yrs with history o “ever smoking” (100 cigarettes in lifetime).
  • Current recommendations for screening of renal artery disease”
    • Hypertension before 30 or severe hypertention after 55, or accelerated hypertension
    • New worsening of renal function
    • Unexplained small kidney
    • Screen with ultrasound
  • Peripheral artery examination:
    • Measure blood pressure in both arms
    • Palpate carotid upstroke, auscultate for bruits
    • Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries.
    • Inspect ankles and feet for color, temperature, skin integrity, etc. hypertrophic nails.
  • Grading pulses:
    • 0 = absent, can’t palpate
    • 1+ = diminished, weaker pulse than expected
    • 2+ = brisk, expected (normal)
    • 3+ = bounding
  • Examining the epitrochlear and superficial inguinal lymph nodes:
    • Feel between biceps and triceps muscle, about 3 cm above medial epicondyle for node
  • Signs of venous thrombosis:
    • Tight, bursting pain, usually in calf. May be painless. Feel for tender veins when you squeeze calf.
  • Allen test:
    • Wrist in ball
    • Press ulnar and radial artery together
    • Let go if ulnar… if hand still white, then have occlusion there
    • Do same for radial.
  • Color changes of arterial insufficiency
    • Pallor when raise arm or leg.
  • Signs and symptoms of advanced chronic arterial vs. venous insufficiency:
    • Chronic Venous insufficiency: Venous engorgement, normal pulse, browning of skin, ulcers, edema, normal temperature
    • Chronic Arterial insufficiency: decreased pulse, pale on elevation, cool temperature.
  • Bates Reading: Head and Neck exam (pages 195-205,236-243, 249-253,281)
  • How does thyroid disease cause hair change?
    • Course hair = hypothyroidism
    • Fine hair = hyperthyroidism
  • Hirsutism:
    • Excessive facial hair
  • Hyperopia vs Presbyopia vs. Myopia
    • Hyperopia = far-sighted
    • Presbyopia = aging vision
    • Myopia = near-sighted
  • Diplopia
    • Diplopia = double-vision
  • Tinnitus vs. Vertigo
    • Tinnitus = ringing
    • Vertigo = dizziness (spinning sensation)
  • Rhinnorrhea vs. epistaxis
    • Rhinnorrhea = leaky nose
    • Epistaxis = bleeding nose
  • Signs and symptoms of hyper vs. hypothyroidism
    • Hyperthyroidism – intolerance to warmth, preference for cold, increased sweat, bulging eyes.
    • Hypothyroidism – intolerance to cold, preference for warm, decreased sweating, goiter
  • anterior vs. posterior triangle of the neck
    • Anterior – Mandible, SCM, Midline of neck
    • Posterior – SCM, Traps, Clavicle. Omohyoid runs across
  • Where is the thyroid gland?
    • Below and around cricoids cartilage
  • Where are the cervical lymph nodes
    • Around Sternocleidomastoid
  • Enlarged supraclavicular lymph nodes mean…
    • Metastasis from a thoracic or abdominal malignancy
  • Tender vs. hard and fixed lymph nodes
    • Tender = inflammation
    • Hard and fixed = malignancy
  • Shotty nodes and their significance:
    • Small, mobile, discrete, nontener (like a “shot”) – found in normal people.
  • Examining the thyroid gland:
    • Feel below the cricoids cartilage
    • Tell patient to swallow water.
    • Feel the thyroid rise.
  • Migraine vs. cluster vs. tension headaches
    • Migraine – unilateral, throbbing, fairly rapid,
    • Tension – temporal, tightening pain, gradual
    • Cluster – unilateral, retro-orbital, deep pain, abrupt
  • Compare symptoms: Cushing’s Syndrome vs. myxedema vs. nephrotic syndrome vs. acromegaly
    • Cushing’s Syndrome – moon face, red cheeks, hirsuitism, due to excessive adrenal cortisol production.
    • Myxedema (hypothyroidism) – goiter
    • Nephrotic Syndrome – edematous, pale face. Swollen eyes.
    • Acromegaly – increased bone growth due to too much growth hormone.