A Practical Guide to Clinical

Medicine
A comprehensive physical examination and clinical education site for medical
students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of

Medicine; Content and Photographs by Charlie Goldberg, M.D., UCSD School of
Medicine and VA Medical Center, San Diego, California 92093-0611.

Introduction Exam of the Abdomen Write Ups

History of Present Male Genital/Rectal
The Oral Presentation
Illness Exam
The Rest of the History The Upper Extremities Outpatient Clinics
Vital Signs The Lower Extremities Inpatient Medicine
The Eye Exam Musculo-Skeletal Exam Clinical Decision Making
Head and Neck Exam The Mental Status Exam Commonly Used Abbreviations
The Lung Exam The Neurological Exam A Few Thoughts
Exam of the Heart Putting It All Together References
Send Comments to: Charlie Goldberg,
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M.D.

The "daVinci Anatomy Icon" denotes a link to related gross anatomy

pictures.

Vital Signs
Vital signs include the measurement of: temperature, respiratory rate, pulse, blood
pressure and, where appropriate, blood oxygen saturation. These numbers provide
critical information (hence the name "vital") about a patient's state of health. In
particular, they:
1. Can identify the existence of an acute medical problem.
2. Are a means of rapidly quantifying the magnitude of an illness and how well
the body is coping with the resultant physiologic stress. The more deranged
the vitals, the sicker the patient.
3. Are a marker of chronic disease states (e.g. hypertension is defined as
chronically elevated blood pressure).

Most patients will have had their vital signs measured by an RN or health care
assistant before you have a chance to see them. However, these values are of such
great importance that you should get in the habit of repeating them yourself,
particularly if you are going to use these values as the basis for management
decisions. This not only allows you to practice obtaining vital signs but provides an
opportunity to verify their accuracy. As noted below, there is significant potential for
measurement error, so repeat determinations can provide critical information.
Getting Started: The examination room should be quiet, warm and well lit. After you
have finished interviewing the patient, provide them with a gown (a.k.a. "Johnny")
and leave the room (or draw a separating curtain) while they change. Instruct them to
remove all of their clothing (except for briefs) and put on the gown so that the
opening is in the rear. Occasionally, patient's will end up using them as ponchos,
capes or in other creative ways. While this may make for a more attractive ensemble it
will also, unfortunately, interfere with your ability to perform an examination! Prior to
measuring vital signs, the patient should have had the opportunity to sit for
approximately five minutes so that the values are not affected by the exertion required
to walk to the exam room. All measurements are made while the patient is seated.

Observation: Before diving in, take a minute or so to look at the patient in their
entirety, making your observations, if possible, from an out-of-the way perch. Does
the patient seem anxious, in pain, upset? What about their dress and hygiene?
Remember, the exam begins as soon as you lay eyes on the patient.

Temperature: This is generally obtained using an oral thermometer that provides a

digital reading when the sensor is placed under the patient's tongue. As most exam
rooms do not have thermometers, it is not necessary to repeat this measurement
unless, of course, the recorded value seems discordant with the patient's clinical
condition (e.g. they feel hot but reportedly have no fever or vice versa). Depending on
the bias of a particular institution, temperature is measured in either Celcius or
Farenheit, with a fever defined as greater then 38-38.5 C or 101-101.5 F. Rectal
temperatures, which most closely reflect internal or core values, are approximately 1
degree F higher then those obtained orally.

Respiratory Rate: Respirations are recorded as breaths per minute. They should be
counted for at least 30 seconds as the total number of breaths in a 15 second period is
rather small and any miscounting can result in rather large errors when multiplied by
4. Try to do this as surreptitiously as possible so that the patient does not consciously
alter their rate of breathing. This can be done by observing the rise and fall of the
patient's hospital gown while you appear to be taking their pulse. Normal is between
12 and 20. In general, this measurement offers no relevant information for the routine
examination. However, particularly in the setting of cardio-pulmonary illness, it can
be a very reliable marker of disease activity.

Pulse: This can be measured at any place where there is a large artery (e.g. carotid,
femoral, or simply by listening over the heart), though for the sake of convenience it
is generally done by palpating the radial impulse. You may find it helpful to feel both
radial arteries simultaneously, doubling the sensory input and helping to insure the
accuracy of your measurements. Place the tips of your index and middle fingers just
proximal to the patients wrist on the thumb side, orienting them so that they are both
over the length of the vessel.

Vascular Anatomy
 Technique for Measuring the Radial Pulse

The pictures below demonstrate the location of the radial artery (surface anatomy on
the left, gross anatomy on the right).
Frequently, you can see transmitted pulsations on careful visual inspection of this
region, which may help in locating this artery. Upper extremity peripheral vascular
disease is relatively uncommon, so the radial artery should be readily palpable in most
patients. Push lightly at first, adding pressure if there is a lot of subcutaneous fat or
you are unable to detect a pulse. If you push too hard, you might occlude the vessel
and mistake your own pulse for that of the patient. During palpation, note the
following:

1. Quantity: Measure the rate of the pulse (recorded in beats per minute). Count
for 30 seconds and multiply by 2 (or 15 seconds x 4). If the rate is particularly
slow or fast, it is probably best to measure for a full 60 seconds in order to
minimize the impact of any error in recording over shorter periods of time.
Normal is between 60 and 100.
2. Regularity: Is the time between beats constant? In the normal setting, the heart
rate should appear metronomic. Irregular rhythms, however, are quite
common. If the pattern is entirely chaotic with no discernable pattern, it is
referred to as irregularly irregular and likely represents atrial fibrillation. Extra
beats can also be added into the normal pattern, in which case the rhythm is
described as regularly irregular. This may occur, for example, when impulses
originating from the ventricle are interposed at regular junctures on the normal
 rhythm. If the pulse is irregular, it's a good idea to verify the rate by listening
over the heart (see cardiac exam section). This is because certain rhythm
disturbances do not allow adequate ventricular filling with each beat. The
resultant systole may generate a rather small stroke volume whose impulse is
not palpable in the periphery.
3. Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel
normal? This reflects changes in stroke volume. In the setting of hypovolemia,
for example, the pulse volume is relatively low (aka weak or thready). There
may even be beat to beat variation in the volume, occurring occasionally with
systolic heart failure.

Blood Pressure: Blood pressure (BP) is measured using mercury based manometers,
with readings reported in millimeters of mercury (mm Hg). The size of the BP cuff
will affect the accuracy of these readings. The inflatable bladder, which can be felt
through the vinyl covering of the cuff, should reach roughly 80% around the
circumference of the arm while its width should cover roughly 40%. If it is too small,
the readings will be artificially elevated. The opposite occurs if the cuff is too large.
Clinics should have at least 2 cuff sizes available, normal and large. Try to use the one
that is most appropriate, recognizing that there will rarely be a perfect fit.
Blood Pressure Cuffs
In order to measure the BP, proceed as follows:
1. Wrap the cuff around the patient's upper arm so that the line marked "artery" is
roughly over the brachial artery, located towards the medial aspect of the
antecubital fossa (i.e. the crook on the inside of their elbow). The placement
does not have to be exact nor do you actually need to identify this artery by
palpation.

Antecubital Fossa

The pictures below demonstrate the antecubital fossa anatomy (surface

anatomy on the left, gross anatomy on the right).

2. Put on your stethescope so that the ear pieces are angled away from your head.
Twist the head piece so that the diaphragm is engaged. This can be verified by
gently tapping on the end, which should produce a sound. With your left hand,
place the diaphragm over the area of the brachial artery. While most
practitioners use the diaphragm of the stethescope, the bell may actually be
superior for picking up the low pitched sounds used for measuring BP.
Experiment with both and see if this makes a difference. It's worth mentioning
that a number of different models of stethescops are available on the market,
each with its own variation on the structure of the diaphragm and bell. Read
the instruction manual accompanying your stethoscope in order to determine
how your device works.
3. Grasp the patient's right elbow with your right hand and raise their arm so that
the brachial artery is roughly at the same height as the heart. The arm should
remain somewhat bent and completely relaxed. You can provide additional
support by gently trapping their hand and forearm between your body and
right elbow. If the arm is held too high, the reading will be artifactually
lowered, and vice versa.
4. Turn the valve on the pumping bulb clockwise (may be counter clockwise in
some cuffs) until it no longer moves. This is the position which allows air to
enter and remain in the bladder.
5. Hold the diaphragm in place with your left hand. Use your right hand to pump
the bulb until you have generated 150 mmHg on the manometer. This is a bit
above the top end of normal for systolic blood pressure (SBP). Then listen. If
you immediately hear sound, you have underestimated the SBP. Pump up an
additional 20 mmHg and repeat. Now slowly deflate the blood pressure cuff
(i.e. a few mm Hg per second) by turning the valve in a counter-clockwise
direction while listening over the brachial artery and watching the pressure
gauge. The first sound that you hear reflects the flow of blood through the no
longer completely occluded brachial artery. The value on the manometer at
this moment is the SBP. Note that although the needle may oscillate prior to
this time, it is the sound of blood flow that indicates the SBP.
6. Continue listening while you slowly deflate the cuff. The diastolic blood
pressure (DBP) is measured when the sound completely disappears. This is the
point when the pressure within the vessel is greater then that supplied by the
cuff, allowing the free flow of blood without turbulence and thus no audible
sound. These are known as the Sounds of Koratkoff.

Technique for Measuring Blood Pressure

 7. Repeat the measurement on the patient's other arm, reversing the position of
your hands. The two readings should be within 10-15 mm Hg of each other.
Differences greater then this imply that there is differential blood flow to each
arm, which most frequently occurs in the setting of subclavian artery
atherosclerosis.
8. Occasionally you will be unsure as to the point where systole or diastole
occurred and wish to repeat the measurement. Ideally, you should allow the
cuff to completely deflate, permit any venous congestion in the arm to resolve
(which otherwise may lead to inaccurate measurements), and then repeat a
minute or so later. Furthermore, while no one has ever lost a limb secondary to
BP cuff induced ischemia, repeated measurement can be uncomfortable for the
patient, another good reason for giving the arm a break.
9. Avoid moving your hands or the head of the stethescope while you are taking
readings as this may produce noise that can obscure the Sounds of Koratkoff.
10. You can verify the SBP by palpation. To do this, position the patient's right
arm as described above. Place the index and middle fingers of your right hand
over the radial artery. Inflate the cuff until you can no longer feel the pulse, or
simply to a value 10 points above the SBP as determined by auscultation.
Slowly deflate the cuff until you can again detect a radial pulse and note the
reading on the manometer. This is the SBP and should be the same as the
value determined with the use of your stethescope.

Normal is between 100/60 and 140/90. Hypertension is thus defined as either SBP
greater then 140 or DBP greater than 90. It is important to recognize that blood
pressure is rarely elevated to a level that causes acute symptoms. That is, while
hypertension in general is common, emergencies resulting from extremely high values
and subsequent acute end organ dysfunction are quite rare. Rather, it is the chronically
elevated values which lead to target organ damage, though in a slow and relatively
silent fashion. At the other end of the spectrum, the minimal SBP required to maintain
perfusion varies with the individual. Therefore, interpretation of low values must take
into account the clinical situation. Those with poorly functioning hearts, for example,
can adjust to a chronically low SBP (e.g. 80-90) and live without symptoms of
hypoperfusion. However others, used to higher baseline values, might become quite
ill if their SBPs were suddenly decreased to these same levels.
Many things can alter the accuracy of your readings. In order to limit their impact,
remember the following:

1. Do not place the blood pressure cuff over a patients clothing or roll a tight
fitting sleeve above their biceps when determining blood pressure as either can
cause elevated readings.
2. Make sure the patient has had an opportunity to rest before measuring their
BP. Try the following experiment to assess the impact that this can have. Take
a patient's BP after they've rested. Then repeat after they've walked briskly in
place for several minutes. Patients who are not too physically active (i.e.
relatively deconditioned) will develop an elevation in both their SBP and
DBP. Also, see what effect raising or lowering the arm, and thus the position
of the brachial artery relative to the heart, has on BP. If you have a chance,
obtain measurements on the same patient with both a large and small cuff.
These exercises should give you an appreciation for the magnitude of error
that can be introduced when improper technique is utilized.
3. If the reading is surprisingly high or low, repeat the measurement towards the
end of your exam.
4. Instruct your patients to avoid coffee, smoking or any other unprescribed drug
with sympathomimetic activity on the day of the measurement.
5. Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are part
of the assessment for hypovolemia. This requires first measuring these values
when the patient is supine and then repeating them after they have stood for 2
minutes, which allows for equilibration. Normally, SBP does not vary by more
then 20 points when a patient moves from lying to standing. In the setting of
significant volume depletion, a greater then 20 point drop may be seen.
Changes of lesser magnitude occur when moving from lying to sitting or
sitting to standing. This is frequently associated with symptoms of cerebral
hypoperfusion (e.g.. light headedness). Heart rate should increase by more
then 20 points in a normal physiologic attempt to augment cardiac output by
providing chronotropic compensation. In the setting of GI bleeding, for
example, a drop in blood pressure and/or rise in heart rate after this maneuver
is a marker of significant blood loss and has important prognostic
implications. Orthostatic measurements may also be used to determine if
postural dizziness, a common complaint with multiple possible explanations,
is the result of a fall in blood pressure. For example, patients who suffer from
diabetes frequently have autonomic nervous system dysfunction and cannot
generate appropriate arteriolar vaosconstriction when changing positions. This
results in postural vital sign changes and symptoms. The 20 point value is a
rough guideline. In general, the greater the change, the more likely it is to
cause symptoms and be of clinical relevance.
6. If possible, measure the blood pressure of a patient who has an indwelling
arterial catheter (these patients can be found in the ICU with the help of a
preceptor). Arterial transducers are an extremely accurate tool for assessing
blood pressure and therefore provide a method for checking your non-invasive
technique.

Oxygen Saturation: Over the past decade, this non-invasive measurement of gas
exchange and red blood cell oxygen carrying capacity has become available in all
hospitals and many clinics. While imperfect, it can provide important information
 about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign.
In particular, for those suffering from either acute or chronic cardio-pulmonary
disorders, it can help quantify the degree of impairment.
Pulse Oxymeter

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