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 Penny sized area in midclavicular line along 5th 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