Differential Diagnosis

ABDUL GHAFFAR
MUHAMMAD BURHAN
VITAL SIGNS:

 Vital signs, observations, and reported associated sign and symptoms are among the best
screening tools available to the therapist.
 The Guide to Physical Therapist Practice recommends that heart rate (pulse) and BP
measurements be included in the examination of new clients.
 Exercise professionals are strongly encouraged to measure BP during each visit.
BOX 4.4 Vital Signs
• Pulse (beats per minute [bpm])
• Blood pressure (BP)
• Core body temperature (oral or ear)
• Respirations
• Pulse oximetry (oxygen [O 2]saturation)
• Skin temperature
• Pain (now called the fifth vital sign)
• Walking speed (the sixth vital sign)
Pulse Rate

 The pulse reveals important information about the client's heart rate and heart rhythm.
 A resting pulse rate (normal range: 60 to 100 beats/min), taken at the carotid artery or radial artery (preferred
sites) pulse point, should be available for comparison with the pulse rate taken during treatment or after exercise.
 A pulse rate above 100 bpm indicates tachycardia; below 60 bpm indicates bradycardia.
 It is recommended that the pulse always be checked in two places in older adults and in anyone with diabetes.
 Pulse strength (amplitude) can be graded as:
 0 Absent, not palpable
 1+ Pulse diminished, barely palpable
 2+ Easily palpable, normal
 3+ Full pulse, increased strength
 4+ Bounding, too strong to obliterate
 Keep in mind that measuring the pulse is not the same as measuring the heart rate.
 A true measure of heart rate requires measuring the electrical impulses of the heart.
 Pulse amplitude (weak or bounding quality of the pulse) gives an indication of the circulating
blood volume and the strength of left ventricle ejection.
 Normally, the pulse increases slightly with inspiration and decreases with expiration.
 Pulse amplitude that fades with inspiration instead of strengthening and strengthens with
expiration instead of fading is paradoxic and should be reported to the physician.
 Paradoxical pulse occurs most commonly in clients with chronic obstructive pulmonary
disease (COPD), but is also observed in clients with constrictive pericarditis.
 A pulse increase with activity of more than 20 beats per minute lasting for more than 3 minutes
after rest or changing position should also be reported.
 The resting pulse may be higher than normal with fever, anemia, infections, some medications,
hyperthyroidism, anxiety, or pain.
 A low pulse rate(below 60bpm) is not uncommon among trained athletes.
 Medications, such as beta-blockers and calcium channel blockers, can also prevent the normal
rise in pulse rate that usually occurs during exercise.
 In such cases the therapist must monitor rates of perceived exertion (RPE) instead of pulse
rate.
Measurement

 When taking the resting pulse or pulse during exercise, some clinicians measure the pulse for
15 seconds and multiply by 4 to get the rate per minute.
 For a quick assessment, measure for 6 seconds and add a zero.
 A 6-second pulse count can result in an error of 10 beats per minute if a one-beat error is made
in counting.
 For screening purposes, it is always best to palpate the pulse for a full minute.
 Longer pulse counts give greater accuracy and provide more time for detection of some
dysrhythmias.
BOX 4.5 PULSE ABNORMALITIES
• Weak pulse beats alternating with strong
beats
• Weak, thready pulse
• Bounding pulse (throbbing pulse followed by
sudden collapse or decrease in the force of the
pulse)
• Two quick beats followed by a pause (no pulse)
• Irregular rhythm (interval between beats is
not equal)
• Pulse amplitude decreases with
inspiration/increases with expiration
• Pulse rate too fast (greater than 100 bpm;
tachycardia)
• Pulse rate too slow (less than 60 bpm;
bradycardia)
Fig. 4.1 Pulse points. The easiest and most commonly palpated pulses are the (A) carotid pulse and (B) radial pulse.
Other pulse points include: (C) brachial pulse, (D) ulnar pulse, (E) femoral pulse, (F) popliteal pulse (knee slightly
flexed), (G) dorsalis pedis, and (H) posterior tibial. The anterior tibial pulse becomes the dorsalis pedis and is palpable
where the artery lies close to the skin on the dorsum of the foot. Peripheral pulses are more difficult to palpate in older
adults and anyone with peripheral vascular disease.
 RESPIRATIONS

 Try to assess the client's breathing without drawing attention to what is being done. This measure can be taken right
after counting the pulse while still holding the client's wrist.
 Count respirations for 1 minute unless respirations are unlabored and regular in which case the count can be taken for
30 seconds and multiplied by 2. The rise and fall of the chest equals 1 cycle.
 The normal rate is between 12 and 20 breaths per minute. Observe rate, excursion, effort, and pattern. Note any use
of accessory muscles and whether breathing is silent or noisy. Watch for puffed cheeks, pursed lips, nasal flaring, or
asymmetrical chest expansion. Changes in the rate, depth, effort, or pattern of a client's respirations can be early
signs of neurologic, pulmonary, or cardiovascular impairment.
PULSE OXIMETRY

 Oxygen saturation on hemoglobin (Sa02 ) and pulse rate can be measured simultaneously using pulse oximetry.
 This is a noninvasive, photoelectric device with a sensor that can be attached to a finger, the bridge of the nose, toe,
or ear lobe.
 Digital readings are less accurate with clients who are anemic, undergoing chemotherapy, or who use fingernail
polish or nail acrylics.
 In such cases, attach the sensor to one of the other accessible body parts.
 The sensor probe emits red and infrared light, which is transmitted to the capillaries.
 When in contact with the skin, the probe measures transmitted light passing through the vascular bed and detects
the relative amount of color absorbed by the arterial blood.
 The Sa0 2 level is calculated from this information.
 The normal Sa0 2 range is 95 to 100 percent.
 Any condition that restricts blood flow (including cold hands) can result in inaccurate Sa0 2 readings.
 Relaxation and physiologic quieting techniques can be used to help restore more normal temperatures in the distal
extremities.
 A handheld device such as the Thermister can be used by the client to improve peripheral circulation.
 Do not apply a pulse oximetry sensor to an extremity with an automatic blood pressure cuff.
 Sa0 2 levels can be affected also by positioning because positioning can impact a person's ability to breathe.
 Upright sitting in individuals with low muscle tone or kyphosis can cause forward flexion of the thoracic spine
compromising oxygen intake.
 Tilting the person back slightly can open the trunk, ease ventilation, and improve Sa0 2 levels.
 Using Sa0 2 levels may be a good way to document outcomes of positioning programs for clients with impaired
ventilation.
 If the client cannot talk easily whether at rest or while exercising, oxygen saturation levels are likely to be inadequate.