CC: CP - the VS
Vital Signs are Vital! Don’t skip.
Just as you will likely be able to see an EKG before you interview and examine your CP patient, you will also probably have a set of VS from triage, but what clues can you gather from the VS to tailor your H&P? Here are just a few things to think about as you review the VS.
Temp -
Fever? Look for infection - pneumonia, myocarditis, endocarditis
Low temp - don’t miss sepsis
HR -
Tachycardia? PE, almost anything else but think twice about d/c when tachycardia
Bradycardic? Perhaps well-conditioned patient - correlate with BP
BP -
BP high? Both systolic and diastolic high - -dissection risk.
Hypotensive? Again, sepsis high on the list. Sudden valvular disease can also be considered, as in the example below…
Notice anything weird about the vital signs in the image, other than the monitor being way too high? Yes, the patient is technically bradycardia, but the systolic BP looks okay so probably not that clinically significant. No, don’t look at the ECG tracing, that’s not part of the VS. Yeah, I don’t know what the blue 13 or green 14 represent, but let’s just say respiratory rate. The 99 is probably the pulse oximetry; looks good.
The number that sticks out to me is the diastolic BP of 51. Why is that weird? I’ll give you a minute to think.
The patient above has a pulse pressure of 72 (SBP - DBP = PP). While technically not “widened” by the strict definition, the low diastolic BP could be a clue about peripheral vascular resistance being low. This could be normal, or it could be an early sign of sepsis that could lead to shock. With the HR not elevated in this particular example, I am not as concerned.
Nevertheless, even “normal” VS can offer clues that may be obvious in retrospect, such as the patient progressing from systemic infection to septic shock. Based on my experience with a patient with acute aortic valve insufficiency, the vital signs were a “vital” clue that I missed early in the work-up. High-output heart failure can also be a puzzling initial presentation in the a patient with “good” BP yet showing CHF.
Another, real life example of a widened pulse pressure being a clue to cause of a patient’s symptoms was a case of aortic insufficiency I almost missed on a patient presenting with “flu-like symptoms” who had endocarditis with destruction of his aortic valve. Check out the image below for more on wide pulse pressures.
Bottom line:
Be wary of abnormal vital signs!!!
Consider charting the following or including it in a template to force yourself to look at the auto-populated VS every time.
Vital signs reviewed with *** abnormalities.
