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A Practical Guide to Clinical Medicine

http://medicine.ucsd.edu/clinicalmed/introduction.htm

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 Illness Male Genital/Rectal Exam
The Oral Presentation
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
Medical Links
Send Comments to: Charlie Goldberg, M.D.

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


pictures.

Introduction
This guide has been assembled with an eye towards clinical relevance. It represents a
departure from the usual physical exam teaching tools which, in their attempts to be all
inclusive, tend to de-emphasize the practical nature of patient care. As a result, students
frequently have difficulty identifying what information is truly relevant, why it's
important and how it applies to the actual patient. By approaching clinical medicine in a
pragmatic and demystified fashion, the significance of the material should be readily
apparent and the underlying principles more clearly understood. In particular:
1. Each section is constructed to answer the question: "What do I really need to
know about this area of medical care?" The material covered is presented in a
concise, ordered fashion that should be readily applicable to the common clinical
scenarios that you will actually see in day to day practice. Esoterica has been
purposely excluded.

2. The Web-Based format allows for easy access to information and provides
integration of text, pictures, and sound.
3. Exam techniques are described in step-by-step detail. Special maneuvers that are
frequently utilized are also described.
4. The rationale for each aspect of the examination is addressed and, where
appropriate, relevant pathophysiology discussed.
5. Detailed descriptions of how to function in clinical settings are included. In
general, students identify their role in patient care either by trial and error or
through the beneficence of more advanced students, residents or staff. This is not
particularly efficient and diminishes the potential for learning and fun. The
following sections are included to specifically address this issue:
a. Oral presentations
b. Patient write-ups
c. Working in outpatient clinics
d. Functioning on an inpatient service
e. Clinical decision making
6. Pictures clearly identifying appropriate techniques accompany each section.
Examples of common pathologic findings are included as well.
7. Images of gross anatomic correlates (denoted by the "daVinci Icon" shown above)
are incorporated within a number of the segments.
8. Video clips of selected examination maneuvers and findings.
9. Carefully selected links to other useful websites are available.
I hope that this site helps to make the educational process both fun and rewarding. As the
skills required of a physician cannot be learned from any single source, I encourage you
to make use of as many other references as possible. This should reinforce basic
principles and alert you to the fact that there are often many ways of achieving the same
end (i.e. there is frequently no single right way of doing something). What follows, then,
serves merely as an introduction. I have tried to capture those core behaviors that define
clinical excellence and will have prolonged applicability, even in a technology driven
world. The learning process continues (I hope) until the day you stop practicing medicine.
There are always new techniques to learn and unusual findings to incorporate into your
personal libraries of medical experience. However, unless you take the time to build a
solid foundation, you will never have confidence in the accuracy and value of what you
can uncover with a sharp mind, agile fingers and a few simple tools!
Please Note: Medical and non medical practitioners are welcome to use this site for
learning purposes. However, it is not meant as a substitute for appropriate evaluation of
medical conditions or pursuit of an advanced education through traditional mechanisms.
While the authors welcome feedback and comments, please do not solicit medical advice.
This site is, and will always remain, a work in progress. I look forward to receiving any
and all comments/suggestions/feedback (use the link to my e-mail, located at the top of
each page).

Charlie Goldberg, M.D.


University of California, San Diego School of Medicine
San Diego VA Medical Center
Jan Thompson
University of California, San Diego School of Medicine
San Diego, CA

September, 2004

History of Present Illness (HPI)


Obtaining an accurate history is the critical first step in determining the etiology of a
patient's problem. A large percentage of the time, you will actually be able make a
diagnosis based on the history alone. The value of the history, of course, will depend on
your ability to elicit relevant information. Your sense of what constitutes important data
will grow exponentially in the coming years as you gain a greater understanding of the
pathophysiology of disease through increased exposure to patients and illness. However,
you are already in possession of the tools that will enable you to obtain a good history.
That is, an ability to listen and ask common-sense questions that help define the nature of
a particular problem. It does not take a vast, sophisticated fund of knowledge to
successfully interview a patient. In fact seasoned physicians often lose site of this
important point, placing too much emphasis on the use of testing while failing to take the
time to listen to their patients. Successful interviewing is for the most part dependent
upon your already well developed communication skills.
What follows is a framework for approaching patient complaints in a problem oriented
fashion. The patient initiates this process by describing a symptom. It falls to you to take
that information and use it as a springboard for additional questioning that will help to
identify the root cause of the problem. Note that this is different from trying to identify
disease states which might exist yet do not generate overt symptoms. To uncover these
issues requires an extensive "Review Of Systems" (a.k.a. ROS). Generally, this consists
of a list of questions grouped according to organ system and designed to identify disease
within that area. For example, a review of systems for respiratory illnesses would
include: Do you have a cough? If so, is it productive of sputum? Do you feel short of
breath when you walk? etc. In a practical sense, it is not necessary to memorize an
extensive ROS question list. Rather, you will have an opportunity to learn the relevant
questions that uncover organ dysfunction when you review the physical exam for each

system individually. In this way, the ROS will be given some context, increasing the
likelihood that you will actually remember the relevant questions.
The patient's reason for presenting to the clinician is usually referred to as the "Chief
Complaint." Perhaps a less pejorative/more accurate nomenclature would be to identify
this as their area of "Chief Concern."
Getting Started:
Always introduce yourself to the patient. Then try to make the environment as private and
free of distractions as possible. This may be difficult depending on where the interview is
taking place. The emergency room or a non-private patient room are notoriously difficult
spots. Do the best that you can and feel free to be creative. If the room is crowded, it's
OK to try and find alternate sites for the interview. It's also acceptable to politely ask
visitors to leave so that you can have some privacy.
If possible, sit down next to the patient while conducting the interview. Remove any
physical barriers that stand between yourself and the interviewee (e.g. put down the side
rail so that your view of one another is unimpeded... though make sure to put it back up at
the conclusion of the interview). These simple maneuvers help to put you and the patient
on equal footing. Furthermore, they enhance the notion that you are completely focused
on them. You can either disarm or build walls through the speech, posture and body
languarge that you adopt. Recognize the power of these cues and the impact that they can
have on the interview. While there is no way of creating instant intimacy and rapport,
paying attention to what may seem like rather small details as well as always showing
kindness and respect can go a long way towards creating an environment that will
facilitate the exchange of useful information.
If the interview is being conducted in an outpatient setting, it is probably better to allow
the patient to wear their own clothing while you chat with them. At the conclusion of
your discussion, provide them with a gown and leave the room while they undress in
preparation for the physical exam.
Initial Question(s):
Ideally, you would like to hear the patient describe the problem in their own words. Open
ended questions are a good way to get the ball rolling. These include: "What brings your
here? How can I help you? What seems to be the problem?" Push them to be as
descriptive as possible. While it's simplest to focus on a single, dominant problem,
patients occasionally identify more then one issue that they wish to address. When this
occurs, explore each one individually using the strategy described below.
Follow-up Questions:
There is no single best way to question a patient. Successful interviewing requires that
you avoid medical terminology and make use of a descriptive language that is familiar to
them. There are several broad questions which are applicable to any complaint. These
include:

1. Duration: How long has this condition lasted? Is it similar to a past problem? If
so, what was done at that time?
2. Severity/Character: How bothersome is this problem? Does it interfere with
your daily activities? Does it keep you up at night? Try to have them objectively
rate the problem. If they are describing pain, ask them to rate it from 1 to 10 with
10 being the worse pain of their life, though first find out what that was so you
know what they are using for comparison (e.g. childbirth, a broken limb, etc.).
Furthermore, ask them to describe the symptom in terms with which they are
already familiar. When describing pain, ask if it's like anything else that they've
felt in the past. Knife-like? A sensation of pressure? A toothache? If it affects their
activity level, determine to what degree this occurs. For example, if they complain
of shortness of breath with walking, how many blocks can they walk? How does
this compare with 6 months ago?
3. Location/Radiation: Is the symptom (e.g. pain) located in a specific place? Has
this changed over time? If the symptom is not focal, does it radiate to a specific
area of the body?
4. Have they tried any therapeutic maneuvers?: If so, what's made it better (or
worse)?
5. Pace of illness: Is the problem getting better, worse, or staying the same? If it is
changing, what has been the rate of change?
6. Are there any associated symptoms? Often times the patient notices other things
that have popped up around the same time as the dominant problem. These tend to
be related.
7. What do they think the problem is and/or what are they worried it might be?
8. Why today?: This is particularly relevant when a patient chooses to make
mention of symptoms/complaints that appear to be long standing. Is there
something new/different today as opposed to every other day when this problem
has been present? Does this relate to a gradual worsening of the symptom itself?
Has the patient developed a new perception of its relative importance (e.g. a
friend told them they should get it checked out)? Do they have a specific agenda
for the patient-provider encounter?
The content of subsequent questions will depend both on what you uncover and your
knowledge base/understanding of patients and their illnesses. If, for example, the patient's
initial complaint was chest pain you might have uncovered the following by using the
above questions:
The pain began 1 month ago and only occurs with activity. It rapidly goes away with rest.
When it does occur, it is a steady pressure focused on the center of the chest that is
roughly a 5 (on a scale of 1 to 10). Over the last week, it has happened 6 times while in
the first week it happened only once. The patient has never experienced anything like this
previously and has not mentioned this problem to anyone else prior to meeting with you.
As yet, they have employed no specific therapy.
This is quite a lot of information. However, if you were not aware that coronary-based
ischemia causes a symptom complex identical to what the patient is describing, you
would have no idea what further questions to ask. That's OK. With additional experience,

exposure, and knowledge you will learn the appropriate settings for particular lines of
questioning. When clinicians obtain a history, they are continually generating differential
diagnoses in their minds, allowing the patient's answers to direct the logical use of
additional questions. With each step, the list of probable diagnoses is pared down until a
few likely choices are left from what was once a long list of possibilities. Perhaps an easy
way to understand this would be to think of the patient problem as a Windows-Based
computer program. The patient tells you a symptom. You click on this symptom and a list
of general questions appears. The patient then responds to these questions. You click on
these responses and... blank screen. No problem. As yet, you do not have the clinical
knowledge base to know what questions to ask next. With time and experience you will
be able to click on the patient's response and generate a list of additional appropriate
questions. In the previous patient with chest pain, you will learn that this patient's story is
very consistent with significant, symptomatic coronary artery disease. As such, you
would ask follow-up questions that help to define a cardiac basis for this complaint (e.g.
history of past myocardial infarctions, risk factors for coronary disease, etc.). You'd also
be aware that other disease states (e.g. emphysema) might cause similar symptoms and
would therefore ask questions that could lend support to these possible diagnoses (e.g.
history of smoking or wheezing). At the completion of the HPI, you should have a pretty
good idea as to the likely cause of a patient's problem. You may then focus your exam on
the search for physical signs that would lend support to your working diagnosis and help
direct you in the rational use of adjuvant testing.
Recognizing symptoms/responses that demand an urgent assessment (e.g. crushing chest
pain) vs. those that can be handled in a more leisurely fashion (e.g. fatigue) will come
with time and experience. All patient complaints merit careful consideration. Some,
however, require time to play out, allowing them to either become "a something" (a
recognizable clinical entity) or "a nothing," and simply fade away. Clinicians are
constantly on the look-out for markers of underlying illness, historical points which
might increase their suspicion for the existence of an underlying disease process. For
example, a patient who does not usually seek medical attention yet presents with a new,
specific complaint merits a particularly careful evaluation. More often, however, the
challenge lies in having the discipline to continually re-consider the diagnostic
possibilities in a patient with multiple, chronic complaints who presents with a variation
of his/her "usual" symptom complex.
You will undoubtedly forget to ask certain questions, requiring a return visit to the
patient's bedside to ask, "Just one more thing." Don't worry, this happens to everyone!
You'll get more efficient with practice.
Dealing With Your Own Discomfort:
Many of you will feel uncomfortable with the patient interview. This process is, by its
very nature, highly intrusive. The patient has been stripped, both literally and figuratively,
of the layers that protect them from the physical and psychological probes of the outside
world. Furthermore, in order to be successful, you must ask in-depth, intimate questions
of a person with whom you essentially have no relationship. This is completely at odds
with your normal day to day interactions. There is no way to proceed without asking

questions, peering into the life of an otherwise complete stranger. This can, however, be
done in a way that maintains respect for the patient's dignity and privacy. In fact, at this
stage of your careers, you perhaps have an advantage over more experienced providers as
you are hyper-aware that this is not a natural environment. Many physicians become
immune to the sense that they are violating a patient's personal space and can
thoughtlessly over step boundaries. Avoiding this is not an easy task. Listen and respond
appropriately to the internal warnings that help to sculpt your normal interactions.

The Rest Of The History


The remainder of the history is obtained after completing the HPI. As such, the
previously discussed techniques for facilitating the exchange of information still apply.
Past Medical History: Start by asking the patient if they have any medical problems. If
you receive little/no response, the following questions can help uncover important past
events: Have they ever received medical care? If so, what problems/issues were
addressed? Was the care continuous (i.e. provided on a regular basis by a single person)
or episodic? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or
other special testing? Ever been hospitalized? If so, for what? It's quite amazing how
many patients forget what would seem to be important medical events. You will all
encounter the patient who reports little past history during your interview yet reveals a
complex series of illnesses to your resident or attending! These patients are generally not
purposefully concealing information. They simply need to be prompted by the right
questions!
Past Surgical History: Were they ever operated on, even as a child? What year did this
occur? Were there any complications? If they don't know the name of the operation, try to
at least determine why it was performed. Encourage them to be as specific as possible.
Medications: Do they take any prescription medicines? If so, what is the dose and
frequency? Do they know why they are being treated?* Medication noncompliance/confusion is a major clinical problem, particularly when regimens are
complex, patients older, cognitively impaired or simply disinterested. It's important to
ascertain if they are actually taking the medication as prescribed. This can provide critical
information as frequently what appears to be a failure to respond to a particular therapy is
actually non-compliance with a prescribed regimen. Identifying these situations requires
some tact, as you'd like to encourage honesty without sounding accusatory. It helps to
clearly explain that without this information your ability to assess treatment efficacy and
make therapeutic adjustments becomes difficult/potentially dangerous. If patients are, in
fact, missing doses or not taking medications altogether, ask them why this is happening.
Perhaps there is an important side effect that they are experiencing, a reasonable fear that
can be addressed, or a more acceptable substitute regimen which might be implemented.

Don't forget to ask about over the counter or "non-traditional" medications. How much
are they taking and what are they treating? Has it been effective? Are these medicines
being prescribed by a practitioner? Self administered?
* You'll be surprised to learn how many patients don't know the answers to these
questions. Encourage them to keep an up to date medication list and/or write one out for
them. When all else fails, ask the patient to bring their meds with them when they return
or, if they are in-patients, see if a family member/friend can do so for them.
Allergies/Reactions: Have they experienced any adverse reactions to medications? The
exact nature of the reaction should be clearly identified as it can have important clinical
implications. Anaphylaxis, for example, is a life threatening reaction and an absolute
contraindication to re-exposure to the drug. A rash, however, does not raise the same level
of concern, particularly if the agent in question is clearly the treatment of choice.
Smoking History: Have they ever smoked cigarettes? If so, how many packs per day and
for how many years? If they quit, when did this occur? The packs per day multiplied by
the number of years gives the pack-years, a widely accepted method for smoking
quantification. Pipe, cigar and chewing tobacco use should also be noted.
Alcohol: Do they drink alcohol? If so, how much per day and what type of drink?
Encourage them to be as specific as possible. One drink may mean a beer or a 12 oz glass
of whiskey, each with different implications. If they don't drink on a daily basis, how
much do they consume over a week or month?
Other Drug Use: Any drug use, past or present, should be noted. Get in the habit of
asking all your patients these questions as it can be surprisingly difficult to accurately
determine who is at risk strictly on the basis of appearance. Remind them that these
questions are not meant to judge but rather to assist you in identifying risk factors for
particular illnesses (e.g. HIV, hepatitis). In some cases, however, a patient will clearly
indicate that they do not wish to discuss these issues. Respect their right to privacy and
move on. Perhaps they will be more forthcoming at a later date.
Obstetric (where appropriate): Have they ever been pregnant? If so, how many times?
What was the outcome of each pregnancy (e.g. full term delivery; spontaneous abortion;
therapeutic abortion).
Sexual Activity: This is an uncomfortable line of questioning for many practitioners.
However, it can provide important information and should be pursued. As with questions
about substance abuse, your ability to determine on sight who is sexually active (and in
what type of activity) is rather limited. By asking all of your patients these questions, the
process will become less awkward. Do they participate in intercourse? With persons of
the same or opposite sex? Are they involved in a stable relationship? Do they use
condoms or other means of birth control? Married? Health of spouse? Divorced? Past
sexually transmitted diseases? Do they have children? If so, are they healthy? Do they
live with the patient?

Family History: In particular, you are searching for heritable illnesses among first or
second degree relatives. Most common, at least in America, are coronary artery disease,
diabetes and certain malignancies. Patients should be as specific as possible. "Heart
disease," for example, includes valvular disorders, coronary artery disease and congenital
abnormalities, of which only coronary disease has genetic implications. Find out the age
of onset of the illnesses, as this has prognostic importance for the patient. For example, a
father who had an MI at age 70 is not a marker of genetic predisposition while one who
had a similar event at age 40 certainly would be. Also ask about any unusual illnesses
among relatives, perhaps revealing evidence for rare genetic conditions.
Work/Hobbies/Other: What sort of work does the patient do? Have they always done
the same thing? Do they enjoy it? If retired, what do they do to stay busy? Any hobbies?
Participation in sports or other physical activity? Where are they from originally? These
questions do not necessarily reveal information directly related to the patient's health.
However, it is nice to know something non-medical about them. This may help improve
the patient-physician bond and relay the sense that you care about them as a person. It
also gives you something to refer back to during later visits, letting the patient know that
you paid attention and really remember them.
In recounting their history, patient's frequently drop clues that suggest issues meriting
further exploration. If, for example, they are taking anti-hypertensive or anti-anginal
medications yet made no mention of cardiac disease, additional history taking would be
in order. Furthermore, if at any time you uncover information relevant to the chief
complaint don't be afraid to revisit the HPI.

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

3.
4.
5.

6.

appreciation for the magnitude of error that can be introduced when improper
technique is utilized.
If the reading is surprisingly high or low, repeat the measurement towards the end
of your exam.
Instruct your patients to avoid coffee, smoking or any other unprescribed drug
with sympathomimetic activity on the day of the measurement.
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.
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

http://medicine.ucsd.edu/clinicalmed/eyes.htm

The Eye Exam


Assessment of Visual Acuity: The first part of the eye exam is an assessment of acuity.
This can be done with either a standard Snellen hanging wall chart read with the patient
standing at a distance of 20 feet or a specially designed pocket card (held at 14 inches).
Each eye is tested independently (i.e. one is covered while the other is used to read). The
patient should be allowed to wear their glasses and the results are referred to as "Best
corrected vision." You do not need to assess their ability to read every line on the chart. If
they have no complaints, rapidly skip down to the smaller characters. The numbers at the
end of the line provide an indication of the patient's acuity compared with normal
subjects. The larger the denominator, the worse the acuity. 20/200, for example, means
that they can see at 20 feet what a normal individual can at 200 feet (i.e. their vision is
pretty lousy). If the patient is unable to read any of the lines, indicative of a big problem
if this was a new complaint, a gross estimate of what they are capable of seeing should be
determined (e.g. ability to detect light, motion or number of fingers placed in front of
them). In general, acuity is only tested when there is a new, specific, visual complaint.
Hand Held Acuity Card
Snellen Chart

Pinhole Testing: The pinhole testing device can determine if a problem with acuity is the
result of refractive error (and thus correctable with glasses) or due to another process. The
pinholes only allow the passage of light which is perpendicular to the lens, and thus does
not need to be bent prior to being focused onto the retina. The patient is instructed to
view the Snellen chart with the pinholes up (below left) and then again with them in the
down position (below right). If the deficit corrects with the pinholes in place, the acuity
issue is related to a refractive problem.

Observation of External Structures:


1. Occular Symmetry: Occasionally, one of the muscles that controls eye movement
will be weak or foreshortened, causing one eye to appear deviated medially or
laterally compared with the other.

2. Eye Lid Symmetry: Both eye lids should cover approximately the same amount of
eyeball. Damage to the nerves controlling these structures (Cranial Nerves 3 and
7) can cause the upper or lower lids on one side to appear lower then the other.

Patient unable to completely close left upper eyelid due to peripheral CN 7


dysfunction.
3. Sclera: The normal sclera is white and surrounds the iris and pupil. In the setting
of liver or blood disorders that cause hyperbilirubinemia, the sclera may appear
yellow, referred to as icterus. This can be easily confused with a muddy-brown
discoloration common among older African Americans that is a variant of normal.
Icteric Sclera

Muddy Brown Sclera

4. Conjunctiva: The sclera is covered by a thin transparent membrane known as the


conjunctiva, which reflects back onto the underside of the eyelids. Normally, it's
invisible except for the fine blood vessels that run through it. When infected or
otherwise inflamed, this layer can appear quite red, a condition known as
conjunctivitis. Alternatively, the conjunctiva can appear pale if patient is very
anemic. By gently applying pressure and pulling down and away on the skin
below the lower lid, you can examine the conjunctival reflection, which is the best
place to identify this finding.
Normal Appearing Conjunctival
Reflection, Lower Lid

Pale Conjunctiva, due to severe anemia.

5.
6. Conjunctivitis
7. Blood can also accumulate underneath the conjunctiva when one of the small
blood vessels within it ruptures. This may be the result of relatively minor trauma
(cough, sneeze, or direct blow), a bleeding disorder or idiopathic. The resulting
collection of blood is called a subconjunctival hemorrhage. While dramatic, it is
generally self limited and does not affect vision.
8. Subconjunctival Hemorrhage

9.
10. Pupil and Iris: Normally, both of these structures are round and symmetric.

When performing the rest of the exam, make sure that you are in a comfortable position.
The critical maneuver is assuring that the patient is seated at a height such that their eyes
are essentially on the same level as your own when you are standing next to them.
Testing Extra-Occular Movements: Instruct the patient to follow your index finger with
their eyes only (i.e. their head remains in one position) as you first move it to either the
extreme right or left. Then, once you have the patient looking out laterally, have them
follow your finger as you move it first up, then down. Now move your finger across to
the other side and repeat. Your path should trace out the letter H. At the end, bring your
finger directly in towards the patient's nose. This will cause the patient to look cross-eyed
and the pupils should constrict, a response referred to as accommodation.
Tracing out this path allows you to test each of the extra-occular muscles individually and
avoids movements that are dependent on more then one muscle, as occurs if you have the
patient look up or down while the pupil is oriented straight ahead. Assessments of both
extra-occular movements and visual acuity are actually tests of cranial nerve (CN)
function. CNs 3, 4, and 6 control movement and CN 2 vision. As these nerves are critical
to eye function, it makes sense to evaluate them at this stage rather then during the
neurological examination.
Testing Extra Occular Movements

CNs and the Muscles That Control Extra Occular Movements

The cranial nerves and the muscles that they innervate can be remembered using the
following pnemonic: SO '4', LR '6', all the rest '3.' Each CN permits the following
movements:

CN 4: Innervates the superior oblique muscle. Allows you to move either eyeball
down and inward.
CN 6: Innervates the lateral rectus muscle. Allows you to move either eyeball
laterally.

Patient with non-functional


left 6th cranial
nerve. He cannot move left
eye all the
way to the left.

CN 3: Innervates the remaining extra occular muscles as well as the upper eye lid.
Therefore allows eyeball movement in all remaining directions as well as lifting of the
upper lid. The dilation is due to disruption of the parasympathetic fibers which run along
the outside of CN3.

Right CN3 Lesion: Note patient's right eye is deviated laterally and there is ptosis of the
lid (picture on left),
and the right pupil (middle picture) is more dilated than the left pupil (picture on far
right).
Disorders of eye movement can also be due to problems with the extraocular muscles
themselves. For example, pictured below is a patient who has suffered a traumatic left
orbital injury. The inferior rectus muscle has become entrapped within the resulting
fracture, preventing the left eye from being able to look downward.

Entrapment of Left Inferior Rectus Muscle


Simulation of extra occular movement and pupillary disorders. from UC Davis.
Visual fields: The normal visual field for each eye extends out from the patient in all
directions, with an area of overlap directly in front. Field cuts refer to specific regions
where the patient has lost their ability to see. This occurs when the transmitted visual
impulse is interrupted at some point in its path from the retina to the visual cortex in the
back of the brain. You would, in general, only include a visual field assessment if the
patient complained of loss of sight; in particular "blind spots" or "holes" in their
vision.Visual fields can be crudely assessed as follows:

1. The examiner should be nose to nose with the patient, separated by


approximately 8 to 12 inches.
2. Each eye is checked separately. The examiner closes one eye and the
patient closes the one opposite. The open eyes should then be staring
directly at one another.
3. The examiner should move their hand out towards the periphery of his/her
visual field on the side where the eyes are open. The finger should be
equidistant from both persons.
4. The examiner should then move the wiggling finger in towards them,
along an imaginary line drawn between the two persons.The patient and
examiner should detect the finger at more or less the same time.
5. The finger is then moved out to the diagonal corners of the field and
moved inwards from each of these directions. Testing is then done starting
at a point in front of the closed eyes. The wiggling finger is moved
towards the open eyes.
6. The other eye is then tested.
Meaningful interpretation is predicated upon the examiner having normal fields, as they
are using themselves for comparison.
If the examiner cannot seem to move their finger to a point that is outside the patients
field dont worry, as it simply means that their fields are normal.
Interpretation: This test is rather crude, and it is quite possible to have small visual field
defects that would not be apparent on this type of testing. Prior to interpreting abnormal
findings, the examiner must understand the normal pathways by which visual impulses
travel from the eye to the brain.
For more information about visual field testing, see the following links:
Washington University, review of visual field of testing and pathology
University of Arkansas, gross anatomy of visual pathway
Using the Opthalmoscope
This aspect of the exam is, at least initially, quite awkward. Don't worry, it will get easier
with practice! Take some time to play with your scope, paying attention to its assembly,
on/off mechanism as well as the various lens and light settings which can be utilized.
There are a number of different brands on the market and each is a bit different. For the
purposes of the general exam, we'll focus on the simplest settings and most basic
techniques.
Side of Scope Facing Examiner

Side of Scope Facing Patient

Assessing Pupillary Response to Light:


The normal pupil constricts when either exposed directly to bright light or when that
same light is presented to the other eye, referred to as the consensual response. This is
due to the fact that stimulation of the afferent (i.e. sensory, carried with CN 2) nerves in
one eye will trigger efferent (i.e. motor, carried with CN 3) activation and subsequent
constriction of the pupils of both eyes. Disease affecting either the efferent or afferent
limbs will alter these responses accordingly. Also, processes which raise intracranial
pressure (e.g. brain tumors, collections of blood) can cause CN 3 dysfunction, resulting in
dilatation of the pupils and uresponsiveness to direct stimulation by light. To assess
pupillary reactions, proceed as follows:
1. Instruct the patient to look towards a distant area in the room (e.g. the corner
where the wall and ceiling meet) while keeping both of their eyes open. You may
need to gently remind them throughout the exam to continue looking in that
direction as it is very difficult to examine a roving eyeball. Do not ask them to
focus on a specific object as this will lead to pupillary constriction.
2. Turn on your opthalmoscope and adjust the light intensity to mid-range power.
The cone of light produced should be a white, medium sized circle. Circle sizes
available include small, medium and large. If possible, turn off most of the lights
in the room. This allows the pupil to dilate and cuts down on reflections from the
surface of the eye.
3. Make note of the size and shape of each pupil. Then assess whether each pupil
constricts appropriately in response to direct and indirect stimulation. If you're
having trouble detecting any change, have the patient close their eye for several
seconds and place your hand over their eyebrows to provide additional shade.
This helps to make it as dark as possible, encouraging greater pupillary dilation
and therefore accentuating any change which may occur after light is introduced.
It may be hard to detect the consensual response if the lighting in your room is
sub-optimal (i.e. if it's too dark, you won't be able to see the other eye). Note that

you do not need to look through the viewing window of the scope to perform this
part of the exam as you are essentially using it as a flashlight.
Closer Exam of the Outer Structures of the Eye:
1. Every opthalmoscope has a mechanism for changing the viewing lens. These
lenses vary in their ability to bend light and are numbered and color coded. The
specific lens that allows you to see something in focus will vary with your
distance from that structure as well as the refractive error of both your eyes and
the patients. To better examine the sclera, conjunctiva, pupil, cornea or iris, start
with the lens identified by a green 4 or 6.
2. Now grasp the handle with your right hand (the following instructions are for
examining the patient's right eye) such that your middle finger is resting on the
lower, front aspect of the head of the opthalmoscope.
3. Bring your right eye up to the viewing window. While you can either wear or
remove your own glasses, the patient's should be taken off. It's OK to leave
contacts in place.
4. Take your left hand and place it on the patient's forehead and gently apply upward
traction on the top lid with your thumb. This will "remind" them not to blink and
let you know their precise location. Obviously, try not to poke them in the eye
with this finger! Alternatively, you can place your left hand on the patient's
shoulder as a means of keeping track of their location. Try to keep both of your
eyes open when performing the exam as you might find it quite tiring to
continually squint with the non-examining eye.
5. Start approximately 15 cm from the patient and approach from about 15 or 20
degrees to the left of center. When you look through the viewing window, the
outer structures of the eye should come into sharp focus. If not, slowly move
closer or further from the patient until these structures become clear. It takes a bit
of experimentation to find the lens that is right for any given distance, so make
lens changes slowly by rotating the adjustment wheel. There is no magic way of
guessing which lens will allow the sharpest view.
*Most clinicians don't perform a detailed examination of the outer structures of the eye if
the patient has neither obvious abnormalities nor complaints referable to this region.
Viewing the Fundus (the retina and associated structures):

1. Repeat steps 1 thru 5 as above. Adjust the


lens selection wheel so that 0 appears in
the display window.

2. Look through the viewing window at the


patient's pupil, using your right eye to
examine their right eye. You should see a
sparkly, orange-red color known as the red
reflex. This is caused by light reflecting
off of the retina and is the same
phenomenon that produces red eyes in
flash photographs. Occasionally, the
translucent structures which allow light to
pass unimpeded from outside the eye to
the retina become opacified and the red
reflex is lost. In adults, this is most
commonly associated with cataracts, a
Red Reflex
process caused by clouding of the lens.
Eye Cross Section
(Picture Courtesy of Ray Kelly)

3. In order to see the fundus in greater detail, you will need to move very close to the
patient, analogous to looking through a key hole (i.e. the closer you are, the more
you'll see). Your middle finger, the one resting on the low front of the head piece,
should be on or near the patient's cheek. Starting with the 0 lens in place, rotate
the adjustment wheel counter clockwise. If you change lenses too quickly, you'll
probably whizz right by the one that gives the sharpest picture, so be patient. In
the event that this does not bring anything into focus, trying rotating the
adjustment wheel in the opposite direction. It doesn't really matter what number
lens is required to achieve the clearest view. Again, this will vary with the

refractive error of both you and the patient. The numbers are simply provided for
reference. Thus, while you may be able to see the fundus of some patients with
the green numbers still visible, you will need red 8 or 10 to visualize the same
region in a different person. Once you're close in and have the retina in clear view,
you should only need to change the lens one or two clicks in order to keep all
structures in focus as you scan across.
4. You will only be able to see a relatively small segment of the retina at any one
time. Your initial view will probably be of blood vessels on a random patch of
retina (see below).
The retina has a refractile, orange-red appearance, varying a bit with the skin color and
age of the patient. Fundoscopy provides important information as it not only enables you
to detect diseases of the eyes but is also the only area of the body where small blood
vessels can be studied with relative ease. There are a number of chronic systemic diseases
(most commonly hypertension, diabetes and atherosclerosis) that affect vessels of this
size in a relatively slow and silent fashion. It is, however, frequently impossible to
directly assess the extent of this damage during physical examination as the affected
organs, e.g. kidneys, are well hidden. Evaluation of the retina provides an opportunity to
directly visualize these processes. Based on this information, clinicians can make
educated guesses as to what is occurring elsewhere in the body. Having said this, do not
be discouraged if it takes a while before you're able to identify structures with any degree
of confidence. Practice on every patient that you examine. It will come with time. A few
things to pay attention to:
1. When you first visualize the retina, you will note branching blood vessels. The
bigger, darker ones are the veins and the smaller, brighter red structures the
arteries. Changes in the appearance of the arteries (copper wiring) as well as
alterations in the arterial-venous crossing pattern (a-v nicking) occur with
atherosclerosis and hypertension respectively (see any text for pictures). These
vessels are more obvious in the superior and inferior aspects of the retina, with
relative sparing of the temporal and medial regions.
2. Imagine that the blood vessels are the branches of a tree. Follow them in a
direction that leads to less branching (i.e. towards the trunk). This will direct you
towards the optic disc, the point at which the vessels enter the retina along with
the head of the optic nerve. The edges of this round disc are sharp and well
defined in the normal state. It should be a bit more yellow/orange when compared
to the rest of the retina. At the center of the disc is the optic cup, a distinct circular
area from which the blood vessels actually emerge. The disc is not located in the
exact center of the retina but rather towards its medial/nasal aspect. Measurements
in the eye are made using disc size as a measuring device (e.g. a finding may be
described as being at 2 O'clock, 2 disc diameters from the center of the disc). If
you are unable to locate the disc after following the vessels in one direction,
simply head the other way.
3. The macula is a region located lateral to the optic disc. It looks somewhat darker
then the rest of the retina and, as opposed to the disc, has no distinct borders. The
macula provides the sharpest vision. It can be best visualized by asking the patient

to stare directly at the light of the opthalmoscope while you remain focused on a
fixed area of the retina.
4. You will not be able to visualize the entire retina at any one time (approximately
one disc diameter should be visible). To view different areas, you'll have to shift
the angle with which you peer through the pupil. This requires very small
movements. Try to examine the entire structure systematically, looking up, down,
left and right. You will undoubtedly have to remind the patient to continue
looking straight ahead, else the fundus will be in continual motion and you will
have no chance of finding anything. It's also a good idea to periodically give the
patient a break (particularly if the exam is taking a while), allowing them to blink
in the dark before resuming.
Retina--Right Eye
(Picture Courtesy of Ray Kelly)

In order to view the patient's left eye, grasp the scope in your left hand and use your left
eye; then repeat the process described above.
If possible, try to avoid eating garlic, onions or other strong smelling food. If you are
"dependent" on these substances, invest in a box of tic-tacs for use during the exam!
It is much easier to examine the retina after the pupil has been pharmacologically dilated.
In actual practice, however, most providers, with the exception of optometrists and
ophthalmologists, do not routinely perform dilated eye exams. This is because dilation
takes time and is a bit uncomfortable for the patient as it causes increased light sensitivity
that lasts for several hours. Additionally, a non-dilated view of the retina is adequate for a
general exam in which the patient has no specific ophthalmologic complaints. Take
advantage of any opportunity to perform an examination through a dilated pupil as this is
a great way of learning. Make use of additional reference texts, paying particular
attention to color photos depicting variants of normal as well as the findings associated
with common disease states.
The following links provide excellent images of assorted ophthalmologic pathology.
Atlas of Ophthalmologic Images
Digital Atlas of Ophthalmology, NY Eye and Ear Infirmary
Eye Atlas (Best when viewed with Internet Explorer), Johns Hopkins University