Elevated blood pressure measurements due to inaccurate blood pressure

measurement techniques such as:

Failure to have patient sit quietly for ≥5 minutes before measurement

Too small cuff size.

Poor adherence to medical therapy

White coat hypertension

Marked brachial artery calcification

Clinician inertia.

References:

Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and

how to screen? Eur Heart J. 2014;35(19):1245-54.

Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management

of arterial hypertension. Eur Heart J. 2018;39(33):3021-104.

PSEUDOHYPERTENSION

Defined as cuff diastolic blood pressure ≥15 mm Hg higher than

simultaneously measured intra-arterial blood pressure.

Elevated blood pressure due to arterial stiffening in elderly patients.

Reference

Rimoldi SF, Scherrer U, Messerli FH. Secondary arterial hypertension: when, who, and how

to screen? Eur Heart J. 2014;35(19):1245-54.

SECONDARY HYPERTENSION

Hypertension due to an identifiable and potentially curable cause.

MASKED HYPERTENSION

Elevated blood pressure at home or on ambulatory blood pressure

monitoring but normal office blood pressure.

WHITE COAT HYPERTENSION

Normal blood pressure at home or on ambulatory blood pressure monitoring

but elevated office blood pressure.

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HYPERTENSIVE CRISIS

Severe elevations in blood pressure (systolic blood pressure ≥180 mm Hg or

diastolic blood pressure ≥120 mm Hg) with impending complications

including target end-organ dysfunction.

HYPERTENSIVE EMERGENCY

Severe elevation in blood pressure which is accompanied by end-organ

damage.

MALIGNANT HYPERTENSION

Malignant hypertension is term used for patients with severely elevated

blood pressure and ischemic end-organ damage usually involving the retina,

but may also include the kidneys, heart, arteries, and/or brain.

HYPERTENSIVE URGENCY

Severe elevation in blood pressure which occurs without end-organ

damage.

References

Whelton PK, Carey RM, Aronow WS, et al. 2017

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the

Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A

Report of the American College of Cardiology/American Heart Association Task Force on

Clinical Practice Guidelines. Hypertension. 2018;71(6):e13.

JVP

Defined as undulating top of oscillating column of blood in right internal

jugular vein that faithfully represents the pressure and volumetric changes in

the right side of heart which changes with various stages of cardiac cycle

and respiration.

ANEMIA

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Anemia is a condition in which the number of red blood cells or their oxygencarrying capacity is insufficient to meet physiologic needs, which vary by

age, sex, altitude, smoking, and pregnancy status.

World Health Organization (WHO) definition of anemia at sea level

(Table 15B.2):

Hemoglobin <13 g/dL (130 g/L) in men ≥15 years old

Hemoglobin <12 g/dL (120 g/L) in nonpregnant women ≥15 years old or

adolescents aged 12–14 years

Hemoglobin <11.5 g/dL (115 g/L) in children aged 5–11 years

Hemoglobin <11 g/dL (110 g/L) in pregnant women, or children aged 6–59

months.

ERYTHROCYTOSIS AND POLYCYTHEMIA

Erythrocytosis is an increase in the number of red blood cells (relative to the

plasma volume), manifested by a persistent increase in the venous

hematocrit, and associated with increased blood viscosity and risk of

thrombosis.

Erythrocytosis and polycythemia are often used interchangeably;

however, erythrocytosis refers exclusively to an increase in erythrocytes,

whereas polycythemia more accurately refers to pan-myeloproliferation (as

seen in some patients with polycythemia vera).

Table 15B.2: Hemoglobin levels to diagnose anemia at sea level (g/L)±.

Non-anemia* Anemia*

Population Mild

a Moderate Severe

Children 6–59 months of age 110 or

higher

100–

109

70–99 Lower

than 70

Children 5–11 years of age 115 or

higher

110–

114

80–109 Lower

than 80

Children 12–14 years of age 120 or

higher

110–

119

80–109 Lower

than 80

Nonpregnant women (15 years of age and

above)

120 or

higher

110–

119

80–109 Lower

than 80

Pregnant women 110 or

higher

100–

109

70–99 Lower

than 70

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Men (15 years of age and above) 130 or

higher

110–

129

80–109 Lower

than 80

± Adapted from references 5 and 6

* Hemoglobin in grams per liter

a “Mild” is a misnomer: iron deficiency is already advanced by the time anemia is detected.

The deficiency has consequences even when no anemia is clinically apparent.

Reference: WHO.

References:

Lee G, Arcasoy MO. The clinical and laboratory evaluation of the patient with

erythrocytosis. Eur J Intern Med. 2015;26(5):297-302.

McMullin MF, Bareford D, Campbell P, et al. Guidelines for the diagnosis, investigation

and management of polycythaemia/erythrocytosis. Br J Haematol. 2005;130(2):174-95.

JAUNDICE

Jaundice (also termed icterus) is a condition of yellow discoloration of the

skin, conjunctivae, and mucous membranes, resulting from widespread

tissue deposition of the pigmented metabolite bilirubin.

Reference

Feldman M, Friedman L, Brandt L. Sleisenger and Fordtran’s Gastrointestinal and Liver

Disease. Philadelphia: Saunders; 2015.

CYANOSIS

Cyanosis refers to a bluish discoloration of the skin that is caused by

increased amounts of reduced hemoglobin in the subpapillary venous

plexus.

Reference

Fishman’s Pulmonary Diseases and Disorders.

CLUBBING

Clubbing of the fingers designates the selective bulbous enlargement of the

distal segments of the digits due to an increase in soft tissue.

Reference

Fishman’s Pulmonary Diseases and Disorders.

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FEVER

Fever is “a state of elevated core temperature, which is often, but not

necessarily, part of the defensive responses of multicellular organisms (host)

to the invasion of live (microorganisms) or inanimate matter recognized as

pathogenic or alien by the host.”

Reference

Commission for Thermal Physiology of the International Union of Physiological Sciences

(IUPS Thermal Commission): Glossary of terms for thermal physiology (3rd ed.). Jpn J

Physiol. 2001;51:245-80.

FUO

Petersdorf and Beeson—“fever higher than 38.3°C (100.9°F) on several

occasions, persisting without diagnosis for at least 3 weeks in spite of at

least 1 week’s investigation in hospital”.

REVISED DEFINITION OF FUO

Requires fever >38.3°C (101°F)

Subcategorized by patient immune status and clinical setting

Classic fever of unknown origin (FUO):

Fever duration >3 weeks

No diagnosis after ≥3 visits or 3 days of hospitalization.

Nosocomial (healthcare-associated) FUO:

Fever duration >3 days

Fever acquired after ≥24 hours in hospital (not present or

incubating on admission)

No diagnosis after 3 days of appropriate in-hospital investigation.

Neutropenic (or immunodeficient) FUO:

Fever duration >3 days

Neutrophil count ≤500 cells/mm3 with negative cultures after 48

hours

No diagnosis after 3 days of appropriate in-hospital investigation.

HIV-associated FUO:

Confirmed HIV infection

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Fever duration >3 weeks for outpatients and >3 days for inpatients.

References:

Wright WF, Mackowiak PA. Fever of unknown origin. In: Mandell GL, Bennett JE, Dolin R,

(Eds). Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases.

8th edition. New York, NY: Saunders; 2014:721-31.

HYPERPYREXIA

A fever of >41.5°C is called hyperpyrexia.

Reference

Harrison’s Principles of Internal Medicine.

HYPERTHERMIA

An uncontrolled increase in body temperature that exceeds the body’s ability

to lose heat without a change in the hypothalamic set point. Hyperthermia

does not involve pyrogenic molecules.

Reference

Harrison’s Principles of Internal Medicine.

HEATSTROKE

Core body temperature ≥104°F (40°C) with central nervous system

dysfunction; can progress to multiple system organ failure.

Reference

Atha WF. Heat-related illness. Emerg Med Clin North Am. 2013;31(4):1097-108.

DYSPNEA

A subjective experience of breathing discomfort that consists of qualitatively

distinct sensations that vary in intensity.

Reference

Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society

statement: update on the mechanisms, assessment, and management of dyspnea. Am J

Respir Crit Care Med. 2012;185(4):435-52.

ORTHOPNEA

Orthopnea signifies dyspnea in the recumbent, but not in the upright or

semi-upright position.

Reference

Fishman’s Pulmonary Diseases and Disorders.

PAROXYSMAL NOCTURNAL DYSPNEA

Acute episodes of severe shortness of breath and coughing that generally

occur at night and awaken the patient from sleep, usually 1–3 hours after

the patient retires.

Reference

Harrison’s Principles of Internal Medicine.

PLATYPNEA

Platypnea signifies dyspnea induced by assuming the upright position and

relieved by recumbency.

Reference

Fishman’s Pulmonary Diseases and Disorders.

ORTHODEOXIA

Desaturation of arterial blood when the patient is upright.

Reference

Fishman’s Pulmonary Diseases and Disorders.

TREPOPNEA

Dyspnea when the affected side of the chest is in the dependent position,

thereby promoting ventilation–perfusion mismatch and resultant hypoxemia.

Reference

Fishman’s Pulmonary Diseases and Disorders.

BENDOPNEA

Shortness of breath may be particularly noticeable when bending forward,

termed bendopnea.

Reference

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.

PALPITATIONS

Palpitations are the awareness of the heartbeat that may be caused by a

rapid heart rate, irregularities in heart rhythm, or an increase in the force of

cardiac contraction, as occurs with a postextrasystolic beat; however, this

perception can also exist in the setting of a completely normal cardiac

rhythm.

Reference

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.

TACHYCARDIA

An abnormally rapid heartbeat, usually applied to a heart rate above 100 per

minute.

Reference

ICD-10.

BRADYCARDIA

The National Institutes of Health defines bradycardia as a heart rate <60

bpm in adults other than well trained athletes.

Reference

National Institutes of Health. Pulse. [online] Available from

https://medlineplus.gov/ency/article/003399.htm [Last accessed November, 2019].

APEX BEAT

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The apex beat or apical impulse is the palpable cardiac impulse farthest

away from the sternum and farthest down on the chest wall, usually caused

by the LV and located near the midclavicular line (MCL) in the fifth

intercostal space.

Reference

McGee S. Palpation of the Heart. Evidence-Based Physical Diagnosis. Netherlands:

Elsevier; 2018. pp. 317-26.

ACUTE CORONARY SYNDROME

Definition of Acute Coronary Syndrome(s)

Acute coronary syndrome includes spectrum of ST-elevation myocardial

infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA).

UA/NSTEMI are defined in an appropriate clinical setting (chest

discomfort or anginal equivalent), often accompanied by:

Electrocardiographic (ECG), ST-segment depression or prominent Twave inversion and/or

Positive biomarkers of necrosis (for example, troponin) in the

absence of ST-segment elevation.

NSTEMI is differenciated from UA by the presence of myocardial necrosis.

STEMI is diagnosed by ECG in the absence of left ventricular hypertrophy

or left bundle branch block (LBBB) in the presence of new ST elevation (at

J point) and either of:

≥2 mm [0.2 millivolts (mV)] in men or ≥1.5 mm (0.15 mV) in women in

leads V2–V3

≥1 mm (0.1 mV) in 2 other contiguous chest leads or limb leads.

Criteria for acute myocardial infarction:

Evidence of acute myocardial injury in clinical setting consistent with

acute myocardial ischemia, as evidenced by any of:

Detection of rise and/or fall of cardiac troponin (cTn) values with ≥1 value

>99th percentile of upper reference limit.

Symptoms of ischemia:

New ischemic ECG changes

Development of pathological q waves on electrocardiogram (ECG)

Imaging evidence of new loss of viable myocardium or new regional

wall motion abnormality

Identification of intracoronary thrombus by angiography or autopsy.

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