Vital Signs

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Chapter 2 Vital Signs

Generalities

Measuring vital signs is the initial but still essential part of bedside examination. Unfortunately, this task is often relegated to nonphysicians, sometimes even technicians. Yet, as the word implies, vital signs can provide a wealth of crucial information, some requiring special skills and knowledge.

A. Vital Statistics

1 What are the vital statistics?

They are weight and height, both important measurements (see Chapter 1, General Appearance, questions 30–49). In contrast to vital signs, vital statistics are usually stable and thus less clinically helpful.

C. Temperature

12 What are the main types of “intermittent” fever?

The classic ones are those of malaria, one of the three great medical killers of mankind (the others being TB and HIV, plus, of course, war and organized religion). Intermittent malarial fevers vary considerably, based on organism involved:

image Quotidian fever: From the Latin quotidianus, daily. This is a fever whose paroxysm (and resolution) occurs every day. It is usually caused by a double tertian malaria, due to infection by two distinct groups of Plasmodium vivax, alternately sporulating every 48 hours. It may also be caused by the most pernicious malarial parasite (P. falciparum), combined with vivax, or by two distinct falciparum generations that mature on different days, thus resulting in a fever that occurs twice a day. Note that a double quotidian fever is a daily two-spikes fever that is not malarial, but gonococcal. It used to be present in 50% of endocarditis cases, but today is mostly extinct.

image Tertian fever: From the Latin tertianus, third. This is a P. vivax fever that recurs every third day, counting the day of an episode as the first. Hence, it occurs every 48 hours (every other day).

image Quartan fever: From the Latin quartanus, fourth. This is a P. malariae fever that recurs every fourth day, counting the day of an episode as the first. Hence, it occurs every 72 hours. Note that a double quartan is instead an infection with two independent groups of quartan parasites, so that the febrile paroxysms occur on two successive days, followed by one without fever.

image Malignant tertian fever: This is the fever of P. falciparum (falciparum fever, or aestivo-autumnal fever, or Roman fever because it was a common ailment in the countryside of Rome up to World War II). It is characterized by 48-hour paroxysms of a severe form of malaria, occurring with acute cerebral, renal, or gastrointestinal manifestations. These are usually due to clumping of the infected red blood cells, causing secondary capillary obstruction and ischemia.

27 What are the signs and symptoms of hypothermia?

They vary, depending on the degree of hypothermia and the type of underlying disorder (a stroke, for example, may obscure the signs of hypothermia). Moreover, symptoms and signs are often a continuum, and there is major variability among patients (Table 2-1).

Table 2-1 Signs and Symptoms of Hypothermia

Mild Hypothermia Moderate Hypothermia Severe Hypothermia
Confusion Level of consciousness diminishes Unresponsiveness or coma
Tachypnea Delirium May appear dead*
Tachycardia Bradycardia Loss of reflexes
Vasoconstriction Bradypnea Very cold skin
Lethargy Shivering stops Hypotension
Shivering Reflexes slowed Pulmonary edema
Ataxia Cold diuresis Respiratory failure
Dysarthria   Profound acidemia and ventricular fibrillation
Loss of fine motor coordination    

* Hence, you are never dead until you are warm and dead (see Chapter 20, Coma).

D. Heart Rate and Rhythm

28 What is the history behind the measurement of heart rate through the arterial pulse?

Interpretation of a weak pulse as a bad prognostic indicator goes all the way back to third-millennium Egypt, but only in Ptolemaic and Hellenistic Alexandria (third and second century BC) did such knowledge eventually get applied to the heart rate. The two leading figures of the time were Herophilus of Chalcedon and his rival Erasistratus of Cos, both Hippocratic Greeks who had moved to Egypt to perform dissections, practice medicine, and conduct research. Erasistratus gave heart valves the names they still carry today and eventually committed suicide because of incurable cancer. Herophilus described not only the duodenum (which he named after the Greek word for 12 fingers, the measurement of its length), but also the liver, spleen, circulatory system, eye, brain, and genital organs. He gave great importance to drugs (“the hands of God”) and was the first to suggest that physicians could be guided diagnostically by the arterial pulse, which he counted by using a portable water clock. Influenced by musical theories, he even developed a classification of pulse characteristics, based on rate, rhythm, strength, and amplitude.

Five hundred years later, the Romans perfected this knowledge through the work of Galen, who defined the diagnostic significance of the pulse in terms of force, length, and speed. Half a millennium later, the Chinese developed an even more complicated classification, requiring analysis of the pulse at various sites and simultaneous timing with the physician’s own respiration. Four pulsations to each respiratory cycle constituted the normal adult rate. To avoid possible distractions, practitioners were asked to banish all extraneous thoughts prior to an exam and to conduct their assessments in the morning (and on an empty stomach).

Things got a little easier in the 18th century, when the British physician John Floyer (1649–1734) asked a local watchmaker to build him a portable clock with a special second hand that ran exactly for 1 minute. This allowed him to accurately determine the speed of the pulse and to publish in 1707 “The Physician’s Pulse Watch,” a little treatise that suggested the use of the watch for a more objective determination of the pulse. Floyer also had other and more eccentric interests. One, for example, involved Dr. Samuel Johnson, whom he examined as a 5-year-old child, eventually recommending a healthy dose of “Royal Touch” as remedy against various evils (Dr. Johnson’s mother complied, and so did Queen Anne, who touched and reportedly “healed” the child). Other eccentricities concerned a lifelong fascination with minerals, vegetables, and animals (he wrote a book about discovering their virtues through taste and smell) and a similarly lifelong fascination with cold bathing (he wrote a book on that, too). Maybe because of all this baggage, Floyer’s recommendations on the pulse went mostly unheard, so that for decades practitioners continued to rely more on their “feel” of the pulse, than on an objective assessment of rate and rhythm.

It was only during the mid-19th century that measurement through a watch became the standard of medical care. That was also the time when Adams and Stokes made the connection between an inappropriate slowing of the pulse and some episodes of syncope and seizure, thus shifting attention from the brain to the heart (and to physical exam).

35 What are the features of the pulse one should consider when evaluating arrhythmias?

Its regularity (or lack thereof) and its response to vagal maneuvers. In this regard:

E. Blood Pressure

42 Who was Potain? How did he contribute to the measurement of blood pressure?

Pierre Potain was one of the several well-rounded giants produced by 19th-century French medicine. A true humanist who never went to sleep without reading a few pages of his beloved Pascal, he was also an interesting man. As an intern, he survived a rendezvous with cholera (which he contracted during the 1849 epidemic) and then an even more dangerous rendezvous with the Prussians (whom he faced during the 1870 war, fighting as a simple foot soldier). Unscathed by these experiences, Potain went on to become one of Trousseau’s protégés, a great promoter of cardiac auscultation, and a very compassionate teacher (he was famous for answering his own question if an examinee failed to provide the answer in time). Before dying peacefully in his sleep at age 76, he made many landmark contributions: he was the first to describe (and name) the gallop rhythms, the opening snap of mitral stenosis, the tambour S2 of syphilitic aortitis (“Potain’s sign”), the hepatic pulsatility of tricuspid regurgitation, and the waveform analysis of the internal jugular vein. He even inspired the figure of the great Parisian diagnostician in Proust’s Remembrance of Things Past. His unique contribution to blood pressure measurement consisted of a contraption made of a compressible bulb filled with air and attached by a rubber tube to an aneroid manometer. To measure the blood pressure, the bulb was pressed on the peripheral artery of the patient until the pulse disappeared. The manometric recording at time of pulse disappearance reflected the patient’s systolic blood pressure. Potain also taught Riva-Rocci, the next link in this blood pressure saga.