Medical Vital Signs

This medical examination routinely did and monitored by healthcare professionals to help assess the general health of a person. Vital signs are useful in detecting or monitoring medical problems. The normal ranges vary with person to person, age, weight, gender, and overall health. The four primary vital signs include:

• Body temperature
• Pulse rate (Heart rate)
• Respiration rate (rate of breathing)
• Blood pressure

English: Pulse evaluation Deutsch: Pulstastung (Photo credit: Wikipedia)

I.  Body temperature

The temperature obtained through a thermometer.  The temperature measured in either degrees Celsius (C) or degrees Fahrenheit (F). The normal body temperature can range from 97.8 degrees Fahrenheit to 99 degrees F, equivalent to 36.5 degrees C to 37.2 degrees C. The normal body temperature of a healthy person varies depending on gender, recent activity or exercise, the time of the day, and during menstrual periods in women. Usually an elevated temperature (in a fever) indicates signs of systemic infection or inflammation. 
Body temperature is usually taken in any of the following methods:

Oral

It is by mouth placed under the tongue using either a classic glass thermometer or a digital thermometer that uses an electronic probe to measure body temperature. This method is the preferred among adults.

Rectal/Anal

The temperature taken rectally using a glass or a digital thermometer. The thermometer inserted in the anus about 1 inch. The anal reading is 1 degree higher because it is higher than the core temperature compared to the oral method. This method is the preferred among children.

Axillary

The thermometer placed under the arm using a glass or a digital thermometer. The axillary reading will be 1 degree lower than those temperatures taken by mouth because it is not a core temperature reading. 

Tympanic

A special thermometer used for this reading. It goes inside the ear to obtain the body's core temperature. 

Temporal

A special thermometer used to quickly measure the temperature of the skin on the forehead and swiped along one side of the face. 

Skin

These are strips that measure the patient's temperature. This method used when there is no other way to get the temperature reading available because the accuracy in not good. 






II.  Pulse Rate

This measures the number of times the heart beats per minute (BPM). It is the physical expansion of the artery as the heart pushes blood to the arteries. Taking the pulse rate will also determine the strength of the pulse and the heart rhythm. Pulse rate increases with exercise, illness, injury, and emotions. It varies with age. Infants have higher beats per minutes compared to adults. Place the tips of your index and middle fingers just proximal to the patient wrist on the thumb side to measure the radial pulse rate.


Normal Values

• Infant: 100 to 130 bpm
• Child:  80 to 100 bpm
• Adult:  60 to 100 bpm

Pulse site

• Brachial
• Carotid
• Dorsal pedal
• Femoral popliteal
• Posterior tibial
• Radial
• Temporal
• Common sites: carotid and radial pulse site

Related Terms

• Bradycardia is a condition of a heart rate consistently  below 100 bpm. Beating is too slow
• Tachycardia when the heart is above 100 bpm. Beating is too fast
• Strong/Regular pulse indicates that there is an adequate force and consistent beats
• Weak indicates a poor force contraction
• Irregular indicates an arrhythmia. Out of normal rhythm

 

Peripheral Pulse Assessment Grading System

• 0-3 scale
• 0 absent
• 1+ weak/thready pulse
• 2+ normal
• 3+ full, firm pulse

Pulse Amplitude Classification

• 0 absent
• 1+ diminished
• 2+ normal
• 3+ moderately increased
• 4+ markedly increased

III. Respiratory Rate

The respiratory rate is the number of breaths a person takes per minute, that is an inhalation-exhalation cycle. Respiration recorded as breaths per minute. It varies with age and increases with fever, illness, or other medical conditions.  Respiratory rate indicates an acidosis condition.

Inspiration - to breathe air into the lungs
Expiration - to breathe air out of the lungs

Normal Rate

• Infant 30 to 50 respiration per minute
• Adults 12 to 18 respiration per minute

IV.  Blood Pressure

Blood pressure is the force that moves blood through our circulatory system. I have a blog post on this topic.

Nursemaid Elbow (Pulled Elbow)

This common pediatric condition refers to radial head subluxation (radiocapitellar joint of the elbow complex) generally occurring between the ages of 1 and 4 years, although it can happen anytime until the age of 7. At that age, the soft tissues, including muscles and bones still continue to develop that even a mild sudden pulling force on the extended pronated forearm produce a partial dislocation. Children at this age are very active in their play activities such that tugging a child or by swinging them around or back and forth by the arms causes the bone to slip out of its normal place at the joint.




Left elbow-joint Left: anterior and ulnar collateral ligaments Right: posterior and radial collateral ligaments (Photo credit: Wikipedia)





Causes:

• Catching a child by holding the hand or wrist to stop a fall.
• Pulling a child up by the hands or wrists to keep out of danger or lifting a child over a high step
• When an adult swing a child by holding the arms or hands.
• Quickly grabbing a child's hand or wrist to walk faster or even pulling a child hand along while walking
• Pulling a child hand through a long-sleeve jacket 
• An infant rolls over in an unusual way in a crib, bed, or in the floor

Signs and Symptoms:

• Moving the injured arm is painful, especially supination
• The child injured arm is kept on his/her side, usually held in flexion and pronation
• Minimal swelling

Differential Diagnoses:

• Elbow Fracture
• Soft Tissue, Hand or Wrist Injury
• Wrist Fracture 

Brief Anatomy:


The bone of the upper arm (humerus) and the two bones of the forearm (radius & ulna) made up the elbow complex. Medial collateral ligament, lateral collateral ligament, and the annular ligament holds the joint together to prevent dislocation. The joint complex has 2 joints namely, the proximal radioulnar joint for flexion & extension and the radiocapitellar joint for forearm pronation & supination.

Diagnosis:

• History of injury
• Physical examination
• A child is reluctant to move the injured arm because of pain
• The injured arm is kept on the side.
• The forearm is usually flexed and pronated
• Some tenderness at the radial head area

Imaging:

• X-ray to rule out possible fracture but are often unnecessary
• Ultrasonography and MRI performed to confirm ligament involvement

Treatment:

• A reduction is a gentle maneuver that allows the bone to go back into its normal place. If unsuccessful after 2-3 attempts, X-ray is needed to rule bone fracture. 
• Over-the-counter pain medicine, such as acetaminophen or ibuprofen may be given. Never give aspirin to a child under age 12.

Prognosis:

• It is usually excellent with treatment. If left untreated, the child may be permanently unable to fully move the elbow. 

Prevention:

• The most important thing is to know the risk 
• Avoid tugging or pulling a child's hand or wrist
• Never swing a child by holding the hand or wrist
• Never lift a child by holding the hand or wrist instead grasp under the arm
• Some children are more likely to get it again, a doctor may teach the family the reduction maneuver

Strain and Sprain

Aside from the other traumatic soft tissue injuries like contusions, sprain and strain are the two most common acute soft tissues injuries that involve muscles, tendons, and ligaments. These injuries often occur with our daily simple or complex activities like occupation, hobby, recreation, sports and exercise activities. These soft tissue injuries have two categories, the acute injuries and overuse injuries. Sprain and strain, together with contusions, belongs to the sudden traumatic acute injuries of the soft tissues. The overuse injuries, such as the tendinitis and bursitis, occur gradually over time and constantly injuring the soft tissue without allowing enough time to heal between occurrence.

            mild 2nd degree sprain, rotated inwards. (Photo credit: Wikipedia)
 

SPRAIN

A sprain is a sudden trauma involving one or more ligaments around a joint. The ligaments, similar to tendon and fascia which are connective tissues, are tough and fibrous connective tissues that connect one bone to another bone to maintain stability and resist mechanical stresses. Sprains can occur in any joint but are most common in the knee, ankle, wrist, and thumb. The injury can be minor that resolves in a few days or it can be a major injury requiring surgical intervention and a period of immobilization. Pain and rapid swelling follow after a sprain. In most cases, the severity of sprain depends on the pain and swelling. The greater it is, the more severe the injury is.

Causes

Risk factors that increase the occurrence of sprain include:

• Twisting, stretching or any excessive forces being applied to the joint that go beyond the functional range of motion 
• Fatigue of muscles predisposes to injury. A tired muscle doesn't give enough support to a joint
• A fall and landing on an outstretched arm, landing on the side of their foot, or twisting a knee with the foot planted firmly on the ground.
• Individuals with sedentary lifestyle, usually less or no physical activity
• Inadequate or no warm-up and cool-down regimen in an exercise or an activity  
• Bumping into a hard object or person such as contact sports
• Poor conditioning and poor techniques to an exercise or an activity

Signs and symptoms

• Pain around the affected joint
• Muscle pain and spasm
• Swelling follows soon after the injury
• Bruising may appear later sometimes at some distance from the affected joint (hematoma) or it may not appear at all
• Joint instability depends on the severity of the injury
• Sometimes may hear a popping sound or feel a tear 
• A loss of the ability to move and use of the affected extremity or to bear weight may lead to joint stiffness

Diagnosis

• Physical examination to demonstrate clinical presentation and method of injury
• X-ray for possible bone fracture
• Magnetic Resonance Imaging (MRI) performed for a detailed look at surrounding soft tissues and the ligament

Grading of injury

Grade I  

• Mild pain and swelling 
• Little to no instability, Little to no tear of the ligament 
• Stretched but intact with no loss of function

Grade II  

• Moderate pain and swelling, 
• Minimal instability of the joint 
• Partial tearing of the ligament from a third to almost all its fibers 
• Decrease in the ROM 

Grade III  

• Severe pain and swelling
• Significant instability of the joint
• Complete rupture of the ligament
• Significant decrease in ROM

                                                                        STRAIN                                                 

A strain is an injury involving the musculotendinous unit that involves a muscle, tendon or their attachment to bone.  Functionally, the tendons and muscles  tightly integrated to move bones.Tendons are fibrous cords of tissue with one end of the tendon connects to muscle and the other end of the tendon connects to a bone. The same with a sprain injury, any excessive forces that stretch or tear the muscle and/or tendons produce an injury. Muscle strains are particularly common in the legs and back, such as hamstring strains and lumbar (lower back) strains.

Causes

A strain caused by an excessive twisting or a pulling action to a muscle or tendon. This is common to contact sports and other sports that require extensive gripping and quick starts. 
The injury can be acute or chronic, just like in a sprain injury 

4 days after a pulled hamstring. Two images of the same leg. One of the pictures was shot through a mirror (Photo credit: Wikipedia)

Sign and Symptoms

• The severity is dependent on the extent of the injury.
• Pain and muscle spasm
• Localized swelling
• Loss of muscle function
• Limited joint range of motion

Grading of injury

Grade I  

• Localized pain, minimal swelling, and tender to touch

Grade II  

• Localized pain, moderate swelling, tenderness, and impaired motor function

Grade III  

• A palpable defect of the muscle, Severe pain, and poor motor function

Treatment of Sprain and Strain

In the acute phase, the focused is on the reduction of pain and swelling and further injury

• PRICE stands for protection, rest, ice, compression, and elevation 24 hours up to 72 hours to reduce pain and swelling or until swelling improves
• No heating such as hot baths or hot packs
• Refrain alcoholic beverages because it will increase bleeding and swelling, and slow down the healing process
• Massage may increase bleeding and swelling in the acute phase
• Don't avoid instead a reduction regular exercise or activities  
• Protection may include a non-weight bearing on the injured site using a crutch may help. A splint or brace may also be helpful for moderate injuries while a surgical repair required for severe injuries
• Apply an ice pack or a cold pack for 15 to 20 minutes to prevent frostbite, 6 to 8 times a day.
• Compression bandages to help reduces swelling
• Elevation of the injured extremity above heart level help also reduces swelling
• Prescription medication or over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB) and acetaminophen (Tylenol)  may be helpful to manage pain and inflammation during the healing process

Start the physical therapy programs early to prevent or minimize the effects of deconditioning. Depending on the patient's rate of recovery such as diminished pain and swelling, incorporate a series of exercises in the rehabilitation to help reduce swelling, prevent joint stiffness, and restore normal, pain-free range of motion. Exercises include: 

• Weight-bearing and balancing exercises
• Strengthening, endurance, and flexibility exercises to increase strength and regain flexibility
• Treatment modalities such as an Ultrasound, a soft-tissue massage or techniques, and a manual therapy techniques(Joint oscillation) help reduce pain and inflammation
• A  continuous passive motion (CPM) machine to maintain or promote flexibility of the joint.

As pain decreases and function improves, progression to functional training based on patient's occupation and/or recreational goals. Patient education and training/retraining for instrumental activities of daily living (IADL). A full recovery may allow a patient to return to full daily activities, including sports. Remind patient the potential danger in accelerating the rehabilitation program as it may lead to serious consequences.

Preventive measures

• Avoid exercising or doing sporting activities when you feel tired or in pain.
• Maintain a healthy, well-balanced diet to keep muscles strong and full of energy
• Wearing appropriate footwear designed for a specific activity such as sports shoes or a protective equipment. A high-heeled is more likely to sprain your ankle than if you wear flat shoes. 
• Practice safety measure to help prevent falls such as slippery floors, cluttered areas, and others
• Run on or walk on even surfaces may help
• A taping, strapping or wrapping your knees, ankles, wrists to protect joints. 
• Do regular stretching and strengthening exercises daily to maintain a healthy weight and promote general well-being
• Be in proper physical condition and in a high spirit to play a sport.
• A short warm-up and cool-down regimen that include stretching may help reduce injuries before engaging in any sports or exercise