VITALS

Radial Pulse
Orient fingers perpendicular to radial artery, just lateral to tendon strings
Ask patient to make fist and flex to identify tendon landmarks
Respiratory Rate
Take simultaneously with radial pulse, safer to use 30 seconds
Blood Pressure
Bell is better for picking up low-pitched BP noises
Brachial artery should be supported at same level as heart
Korotfkoff sounds result from turbulent flow. They cease when arterial pressure overcomes cuff
pressure and laminar flow resumes
Clinical
1. Orthostatic Hypotension: Drop of > 20 SBP on standing versus sitting
2. Asymmetry: Difference > 10-15 BP between arms
Temperature
Fever when above 38.5 C/101.5 F
Rectal better approximates core temperature, 1 degree higher

CARDIAC
S1/S2 Heart Sounds
Murmurs, Rubs, Gallops
Maximum Impulse
th
Penny sized area in midclavicular line along 5 ICS
Edge of index finger should border bottom breast
Easier to feel in left lateral decubitus position
Clinical
1. Dilation: Lateral displacement of PMI
2. Thrill: Spurts of turbulent blood, indicates valve pathology

JVD
Originates between clavicular and sternal heads of the SCM, travels to area in front of ear
Do not confuse with external jugular (outside SCM) or carotid artery (pulses with radial artery)
Important because in straight line with RA, no valves in the way
Sit up at 45 degrees to ensure distinct top of tube
Flickers due to JVP waves, but no palpable tube
If problematic, press on RUQ for 5-10 sec to elicit hepato-jugular reflex
Height from angle of Louis to top of column + 5, normally 7-9 cm
Clinical
1. Pulsation: High central venous pressure/backflow

Carotid Bruits
Slide two fingers along lateral trachea
Push harder depending on fat but generally powerful
Never take bilateral carotid pulse
Clinical
1. Bruit: Indicates carotid artery stenosis turbulent flow

Radial Pulse
Orient fingers perpendicular to radial artery, just lateral to tendon strings
PVD rare in uppers, so use as benchmark versus lower limb pulses

Peripheral Pulses
1. Femoral
2. Popliteal
3. Tibialis Posterior
4. Dorsalis Pedis

PULMONARY
Breath Sounds
Front: Superior lobes (1x), middle lobe/lingual (1x)
Back: Inferior lobes (3x)
Findings
1. Breath Sounds : Fluid, atelectasis, pneumothorax
2. Rales: Scratchy noise indicates fluid in alveoli, lowers and rising means pulmonary edema,
scattered means pneumonia. Ripping Velcro sound rare, indicates fibrosis
3. Rhonchi: Sounds like gurgling milkshake dregs, indicates mucus or secretions clogging
larger airways
4. Wheezing: Whistling noise on expiration, especially in forceful
5. Stridor: Wheezing on inspiration only, indicates mechanical obstruction
6. Egophony: Converts EEE to AAA sound on auscultation, indicates consolidation

Excursion
Align thumbs along long spine axis, spread fingers and have patient inhale
Asymmetric lung expansion occurs when pleural space stuffed
Generally only in extreme late stage
Fremitus
Norma lung transmits vibration; feel with bone under thin skin of hands
Place knife-edge of hands parallel to long spine axis at all levels, say 99
Clinical
1. Vibration : Consolidation
2. Vibration : Fluid, Atelectasis, Pneumothorax
Percussion
Ask patient to hunch forward and clasp hands to laterally retract scapulae
Percuss side to side down alley between vertebral muscles and scapular border
Clinical
1. Dullness: Consolidation, Fluid, Atelectasis
2. Hyperresonance: Pneumothorax

Observed Pathologies
1. Respiratory Distress, Nasal Flaring
2. Shallow or Deep
3. Quick versus slow
4. Accessory muscle use
5. Tripod position
6. Cyanosis: Blue lips or nails
7. Clubbing
8. Exhale through pursed lips
9. Spine, Ribcage deformities

ABDOMINAL
*Do not allow head flexion, as this will tighten the abdominal musculature
*If too tense, flex knees and plant soles on table
*Valsalva will accentuate abdominal wall hernias
Bowel Noises
Characterization
1. Presence
2. Frequency
3. Quality
Should occur every 2-5 seconds, although variable
Clinical
1. Absent: Inflammation of serosa (peritoneum)
2. Hyperactive: Inflammation of mucosa
3. Rush-Tinkle: Frequent burst, then silence. Indicates obstruction
4. Silence-Return: Indicates recovery after surgery or injury

Renal Artery Bruits

Caused by turbulent flow from atherosclerosis or stenosis
Listen a few cm above belly at lateral edge of rectus
Press very hard, since kidneys retroperitoneal
Percussion
Tympanic: Drum head, hollow structure
Dull: Solid structure can be organ or fluid
Liver should be entirely covered by ribs, no more than 1-2 cm below costal margin
Spleen should be totally concealed under ribs
Palpation
*Fluid Wave