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Vital Signs (Blood Pressure (Secondary hypertension (The possibilities…

- - - - Examples include severe aortic insufficiency; patent ductus arteriosus; and high-output cardiac failure, as in pregnancy, fever, anemia, thyrotoxic heart disease, and beriberi.
        
        In aortic insufficiency, at least, we know that muffling best approximates the directly measured intra-arterial pressure when the indirect diastolic blood pressure is “zero” (Goldstein and Killip, 1962).
        
        An extremely widened pulse pressure > 50&percnt is seen
        
        If an extremely wide pulse pressure is found in only one limb, one should search for an arteriovenous fistula in that limb. The Branham sign (see later in this chapter) will be confirmatory even without angiography.
  - - - R-type (high renin)
        
        total peripheral resistance, set by the renin-angiotensin system, is high
        
        responds to beta-blockers and angiotensin converting enzyme inhibitors (Laragh, 2001).
      - V-type (low renin)
        
        sodium retention and expanded plasma volume support increased cardiac output.
        
        predominantly found in black patients, responds well to sodium restriction and diuretics
  - - - The systolic blood pressure in the lower extremity is found to be significantly less (at least 6 mm Hg) than in the upper extremity in cases of obstruction in the lower extremity vascular tree.
        
        most common cause in the young hypertensive is coarctation of the aorta
        
        most common cause of obstruction in the elderly is atherosclerosis
      - The systolic blood pressure in the lower extremities is significantly higher than in the upper extremities in patients with occlusion of the upper extremity vasculature, as in Takayasu disease, Buerger disease, or other selective disease of the upper extremities;; in some cases of dissecting aneurysm; and in conditions of high stroke volume (the Hill sign).
        
        In the Hill sign, especially because of aortic insufficiency, the indirect lower extremity systolic pressure may be 20 to 60 mm Hg higher than that in the upper extremity.
- - - - afebrile days alternating with days of fever
      - Diseases characterized by relapsing fevers include familial Mediterranean fever; brucellosis in which the fever is associated with physical activity and disappears on days of bed rest; Hodgkin disease; Borrelia infections; tuberculosis, especially extrapulmonary; and malaria.
      - Malaria Fever
        
        Tertian fevers
        
        return on the third day and so have a periodicity of 48 hours
        
        signify infection with Plasmodium vivax or P. ovale
        
        Quartan fever
        
        returns on the fourth day and so has a 72-hour periodicity
        
        seen with P. malariae
        
        Triple quartan fever
        
        results from infection with three different strains of P. malariae
        
        resulting in daily (quotidian) fever. (Of course, not all such fevers are due to malaria.)
    - - one that falls each day but not quite to normal, remaining at 99.2°F (37.3°C) or above
    - - falls to normal or below each day
  - - - salmonelloses (including typhoid fever), tularemia, brucellosis, bacterial meningitis complicated by increased intracranial pressure, mycoplasmal pneumonia, rickettsialpox, Legionella pneumonia, mumps, infectious hepatitis, Colorado tick fever, and dengue
- - - - any type of congestive heart failure or any high-output state, such as fever, anemia, or thyrotoxicosis
  - - - With PACs, there is no compensatory pause
    - - This type of ectopic beat is followed by a fully compensatory pause.
        
        One effect of the compensatory pause is to allow a longer filling period and hence greater stroke volume. Thus, the postextrasystolic pulse amplitude should normally be greater. In fact, it is usually this postextrasystolic contraction that attracts the patient's attention, rather than the extrasystole itself. Patients often describe it by saying “my heart flipped over'.
    - - One bedside trick that helps to identify atrial fibrillation is the apical-radial pulse deficit. If one simultaneously measures the apical ventricular rate and the radial pulse, one will find the radial rate to be lesser in all cases of atrial fibrillation
      - If a digitalized patient with a prior diagnosis of chronic atrial fibrillation presents with a perfectly regular pulse, one should suspect digitalis intoxication with a regular nodal rhythm and atrioventricular dissociation.
      - Atrial fibrillation plus stroke suggests cerebral embolism.
      - Atrial fibrillation plus acute abdominal pain suggests a superior mesenteric artery embolism.
      - Atrial fibrillation by itself suggests ischemic heart disease, long-standing mitral valve disease (especially mitral stenosis), long-standing hypertensive heart disease, or recent onset of masked hyperthyroidism.
    - - An important difference between this rhythm and atrial fibrillation is that this rhythm is “regular enough” to permit valid blood pressure measurements because the filling is equal for most beats
- - - - regular, deep, and usually fast
      - basically an exaggeration of the normal
      - results from central hyperventilation
      - is a response to any type of acute metabolic acidosis, including salicylate intoxication and diabetic ketoacidosis