10.

CLASSIFICATION OF OVERWEIGHT
AND OBESITY BY BMI
Step 1: Measure the BMI and Assess Risk Factors. Classify the
BMI

according to the national guidelines in the following table. If

the BMI is above

25 kg/m2, assess the patient for additional risk factors for

heart disease and other

obesity-related diseases: hypertension, high low-density

lipoprotein (LDL) cholesterol, low high-density lipoprotein
(HDL) cholesterol, high triglycerides, high
Side note: Waist Circumference. If the BMI is ≥35 kg/m2,
blood glucose, family history of premature heart disease, measure the patient’s waist circumference just above the
physical inactivity, and hips. Risk for diabetes, hypertension, and cardiovascular
disease increases significantly if the waist circumference is 35
cigarette smoking. Patients with a BMI over 25 kg/m2 and
inches or more in women and 40 inches or more in men.
two or more risk factors should pursue weight loss—
especially if the waist circumference is elevated.
12. THE VITAL SIGNS
A. BP

Automated ambulatory blood pressure monitoring measures

blood pressure at preset intervals over 24 to 48 hours,
usually every 15 to 20 minutes during the day and 30 to 60
minutes during the night. It is now considered the reference
standard for confirming elevated office blood pressures.

11. METHODS OF CALCULATING BODY MASS

INDEX (BMI)
Body Mass Index is a simple calculation using a person's
height and weight. The formula is BMI = kg/m2 where kg is a
person's weight in kilograms and m2 is their height in meters
squared. A BMI of 25.0 or more is overweight, while the
healthy range is 18.5 to 24.9.

If you recommend home blood pressure monitoring, advise
patients about how to choose the best upper arm cuff for
home use and have it recalibrated. Let them know that wrist
and fingers monitors are popular but less accurate. Systolic
pressure increases in more distal arteries, whereas diastolic
pressure falls; and hydrostatic effects introduce errors due to to falsely high readings.
differences in position relative to the heart.
If the cuff is too small (narrow), the blood pressure will
read high; if the cuff is too large (wide), the blood
pressure will read low on a small arm and high on a
large arm.
If the brachial artery is below heart level, the blood pressure
reading will be higher; if the brachial artery is above heart
level, the reading will be lower.
Position the Cuff and Arm. With the arm at heart level,
center the inflatable bladder over the brachial artery. The
lower border of the cuff should be about 2.5 cm above the
antecubital crease. Secure the cuff snugly. Slightly flex the
patient’s arm at the elbow.
A loose cuff or a bladder that balloons outside the cuff leads
Estimate the Systolic Pressure and Add 30 mm Hg. To decide
how high to raise the cuff pressure, first estimate the systolic
pressure by palpation. As you palpate the radial artery with
the fingers of one hand, rapidly inflate the cuff until the
radial pulse disappears. Read this pressure on the
manometer and add 30 mm Hg. Using this sum for
subsequent inflations prevents discomfort from
unnecessarily high cuff pressures. It also avoids the
occasional error caused by an auscultatory gap—a silent
interval that may be present between the systolic and the
diastolic pressures (Fig. 4-5). Deflate the cuff promptly and
completely and wait for 15 to 30 seconds.
An unrecognized auscultatory gap may lead to serious
underestimation of systolic pressure (150 instead of 200 in
the example below) or overestimation of diastolic pressure.
Position the Stethoscope Bell Over the Brachial Artery. Now
place the bell of a stethoscope lightly over the brachial
artery, taking care to make an air seal with the full rim (Fig. 4-
6). Because the sounds to be heard, the Korotkoff sounds,
are relatively low in pitch, they are generally better heard
with the bell.

If you find an auscultatory gap, record your findings

completely (e.g., 200/98 with an auscultatory gap from 170
to 150). An auscultatory gap (Fig. 4-6) is associated with
arterial stiffness and atherosclerotic disease.

Identify the Systolic Blood Pressure. Inflate the cuff again

rapidly to the target level, and then deflate the cuff slowly at
a rate of about 2 to 3 mm Hg per second. Note the level
when you hear the sounds of at least two consecutive beats.
This is the systolic pressure When the systolic and diastolic levels fall in different
Identify the Diastolic Blood Pressure. Continue to deflate the categories, use the higher category. For example, 170/92 mm
cuff slowly until the sounds become muffled and disappear. Hg is stage 2 hypertension; 135/98 mm Hg is stage 1
To confirm the disappearance point, listen as the pressure hypertension. In isolated systolic hypertension, systolic blood
falls another 10 to 20 mm Hg. Then deflate the cuff rapidly to pressure is ≥140 mm Hg, and diastolic blood pressure is <90
zero. The disappearance point, which is usually only a few mm Hg.
mm Hg below the muffling point, provides the best estimate Low Blood Pressure. Interpret relatively low levels of blood
of diastolic pressure. pressure in the light of past readings and the patient’s clinical
In some people, the muffling point and the disappearance state
point are farther apart. Occasionally, as in aortic A pressure of 110/70 mm Hg would usually be normal, but
regurgitation, the sounds never disappear. If the difference is could also indicate significant hypotension if past pressures
10 mm Hg or greater, record both figures (e.g., 154/80/68). have been high.
Average Two or More Readings. Read both the systolic and Orthostatic Hypotension. If indicated, assess orthostatic
the diastolic levels to the nearest 2 mm Hg. Wait 2 or more hypotension, common in older adults. Measure blood
minutes and repeat. Average your readings. If the first two pressure and heart rate in two positions—supine after the
readings differ by more than 5 mm Hg, take additional patient is resting from 3 to 10 minutes, then within 3 minutes
readings. once the patient stands up. Normally, as the patient rises
When using an aneroid instrument, hold the dial so that it from the horizontal to the standing position, systolic pressure
faces you directly. Avoid slow or repetitive inflations of the drops slightly or remains unchanged, whereas diastolic
cuff because the resulting venous congestion can cause false pressure rises slightly. Orthostatic hypotension is a drop in
readings. systolic blood pressure of at least 20 mm Hg or in diastolic
blood pressure of at least 10 mm Hg within 3 minutes of
By making the sounds less audible, venous congestion may standing.
produce artificially low systolic and high diastolic pressures.
Causes of orthostatic hypotension include drugs, moderate
Measure Blood Pressure in Both Arms At Least Once. or severe blood loss, prolonged bed rest, and diseases of the
Normally, there may be a difference in pressure of 5 mm Hg autonomic nervous system.
and sometimes up to 10 mm Hg. Subsequent readings should
be made on the arm with the higher pressure. Special Situations
A pressure difference of more than 10 to 15 mm Hg occurs in Weak or Inaudible Korotkoff Sounds. Consider technical
subclavian steal syndrome, supravalvular aortic stenosis, and problems such as erroneous placement of your stethoscope,
aortic dissection, and should be investigated. failure to make full skin contact with the bell, and venous
engorgement of the patient’s arm from repeated inflations of
the cuff. Also consider the possibilities of vascular disease or
shock. When you cannot hear Korotkoff sounds at all,
alternative methods using a Doppler probe or direct arterial B. Heart Rate.
pressure tracings may be necessary.
The radial pulse is commonly used to assess the heart rate.
In rare cases, patients are pulseless due to occlusive disease
With the pads of your index and middle fingers, compress the
in the arteries of all the limbs from Takayasu arteritis, giant
radial artery until a maximal pulsation is detected. If the
cell arteritis, or atherosclerosis. rhythm is regular and the rate seems normal, count the rate
White Coat Hypertension. Encourage the patient to relax and for 30 seconds and multiply by 2. If the rate is unusually fast
remeasure the blood pressure later in the encounter. or slow, count for 60 seconds. The usual range of normal is
Consider automated office readings or ambulatory 60 to 90 to 100 beats per minute
recordings.

The Obese or Very Thin Patient. For the obese arm, use a
cuff 16 cm in width. If the upper arm is short despite a large
circumference, use a thigh cuff or a very long cuff. If the arm
circumference is >50 cm and not amenable to use of a thigh
cuff, wrap an appropriately sized cuff around the forearm,
hold the forearm at heart level, and feel for the radial
pulse.42 Other options include using a Doppler probe at the
radial artery or an oscillometric device. For the very thin arm,
consider using a pediatric cuff.

Arrhythmias. Irregular rhythms produce variations in

pressure and therefore unreliable measurements. Ignore the
effects of an occasional premature contraction. With
frequent premature contractions or atrial fibrillation,
determine the average of several observations and note that
your measurements are approximate. Ambulatory
monitoring for 2 to 24 hours is recommended.

Detection of an irregularly irregular rhythm suggests atrial

fibrillation. For all irregular patterns, obtain an ECG to C. Respiratory Rate and Rhythm
identify the type of rhythm.
Observe the rate, rhythm, depth, and effort of breathing.
The Hypertensive Patient with Systolic Blood Pressure
Count the number of respirations in 1 minute either by visual
Higher in the Arms than in the Legs. Compare blood
inspection or by subtly listening over the patient’s trachea
pressure in the arms and the legs and assess “femoral delay”
with your stethoscope during your examination of the head
at least once in every hypertensive patient.
and neck or chest. Normally, adults take approximately 20
■ Coarctation of the aorta arises from narrowing of the breaths per minute in a quiet, regular pattern. An occasional
thoracic aorta, usually distal to origin of the left subclavian sigh is normal. Check to see if expiration is prolonged.
artery, and classically presents with systolic hypertension
greater in the arms than the legs. In normal patients, the
systolic blood pressure should be 5 to 10 mm Hg higher in
the lower extremities than in the arms.

In coarctation of the aorta and occlusive aortic disease there

is systolic hypertension in the upper extremities and lower
blood pressure in the legs, and diminished or delayed
femoral pulses, sometimes termed femoral delay.
D. Temperature
The core body temperature, measured internally, is
approximately 37°C (98.6°F) and fluctuates approximately
1°C over the course of the day. It is lowest in the early
morning and highest in the afternoon and evening. Women
have a wider range of normal temperature than men.
Although the research gold standard for core body
temperature is the blood temperature in the pulmonary
artery, clinical practice relies on noninvasive oral, rectal,
axillary, tympanic membrane, and temporal artery
measurements. Tympanic membrane and temporal artery
temperatures use infrared thermometry.
■ Oral and rectal temperature measurements remain
common. Oral temperatures are generally lower than the
core body temperature. They are also lower than rectal
temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and direction pointing to the umbilicus. Remove it after 3
higher than axillary temperatures by approximately 1°.
Axillary temperatures take 5 to 10 minutes to register and
are considered less accurate than other measurements.
An accurate temperature recording usually takes about 10
seconds.
For glass thermometers, shake the thermometer down to
35°C (96°F) or below, insert it under the tongue, instruct the
patient to close both lips, and wait for 3 to 5 minutes. Then
read the thermometer, reinsert it for a minute, and read it
again. If the temperature is still rising, repeat this procedure
until the reading remains stable. Note that hot or cold
liquids, and even smoking, can alter the temperature reading.
In these situations, delay taking the temperature for 10 to 15
minutes.
Rectal Temperatures. For a rectal temperature, ask the
patient to lie on one side with the hip flexed. Select a rectal
thermometer with a stubby tip, lubricate it, and insert it
about 3 cm to 4 cm (1.5 inches) into the anal canal, in a
minutes, then read. Alternatively, use an electronic
thermometer after lubricating the probe cover. Wait about
10 seconds for the digital temperature recording to appear.

■ Tympanic membrane temperatures can be more variable Rapid respiratory rates tend to increase the discrepancy
than oral or rectal temperatures. Studies vary in between oral and rectal temperatures. In these situations,
methodology, but suggest that in adults, oral and temporal rectal temperatures are more reliable.
artery temperatures correlate more closely with the Tympanic Membrane Temperatures. The tympanic
pulmonary artery temperature, but are about 0.5°C lower. membrane shares the same blood supply as the
Fever, or pyrexia, refers to an elevated body temperature. hypothalamus, where temperature regulation occurs in the
Hyperpyrexia refers to extreme elevation in temperature, brain. Accurate temperature readings require access to the
above 41.1°C (106°F), whereas hypothermia refers to an tympanic membrane. Make sure the external auditory canal
abnormally low temperature, below 35°C (95°F) rectally. is free of cerumen, which can lower temperature readings.
Position the probe in the canal so that the infrared beam is
Causes of fever include infection, trauma such as surgery or aimed at the tympanic membrane, or otherwise the
crush injuries, malignancy, drug reactions, and immune measurement will be invalid. Wait for 2 to 3 seconds until the
disorders such as collagen vascular disease. digital temperature reading appears.
The chief cause of hypothermia is exposure to cold. Other Temporal Artery Temperatures. This method takes
causes include reduced movement as in paralysis, advantage of the location of the temporal artery, which
interference with vasoconstriction from sepsis or excess branches off the external carotid artery and lies within a
alcohol, starvation, hypothyroidism, and hypoglycemia. Older millimeter of the skin surface of the forehead, cheek, and
adults are especially susceptible to hypothermia and also less
behind the ear lobes. Place the probe against the center of
likely to develop fever. the forehead, depress the infrared scanning button, and
Oral Temperatures. For oral temperatures, options include brush the device across the forehead, down the cheek, and
electronic or glass thermometers. Due to breakage and behind an earlobe. Read the display, which records the
mercury exposure, glass thermometers are being replaced by highest measure temperature. Industry information suggests
electronic thermometers. If using an electronic thermometer, that combined forehead and behind the ear contact is more
carefully place the disposable cover over the probe and accurate than scanning only the forehead.
insert the thermometer under the tongue. Ask the patient to
close both lips, and then watch closely for the digital readout.