Physical Examinations I (JoVE)

JOVE SCIENCE EDUCATION DATABASE
PHYSICAL EXAMINATION I
AUGUST 2021
Nabila Larasati Balqis - 1102017162 1

TABLE OF CONTENTS
TABLE OF CONTENTS .......................................................................................................... 2

GENERAL APPROACH TO THE PHYSICAL EXAM ......................................................... 3
OBSERVATION AND INSPECTION..................................................................................... 9
PALPATION ........................................................................................................................... 15
PERCUSSION ........................................................................................................................ 23
AUSCULTATION ................................................................................................................... 31
PROPER ADJUSTMENT OF PATIENT ATTIRE DURING THE PHYSICAL EXAM ... 37
MEASURING VITAL SIGNS ................................................................................................ 53
RESPIRATORY EXAM I: INSPECTION AND PALPATION............................................ 59
RESPIRATORY EXAM II: PERCUSSION AND AUSCULTATION ................................. 70
CARDIAC EXAM I: INSPECTION AND PALPATION ..................................................... 77
CARDIAC EXAM II: AUSCULTATION .............................................................................. 84
CARDIAC EXAM III: ABNORMAL HEART SOUNDS ..................................................... 89
PERIPHERAL VASCULAR EXAM ...................................................................................... 96
PERIPHERAL VASCULAR EXAM USING A CONTINUOUS WAVE DOPPLER ....... 107

GENERAL APPROACH TO THE PHYSICAL EXAM
Overview
Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of
Medicine, New Haven, CT
The examination of the body is fundamental to the practice of medicine. Since the Roman
Empire, physicians have described the connection between alterations in function of specific
parts of the body and specific disease states and have sought to further scientific understanding
to improve bedside diagnosis. However, in this modern age of increasing technology within
medical diagnostics, it is important to consider the role that physical examination plays today.
It is misguided to believe that physical examination holds all the answers, and much has been
written about the questionable utility of certain maneuvers previously held in high regard. It is
equally misguided to suggest that physical examination plays little role in the modern patient
encounter.
Physical examination remains a valuable diagnostic tool; there are many diagnoses that can
only be made by physical examination. A diagnosis made by labs or imaging is rarely done in
the absence of findings detectable at the bedside. As the provider conducts a history and
physical, they are actively generating and testing hypotheses to explain the patient's condition.
The information one gathers may not replace the need for testing, but having firm hypotheses
in place allows the provider to order tests more judiciously and ask better questions of those
tests. This, in turn, has the potential to reduce risk to the patient and save cost for the health
care system. Finally, physical examination plays a critical role in the therapeutic relationship.
By engaging in the time-honored ritual of physical examination, the clinician has the
opportunity to develop rapport (by demonstrating attention and sensitivity) and promote
healing through the deliberate and responsible use of touch.
Procedure
1. Before patient encounter
1. Prepare the exam room for the patient by disinfecting surfaces touched by the previous
patient (e.g., exam table); this is typically done by support staff.
2. Disinfect any equipment you plan to use during the encounter (e.g., stethoscope, reflex
hammer).

3. Wash your hands with soap and water or topical disinfectant solution.
4. Determine if any specific infection control precautions are needed for the clinical
encounter (e.g., contact precautions) and obtain necessary protective equipment.
5. Attempt to calm your own anxieties, as the patient may be feeling vulnerable due to
illness. The patient is likely to feel much more at ease if you appear calm.
2. Enter the room
1. Knock on the door and ask permission to enter.

2. Introduce yourself and your role.
3. Patient privacy
1. Ask family members who have accompanied the patient to step out of the room. This
provides an important opportunity to speak to the patient alone. Requests by patients to
have family members remain present should generally be respected.
2. Ensure the exam room curtains are drawn and doors are closed.
3. Determine if a chaperone will be present during the exam, which is fine if either the
patient or provider feels it necessary. This is often done standardly for genitourinary,
rectal, and female breast exams.
4. Consider your approach
1. Determine what aspects of the examination you plan to perform. This can range from a
comprehensive assessment, as one might do during a preventive visit, to a more focused
examination based on patient complaints and your clinical suspicion for specific
diseases.
2. Whether focused or comprehensive, the exam should be performed in a deliberate,
active way, with constant attention given to what one is seeking, rather than through
solely a rote/automatic process. Achieving the state in which one is able to focus on the
findings, rather than just the process, takes much practice.
3. Plan your sequence of examination to optimize efficiency and patient comfort. You
should strive to minimize patient repositioning by grouping maneuvers together that
need to be performed in a particular position. It is helpful to have a plan in mind before
starting the examination.

5. Patient attire
1. Ensure the patient is dressed appropriately for the planned exam. If necessary, provide
the patient with a gown and drape.
6. Other environmental considerations
1. Adjust the height of the chair and exam table as needed to optimize your ability to
perform maneuvers.
2. Adjust lighting and ambient noise as able.
3. The conventional approach to the examination places the examiner on the patient's right
side.
7. Components of the exam
1. The physical examination is subdivided into the following regional/anatomic

components: general survey; vital signs; head, eyes, ear, nose, throat (HEENT); neck;
chest; cardiovascular; back; abdomen; extremities; neurologic; musculoskeletal; skin;
breast; genitourinary; rectal; lymph nodes; mental status. There is substantial overlap
between components.
2. Each component exam consists of maneuvers employing the techniques of inspection,
percussion, palpation, and auscultation, each of which is explored in detail in separate
videos. Newer modalities, such as bedside diagnostic ultrasound, are increasingly
incorporated into the physical examination.
3. Ask the patient's permission to proceed with the exam and at major transition points
during the exam (e.g., "Now that I've explained what I am going to do, may I start the
examination?" and "Next, I'd like to examine your heart.").
8. Clinical Reasoning
1. The examiner must actively weigh how the presence or absence of particular findings
affects disease probability. Experienced clinicians do this in real time during the
examination.
2. Modify the initial plan of approach based on findings encountered during the exam. For
example, while one may have only planned to perform simple auscultation of the lungs,

the presence of decreased breath sounds in a given area may prompt the examiner to
utilize specialized techniques (e.g., egophony, vocal fremitus).
3. The consolidation of information obtained during history (symptoms) and physical
(signs) informs the next steps in management. Treatment may be initiated if the
probability of a particular disease is high enough, or additional testing may be requested
in a deliberate and judicious manner.
9. Ending the examination
1. Have the patient change back into regular clothing at the conclusion of the exam.
2. It is optimal to wait until the patient is dressed again before offering your advice and
opinions.
Applications and Summary
This video demonstrates the role that physical examination plays in the modern patient
encounter and has reviewed some critical steps to ensure the exam is carried out in a safe and
sensitive manner. Important preparatory steps before the examination help to reduce risk of
infection as well as patient and provider anxiety. Ensuring patient privacy and using gowns
and drapes in a sensitive manner also makes patients feel more comfortable. A deliberate
approach to the examination that is grounded in clinical reasoning is valuable to optimize
efficiency and the predictive value of the exam. An organized approach to the maneuvers being
performed minimizes the need for unnecessary patient repositioning. The specific maneuvers
to be performed vary based on the clinical circumstance, but an examiner's efforts to maintain
clear communication with attention to patient comfort should not vary.
The physical examination has played a vital role in patient care for millennia and should
continue to do so even in the face of technological advances. Over the past forty years, multiple
studies in various clinical settings have demonstrated that history and physical alone allow
physicians to arrive at the correct diagnosis a great majority of the time. In almost all other
circumstances, the information gained at the bedside allows the clinician to utilize clinical
reasoning to judiciously order and interpret tests to make diagnoses. Given the recent emphasis
on medical cost containment, patient safety, and access to services, bedside diagnostics remain
inexpensive, widely available, and carry little risk of adverse effects.

Transcript
Physical examination has been fundamental to the practice of medicine for centuries. Despite
substantial advancement in medical instrumentation, physical examination remains a valuable
diagnostic tool, and its importance cannot be overstated. As physicians assess history and
conduct a physical, they gather information leading to a firm hypothesis, which promotes a
more judicious approach to ordering tests and analysis of those tests. This, in turn, has the
potential to reduce patient risk and health care costs.
This video will illustrate some of the important steps that every physician must take to ensure
that the physical exam is carried out in a safe and sensitive manner.
A physical exam can be comprehensive or specific, but the overall steps before and during each
exam remain the same. Let's review these steps in detail.
First, the exam room should be prepared for the patient by disinfecting surfaces to be used
during the examination. In addition, a physician should disinfect equipment like the
stethoscope or the reflex hammer, which may be used during the exam. Before every exam,
wash your hands with soap and water or apply topical disinfectant solution. If the patient is
suffering from a known specific infection, then control precautions should be taken by
obtaining the necessary protective equipment. Make sure that cuffs of the gloves cover the
gown so that no skin is exposed.
Once the patient is seated in the room, knock on the door and ask for patient's permission to
enter the room. Introduce yourself and your role. Request the family members or friends who
have accompanied the patient to step out of the room. This provides an important opportunity
to speak to the patient alone. Ensure that the exam room curtains are drawn and doors are
closed. While talking to the patient, general observations should be made regarding the patient's
health. These include, appearance consistency with the stated age, overall health (fit or frail?),
alertness, affect, thought content and organization, and perception.
After this initial conversation, determine what aspects of the examination are necessary. Ensure
the patient is dressed appropriately for the planned exam. If necessary, provide the patient with
a gown and drape and give them some time to change. After some time, knock on the door and
ask for the patient's permission to enter the room. Request the patient to occupy the exam table.

Adjust the back of the exam table as needed to optimize your ability to perform maneuvers.
The physical examination can be subdivided into the following components: general survey,
measuring vital signs, examination of the neurologic functioning and mental status,
examination of the head, eyes, ears, nose, throat, chest, lungs, lymph nodes, cardiovascular,
abdomen, musculoskeletal, skin, genitourinary, and rectal. A chaperone may be necessary if a
sensitive exam like genitourinary, rectal, or breast exams is to be conducted.
Explain the patient the physical exam that is going to be conducted and ask for their permission
to proceed with the exam. "Now that I've explained what I am going to do, may I proceed with
the examination?" Each exam consists of maneuvers employing the techniques of inspection,
percussion, palpation, and auscultation, each of which is explored in detail in separate videos
of this collection. You should strive to minimize patient repositioning by grouping maneuvers
together that need to be performed in a particular position. After the exam is complete, request
the patient to change back to regular clothing. It is optimal to wait until the patient is dressed
again before offering advice and opinion. Subsequently, weighing how the presence or absence
of particular findings affects disease probability and consolidating the information obtained
from patient's history and physical exam, one may decide to initiate a therapy or order
additional testing in a deliberate and judicious manner.
You have just watched JoVE's video on general approach to the physical examination.
This video reviewed the importance of physical examination in the modern patient encounter
and demonstrated some critical steps to ensure the exam is carried out in a safe and sensitive
manner. Important preparatory steps before the examination help to reduce risk of infection,
and an organized approach to the maneuvers being performed minimizes the need for
unnecessary patient repositioning.
Given the recent emphasis on medical cost containment, patient safety, and access to services,
physical examination remains inexpensive, widely available, and carries little risk of adverse
effects. As always, thanks for watching!

OBSERVATION AND INSPECTION
Overview
Observation and inspection is fundamental to physical examination and begins at the first point
of contact with a patient. While observation and inspection are often used interchangeably,
observation is a general term that refers to the careful use of one's senses to gain information.
Inspection is an act limited to what one can observe visually, and when referring to physical
examination, typically refers to findings on the surface of the body, rather than to behaviors.
Skilled clinicians utilize all of their senses to assist with gaining an understanding of their
patients, relying on vision, touch (percussion and palpation), and hearing (percussion and
auscultation) primarily. Smell can also provide important diagnostic information during the
patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately
the sense of taste is largely a historical relic in medicine, though it is interesting to note that
diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through
experience, clinicians develop an important sixth sense - the gut instinct - that can only be
gained through deliberate practice of clinical skills on thousands of patients over many years.
The clinician's gut instinct, which is based largely on bedside observations, has been shown to
be a strong predictor of serious illness. This video and the others in the clinical skills video
collection are steps on the way to learning this level of mastery.
Procedure
Observation occurs as a constant process during the clinical encounter. Many of the items listed
in the procedure are typically done simultaneously and when opportunities present themselves.
The procedure highlights the components of observation, but is not intended to suggest a
preferred sequence.
1. General survey
1. Note the general state of health in the patient. Is the patient's appearance consistent with
the stated age? Does the patient appear fit and healthy or weak and frail?
2. Note their level of consciousness (e.g., awake, alert, or somnolent).

3. Observe for signs of pain. Note facial expressions, guarded movements, diaphoresis,
etc.
4. Observe for signs of respiratory distress. Can the patient speak in complete sentences
without difficulty? Is the patient "tripoding" (leaning forward with the arms supported)?
Are visible accessory muscles of respiration being used?
5. Observe for signs of emotional distress. Is the patient fidgeting excessively, exhibiting
generalized psychomotor slowing, or crying? Is eye contact appropriate?
6. Make note of clothing, jewelry, tattoos, grooming, hygiene, and any other features that
may provide insight into the patient's medical, social, and emotional situation.
7. Note any signs of pathology that may be evident on general observation, such as skin
lesions, abnormal fat distribution, hearing deficits, muscle atrophy, odors, etc.
2. Organ-specific observation
During the remainder of the physical examination, active observation is done with an
examination of each organ system. For some organ systems, inspection requires the use of
equipment (e.g., otoscope or ophthalmoscope). Refer to the videos for each organ system for
specific details.
3. Skin exam
Detailed inspection is the main component of the skin exam. A complete skin exam includes
inspection of all anterior, posterior, and lateral body surfaces and mucous membranes.
Inspection of certain areas requires manipulation for examination to be performed. These areas
include the hair, scalp, mastoid processes, posterior auricles, external auditory canals, nares,
axilla, nails, palpebral conjunctiva, oral mucosa, inferior aspects of the breasts, skin underlying
a pannus, surfaces of genitals, vaginal mucosa, and gluteal cleft.
1. Note the color of the skin or mucosa at each site examined. Common findings include
areas of hypo- or hyper-pigmentation, pallor (palpebral conjunctiva, palms, soles, and
nailbeds), cyanosis (nailbeds, lips, and perioral), and jaundice (sclera, skin, and mucous
membranes).
2. At each site examined, also note the degree of hydration (i.e. dryness or oiliness),
turgor, and texture of the skin.

4. Mental status exam
1. Observe the patient's appearance and behavior including posture, dress, facial
expressions, motor activity, mannerisms, physical characteristics, and reactions to the
questions asked during the exam.
2. Note the fluency, rate, and volume of speech.
3. Assess the patient's affect, including the range, appropriateness, intensity, and ability.
The examiner's objective assessment of affect should be compared to the patient's
subjective report of mood, which is obtained via direct inquiry.
4. Evaluate the patient's thought process, which is composed of elements, such as level of
organization, presence of tangentiality, loose associations, and "flight of ideas."
5. Evaluate the patient's thought content and perceptions, though these are typically not
completed by observation alone, and specific questioning may be required. Thought
content encompasses obsessions, anxieties, phobias, somatic pre-occupation, delusions,
and ideas of persecution, influence, and reference. Perceptions include hallucinations,
de-realization, and de-personalization.
6. Note the patient's cognitive function. Clues to abnormalities of attention, orientation,
memory, judgment, and insight can emerge if the examiner is attuned to look for them,
though the use of specific questions and validated instruments may be necessary to
quantify deficits.
7. Use specific questions to assess for suicidality and homicidality.
5. Ancillary observations
1. Certain examination locations offer opportunities to learn about a patient's social

supports, interests, and lifestyle. When visiting a patient in a space they are occupying
for more than a few hours (e.g., hospital room, nursing home, home), note the presence
(or absence) of decorations, get-well cards, family photos, books, etc. to gain an
understanding of the patient's life outside of the patient role.
2. When family members or friends are present with patients, observe the interpersonal
dynamics. This opportunity for observation offers important information about the
patient. Does the family member speak for the patient? Does the patient look to the
family member before responding to questions?
3. Pay attention to the way you are feeling in the presence of the patient, as this may prove
diagnostically useful, especially in terms of psychiatric illness. While providers must

be aware of the pitfalls of countertransference, if the feeling that the patient is triggering
in you is not typical or easily explained, there may an underlying explanation in the
patient's mental health. For example, an uncharacteristic feeling of sadness in the
clinician during the encounter may lead the clinician to consider a diagnosis of major
depressive disorder.
Observation is an important component of the patient encounter that begins at the first point of
contact with the patient. Observation relates to information gained by using one's senses during
the examination and encompasses physical findings as well as behavioral, situational, and
ancillary observations. A specific set of observations makes up the general survey, which
should be a part of every patient encounter. Additional observations occur during each organ-
specific part of the physical examination, with inspection accounting for the bulk of the skin
examination. In addition to direct observations of the patient, astute clinicians attend to
information in the patient's surroundings and social relationships, as well as the feelings that
patients may evoke in them, as part of good patient care.
Transcription
Observation and inspection are fundamental to any clinical examination. General observations
begin at the first point of contact with any patient and continue throughout the clinical
encounter, even while just having a conversation with the patient. Inspection is more goal-
directed and it is limited to what one can observe visually while examining specific body parts
like skin, eyes or ears, sometimes with the help of a specialized equipment.
Here, we illustrate the general observations that a clinical should consider performing during
each clinical encounter, followed by a few considerations related to the visual inspection steps.
First, let's go over some general observation steps that a clinician should keep in mind when
meeting with any patient. These observations can be made anytime during the examination.
During the initial conversation when a patient is explaining their illness, note the state of their
physical health and ask yourself "Is the patient's appearance consistent with the stated age?
Does the patient appear fit and healthy or weak and frail? Is the patient awake and alert, or

somnolent?" Simultaneously, gauge their mental status and affect, and examine whether their
thoughts are organized.
During the conversation, a physician can also evaluate the patient's thought content and
perceptions. In addition, look for signs of emotional distress like excessive fidgeting or
inadequate eye contact. Also, pay attention to the way you are feeling in the presence of the
patient, as this may prove diagnostically useful. An uncharacteristic feeling of sadness in the
clinician may lead to considering a diagnosis of major depressive disorder. Furthermore, during
the conversation, observe for signs of pain by looking at facial expressions, and by noting if
the patient is exhibiting guarded movements or autonomic signs like diaphoresis. Also, note
the patient's hygiene, clothing, make up, etc. for additional clues that might help in diagnosis.
In addition, look for signs of respiratory distress. Note whether the patient speaks in complete
sentences without any difficulty. Observe if the patient is "tripoding", which is leaning forward
with the arms supported. Notice if visible accessory muscles of respiration are being used,
which is common in cases of respiratory distress.
Taken together, these simple observations can provide substantial insight into the patient's
physical and mental status, and can help in diagnosis of their illness.
Now that you know about general observations, let's look at inspection, which is critical to
comprehensive and organ-specific physical examination.
First, explain the patient the purpose of inspection and obtain their consent. As mentioned
earlier, this involves visually observing body surfaces to check for any abnormalities. During
a comprehensive skin exam, inspection of all anterior, lateral, and posterior body surfaces and
mucous membranes is necessary. Note the color of the skin or mucosa at each site examined.
Common findings include areas of hypo- or hyper-pigmentation, pallor, cyanosis, jaundice.
Also, check for the degree of hydration, turgor, and texture.
Mostly inspection involves keenly looking at different regions of the body surface with naked
eye. Sometimes, special equipment is required for inspection of the structures inaccessible to
the naked eye. For example, an otoscope is necessary for the inspection of tympanic
membranes. Some areas of the body require inspection with manipulation. Like, for scalp
examination, a physician may have to manipulate through the patient's hair to expose the

surface. Note the inspection results for each site examined, which can be combined with
observations and patient's history to predict the illness. At the end of every exam, thank the
patient for their cooperation.
You have just watched JoVE's video on general observations and inspection during a patient
encounter.
Taken together, observation and inspection skills play a critical role in clinical diagnosis. Here,
we reviewed a specific set of observations that should be a part of every clinical encounter.
Additionally, we discussed inspection, which is an important aspect of any physical exam and
can assist in bedside diagnosis. As always, thanks for watching!

PALPATION
Overview
The physical examination requires the use of all of the provider's senses to gain information
about the patient. The sense of touch is utilized to obtain diagnostic information through
palpation.
The specific parts of the examiner's hand used for palpation differ based on the body part being
examined. Because of their dense sensory innervation, the finger pads are useful for fine
discrimination (e.g., defining the borders of masses, lymph nodes) (Figure 1). The dorsal
surface of the hand provides a rough sense of relative temperature (Figure 2). The palmar
surfaces of the fingers and hands are most useful for surveying large areas of the body (e.g.,
abdomen) (Figure 3). Vibration is best appreciated with the ulnar surface of the hands and
5th fingers (e.g., tactile fremitus) (Figure 4).
While palpation is fundamental to the diagnostic aspect of the physical exam, it is also
important to acknowledge the role that touch plays in communicating caring and comfort
during the patient encounter. Patients generally perceive touch from a healthcare provider in a
positive light, and their perceptions of a healthcare provider can be shaped by the skilled use
of touch during clinical encounters.1 Physical contact has been associated with alterations in
hormonal and neurotransmitter levels, specifically decreases in cortisol and increases in
serotonin.2
Therefore, through the careful use of palpation, and touch in general, during the physical
examination, the clinician has the opportunity to gain important diagnostic information, while
developing rapport and promoting healing.

Figure 1. Lymph node examination with finger pads.
Figure 2. Using the dorsum of hand to assess for warmth.

Figure 3. Abdominal palpation with palmar surface of fingers and hands.
Figure 4. Using the ulnar surface of the hand to assess for tactile fremitus.

Procedure
1. Before the patient encounter
1. Keep fingernails clean, groomed, and trimmed.

1. Wash your hands with soap and water or topical disinfectant solution.
2. Warm your hands as able (e.g., with warm water or by rubbing them together)
before patient contact.
3. If any specific infection control precautions are needed for the clinical
encounter (e.g., contact precautions), explain to the patient why you are wearing
protective equipment. Be aware that gowns, gloves, and masks can present a
barrier to building a relationship with the patient.3
1. Familiarize oneself with the specific palpation techniques for each regional/anatomic
component of the exam; refer to each of the individual videos for exploration of how
palpation is utilized.
2. Perform the palpation directly on the patient's skin. Employ draping techniques to
optimize access, while balancing patient modesty. Refer to the videos on draping for
specific details.
3. General considerations
1. In order to slowly invite oneself into the patient's personal space and gauge the patient's
comfort with the clinician's touch, many providers start the examination with the hands.
Perform gentle palpation of the nailbeds with your fingertips (to assess for capillary
refill and pallor) and palpation of the radial pulse with your finger pads to initiate the
first contact in a non-threatening way.
2. Use the finger pads when performing most of palpation, with the following notable
exceptions:
1. Use the fingertips to palpate the nailbeds, liver edge, and cervix.
2. Use the ulnar surface of the hands when assessing tactile fremitus.

3. Use the palmar surface of the fingers and/or hands for assessing chest
expansion, precordium for PMI/heaves/lifts/thrills, performing light and deep
palpation of the abdomen, and strength testing against resistance.
4. Use the dorsal surface of the hands for assessing the relative temperature of the
skin (typically in comparison to another portion of the patient's body).
3. Be aware of the pressure used for palpation, which varies based on the structures being
examined. For example, excessive pressure may occlude a pulse, causing discomfort
and limiting utility. Insufficient pressure may limit one's ability to palpate deep
structures (e.g., aorta).
4. Be deliberate about the duration when applying pressure, which varies based on the
structures being examined. For example, tense lower extremity pitting edema can be
missed, if the examiner does not apply steady pressure for at least a few seconds.
Similarly, a blanching rash may not be identified as such without ample duration of
pressure. Conversely, excessive duration of palpation in a patient with peritoneal signs
causes undue discomfort without increasing diagnostic yield.
5. Consider palpating areas of known discomfort toward the end of the examination,
making it clear to patients this is done in the interest of their comfort. For example, if a
patient has acute right knee pain, initiating the exam on the left lower extremity,
followed by examination of the right ankle and hip, may make the patient less guarded
when the painful right knee is examined.
6. Express empathy while acknowledging that certain parts of the examination may cause
the patient discomfort. Patients expect to be examined, but ask permission and provide
a warning if you are about to do something that is likely to worsen a patient's pain (e.g.,
palpation of the abdomen in a patient with suspected appendicitis).
This demonstration covered the general considerations related to palpation during the physical
examination. While specific techniques vary based on each individual portion of the exam,
many general principles related to palpation hold throughout the exam. Attention to patient
safety and comfort is achieved through hand-washing, proper grooming, warming of the hands,
infection control precautions, and sensitive draping. The correct part of the fingers and hands
should be used for different types of palpation, with finger pads being used most commonly
during the exam. The clinician should be deliberate about the amount and duration of pressure

being applied during palpation; these variables change based on the part of the body being
examined and specific patient circumstances. Finally, the clinician should remember the
important role that touch plays in the patient encounter in terms of therapeutic value and the
clinician-patient relationship. The most direct physical contact during the encounter occurs
through palpation, which provides an opportunity to secure the bond the clinician has started
to develop during history taking.
References
1. McCann, K., McKenna, H.P. An examination of touch between nurses and elderly
patients in a continuing care setting in Northern Ireland. Journal of Advanced
Nursing. 18, 838-46 (1993).
2. Field, T. Violence and touch deprivation in adolescents. Adolescence. 37 (148), 735-
749 (2002).
3. Verrees, M. Touch me. JAMA. 276 (16), 1285-1286 (1996).
Transcript
During a physical exam, the clinician uses the sense of touch through palpation to obtain useful
diagnostic information. It is an assessment technique in which the examiner uses the surface of
the fingers and hands to feel and examine an organ or body part. While palpation is fundamental
to the diagnostic aspect of the physical exam, it is also important to acknowledge the role that
touch plays in communicating caring and comfort during the patient encounter.
This video will illustrate the different palpation techniques, and discuss the approach and
considerations for this procedure.
First, let's discuss the different types of palpation techniques that are based on the specific parts
of the examiner's hand used to perform the procedure. Finger pads are used for palpation of
most of the body parts. Because of their dense sensory innervation, the finger pads are useful
for fine discrimination, for example defining the borders of masses, or while examining the
lymph nodes. Fingertips are used for palpating specific structures like the nailbeds, liver edge,
and cervix. In addition to fingertips and finger pads, physicians also use the ulnar surface of
the hands and fifth fingers to appreciate vibration when performing specialized test like tactile
fremitus. One should use the palmar surface of the fingers and hands for assessing functions
like chest expansion, palpation of the precordium, light and deep abdominal palpation, and

muscle strength testing. Lastly, the dorsal surface of the hands is used for getting rough sense
of relative temperature, typically in comparison to another portion of the patient's body.
Now that you know about different palpation techniques, let's discuss the general approach to
palpation during any clinical exam.
Before every patient encounter, make sure that your fingernails are clean, groomed, and
trimmed. Wash your hands with soap and water or apply topical disinfectant solution. Warm
your hands either with warm water or by rubbing them together. If any specific infection
control precautions are needed, then wear the protective equipment and explain to the patient
why it's necessary. Remember: gowns, gloves, and masks can present a barrier to building a
relationship with the patient.
In order to gauge the patient's comfort with the clinician's touch, you may start the examination
with the hands. First, perform palpation of the nailbeds with your fingertips to assess for
capillary refill and pallor. Then, palpate the radial pulse with your finger pads. After that, move
to the anatomic region of interest, in this case the abdominal region. Employ draping techniques
to optimize access, while balancing patient's modesty. Next, ask the patient to point to the area
of discomfort. Consider palpating it towards the end, making it clear to patients this is done in
the interest of their comfort, "I'm going to examine this area last in order just to make it more
comfortable for you."
In general, be aware of the pressure used for palpation, which varies based on the structures
being examined. For example, insufficient pressure may limit one's ability to palpate deep
structures, and excessive pressure may occlude a pulse, causing discomfort and limiting utility.
Be deliberate about the palpation duration as well, which again differs based on the structure
under examination. For example, while examining the lower extremities, the palpation needs
to be performed for sufficient amount of time to reveal pitting edema, if present. This kind of
information can be missed if palpation duration is insufficient. In addition, express empathy
while acknowledging that examination of certain parts may cause the patient discomfort.
Although patient expects to be examined, always ask permission and provide a warning if you
are about to do something that may worsen the pain. At the end of the exam, drape the patient
back and thank them for their cooperation.

You've just watched JoVE's introduction to palpation. This demonstration covered the types
and general considerations related to palpation during a physical exam. Through the careful
use of this technique, the clinician has the opportunity to gain important diagnostic information,
while developing rapport and promoting healing. As always, thanks for watching!

PERCUSSION
Overview
Simply stated, percussion refers to the striking of one object against another to produce sound.
In the early 1700s, an Austrian inn-keeper's son, named Leopold Auenbrugger, discovered that
he could take inventory by tapping his father's beer barrels with his fingers. Years later, while
practicing medicine in Vienna, he applied this technique to his patients and published the first
description of the diagnostic utility of percussion in 1761. His findings faded into obscurity
until the prominent French physician Jean-Nicolas Corvisart rediscovered his writings in 1808,
during an era in which great attention was focused on diagnostic accuracy at the bedside.1
There are three types of percussion. Auenbrugger and Corvisart relied on direct percussion, in
which the plexor (i.e. tapping) finger strikes directly against the patient's body. An indirect
method is used more commonly today. In indirect percussion, the plexor finger strikes a
pleximeter, which is typically the middle finger of the non-dominant hand placed against the
patient's body. As the examiner's finger strikes the pleximeter (or directly against the surface
of the patient's body), sound waves are generated. If using indirect percussion, important
information is gained from the vibration in the pleximeter finger, as well.2 The third type of
percussion, auscultatory percussion, relies on the clinician using a stethoscope to discern
differences in sounds created by the plexor finger.
The density of the structure underlying the site of percussion determines the tone of the
percussion note; the denser the structure, the quieter the note. Notes differ in relative intensity,
pitch, and duration, and help the examiner determine what lies below the skin surface.
Knowledge of what particular locations on the body should sound like, in conjunction with the
particulars of a specific clinical situation, can help a clinician determine if percussion notes in
a particular patient are normal or not.

Procedure
1. Before the patient encounter
1. Keep fingernails clean, groomed, and trimmed.

2. Wash your hands with soap and water or apply topical disinfectant solution.
3. Warm your hands as able (e.g., with warm water or by rubbing them together) before
patient contact.
In theory, percussion can be utilized on any part of the body, but it is clinically most useful in
the examinations of the chest and abdomen. Refer to the individual videos for these regions to
learn about how percussion is specifically utilized.
3. Indirect percussion
1. Establish a pleximeter by placing the middle finger of your non-dominant hand firmly
against the body surface being examined.
2. Make sure the entire distal phalanx is in contact with the patient, but the rest of the
fingers are not, and instead they are splayed out to avoid making contact with the
patient, which could dampen the sound.
3. Using a quick, relaxed, snapping motion from the wrist, strike the distal interphalangeal
joint of the pleximeter finger with the tip of the middle finger on your dominant hand.
This is the plexor finger. The plexor finger should be lifted rapidly to avoid dampening
the sound.
4. One should familiarize themselves with the different percussion notes (Table 1). Gas-
filled structures sound louder with longer notes, while solid structures create quieter,
shorter notes. Liquid notes are typically between the gas-filled and solid structure notes.
There are five common terms used to describe percussion notes in the physical
examination: tympanitic, hyperresonant, resonant, dull, and flat.
1. Percuss over the abdomen. Gas-filled areas reveal the loud, high-pitched
tympanitic note, as is commonly found over the stomach.
2. Percuss over the lungs. Normal lung tissue reveals a loud, low-pitched resonant
note. Hyperresonance cannot be demonstrated on normal subjects, but it is

found in lung diseases, such as emphysema or pneumothorax. It can be
distinguished from resonance, because it is louder and lower-pitched.
3. Percuss the liver span. The dull percussion note heard over the liver is medium
in intensity and pitch. The margins can be identified by a change in note, since
a resonant note of normal lung tissue can be heard superior to the liver, and a
tympanitic (or sometimes less dull) note can be heard inferiorly, due to the
bowels.
4. A soft, high-pitched flat note is heard when the underlying tissue is dense, as is
the case with pleural effusions or ascites. In a patient without these pathological
processes, appreciate a flat note by percussing over the dense quadriceps
muscles, though percussing in this location holds no clinical utility during a
physical exam.
Percussion Location
Pitch Intensity Duration Pathological example
note (normal)
Gastric
Tympanitic High Loud Longer Large pneumothorax
bubble
Normal lung
Resonant Low Loud Long Simple chronic bronchitis
tissue
Very
Hyperresonant Lower Longer COPD, pneumothorax
loud
Intra-abdominal tumors and

Dull Medium Medium Medium Liver
masses, pneumonia
Flat High Soft Short Thigh Pleural effusion
Table 1. Characteristics of different percussion notes.

5. Note the amount of vibration in the pleximeter finger. Gas-filled structures allow for
more movement of the pleximeter finger than liquid or solid structures. The differences
are subtle and require keen attention and practice to appreciate.
6. Percuss at each point a few times in rapid succession to ensure consistency of notes
before moving to the next spot.
4. Fist percussion
The maneuver can be performed directly against the patient's body, or indirectly with the
examiner's non-plexor hand placed palm down on the patient's body wall, and the plexor fist
striking the dorsum of the hand to attenuate the force of the blow. Direct or indirect percussion
with the ulnar aspect of the examiner's fist is most commonly utilized to elicit tenderness
originating from the kidneys, but can also be utilized to identify tenderness in other deep organs
(e.g., the liver).
1. Deliver a quick, firm blow to the area of interest (e.g., costo-vertebral angle) with the
ulnar aspect of a hand flexed gently into a fist. The examiner's motion is brisk, with
movement originating at the elbow.
2. Use the same technique when searching for an area of tenderness. It is critical to deliver
the right amount of force - enough to uncover tenderness in a patient with pathology,
but not so much to cause undue discomfort or pain in a patient without disease.
5. Other factors affecting a percussion note
1. Make sure percussion is done directly on the patient's skin. Any barrier between the
examiner and the patient can alter findings in percussion. This is especially true
regarding vibrations sensed by the pleximeter finger, which can be affected by clothing,
gowns, and even examination gloves. If gloves are worn during this portion of the
exam, the clinician must account for the difference in the way the percussion note feels
on the pleximeter finger.
2. Note that applying more pressure with the pleximeter finger can augment sounds.
Inadequate pressure with the pleximeter finger can cause artificial dullness. Striking
more forcefully with the plexor finger is rarely helpful, though striking too lightly can
also lead to artificial dullness.

3. Remember that percussion notes and vibrations on the pleximeter finger are impacted
by subcutaneous fat, which dampens vibrations, leading to increased areas of dullness.
4. When moving around the area of the body being percussed (e.g., to establish liver span),
maintain a consistency in exam technique. Keep a stable amount of pressure with the
pleximeter finger and force with the flexor finger. Continue to strike the pleximeter
finger at the same spot, using the same part of the plexor finger.
This video covers the general considerations related to percussion during the physical
examination. The routine incorporation of percussion into the physical examination
revolutionized bedside diagnostics in the eighteenth and nineteenth centuries, and it still holds
high value in the detection of common thoracic and abdominal pathology, such as
hepatomegaly, splenomegaly, pleural effusion, pneumothorax, and ascites. An understanding
of the positioning, pressure, and movements required by the plexor and pleximeter fingers is
critical to successful percussion. Similarly, knowledge of the factors that can impact percussion
notes is important to enable proper interpretation of findings. Practice with attention to auditory
and tactile input helps the clinician develop mastery of the way different percussion notes
(tympanitic, hyperresonant, resonant, dull, and flat) sound and feel, allowing differentiation of
gas-filled, liquid, and solid structures. Percussion remains an important technique that enables
clinicians to evaluate deep anatomic structures that are not visible.
References
1. Nuland, S.B. Doctors: The Biography of Medicine. Vintage Books, New York (1988).
2. McGee, S. Evidence-based Physical Diagnosis. 3rd ed., Elsevier, Philadelphia (2012).
Transcript
Percussion is a commonly used clinical skill that is most useful in the examinations of the chest
and abdomen. Simply stated, percussion refers to the striking of one object against another to
produce sound.
The discovery of percussion's usefulness in medicine dates back to the 1700s. In former years
of this century, an Austrian innkeeper's son, named Leopold Auenbrugger, discovered that he
could take inventory by tapping his father's beer barrels with his fingers. Then, in 1761, while

practicing medicine, he applied this technique on his patients and published the first description
of the diagnostic utility of percussion. However, his findings faded into obscurity until the
French physician, Jean-Nicolas Corvisart, in 1808, rediscovered Auenbrugger's writings and
used them to teach percussion to his medical students. Since then this technique has become
an integral part of day-to-day clinical practice.
This video will first illustrate the types of percussion and the commonly heard percussion notes.
Then, we'll go over the procedure and considerations for performing this technique during a
physical examination.
There are several types of medical percussion techniques. The historic type is 'direct
percussion' in which the plexor-that is the tapping finger-strikes directly against the patient's
body, but this method is obsolete and is no longer employed in clinical practice. It has been
supplanted by 'indirect percussion' in which the plexor finger strikes a pleximeter, which is
typically the middle finger of the non-dominant hand placed against the patient's body.
The third type is the 'auscultatory percussion', which relies on using a stethoscope to discern
differences in sounds created by the plexor finger. Auscultatory percussion is a commonly used
alternative method to assess liver size using the 'liver scratch test'. With the stethoscope held
over the patient's liver, the examiner gently scratches the patient's skin while listening for
changes in sound quality as the plexor finger makes its way over the liver edge.
Another percussion technique is called the 'fist percussion', which is performed using the ulnar
aspect of the plexor fist. Again, this can be performed either directly against the patient's body,
or by using an indirect method in which the examiner's non-plexor hand is placed palm down
on the patient's body wall and the plexor fist strikes the dorsum of the hand to attenuate the
force of the blow. Here, the examiner's motion should be brisk with movement originating at
the elbow, and it is critical to deliver the right amount of force-enough to uncover tenderness
in a patient with pathology, but not so much to cause undue discomfort or pain in a patient
without any disease.
Now, let's talk about the notes normally heard while performing indirect percussion. The
percussion notes differ in relative intensity, pitch, and duration depending on the density of the
underlying structure.

A tympanitic sound is loud, high-pitched, and longer in duration than other sounds. It is
normally heard over parts of the gastrointestinal tract that contain air, such as the stomach. A
resonant note is also loud, but low-pitched, and long in duration. It is normally heard over the
lung tissue. A dull note is medium in intensity, pitch and duration, and it appears over solid
organs like the liver. A flat percussion note is soft, high-pitched, short and therefore hard to
listen to. This note can be appreciated by percussing over the extremely dense quadriceps
muscles, but percussing in this location holds no clinical utility. However, if a flat note is heard
over the lungs, it may indicate pleural effusion, and if heard over a protruded abdomen it may
indicate ascites. Another pathological percussion sound is hyperresonance, which, as compared
to the resonant sound, is louder in intensity, lower in pitch and longer in duration.
Hyperresonant sounds on lung percussion may indicate pneumothorax or chronic obstructive
pulmonary disorder.
Now that you know about the types of notes heard during indirect percussion, let's briefly
review the general steps for performing this technique. Before starting with the exam, make
sure that your fingernails are clean, groomed, and trimmed. Wash your hands with soap and
water, or apply topical disinfectant solution. Warm your hands with warm water or by rubbing
them together before patient contact.
To percuss, place the pleximeter finger firmly against the body surface being examined. Make
sure the entire distal phalanx is in contact with the patient, but the rest of the fingers should be
splayed out to avoid making contact, as this could dampen the sound. With the tip of the plexor,
strike the distal interphalangeal joint of the pleximeter using a quick, relaxed, snapping motion
from the wrist. After the strike, lift plexor finger rapidly to avoid sound dampening.
In addition to the sounds, note the amount of vibration in the pleximeter. The differences in
vibration are subtle and require keen attention and practice to appreciate. The gas-filled
structures might lead to more movement of the pleximeter finger, whereas the solid or liquid-
filled regions may cause decreased vibration. During any physical exam, percuss at each point
a few times in rapid succession to ensure consistency of notes before moving to the next spot.
In addition to performing percussion accurately, one must also pay attention to a few other
factors that might affect the percussion notes.

Make sure percussion is done directly on the patient's skin. Performing percussion on the
patient with clothing on is impermissible. While the use of gloves might be necessary for
infection control purposes, in cases where gloves are necessary, the clinician must account for
the difference in the way the percussion note will "feel" on the pleximeter finger, because the
vibrations will feel different.
Note that the pressure applied with the pleximeter finger affects the percussion note. Inadequate
pressure can cause artificial dullness, and more pressure can augment the sound. Also, the force
with which the plexor strikes may affect the interpretation of one's findings. Striking more
forcefully with the plexor finger is rarely helpful, though striking too lightly can also lead to
artificial dullness. Remember that the percussion notes and vibrations are also impacted by the
subcutaneous fat, which, if excess, may dampen the movement of the pleximeter. Finally, when
examining a particular area of the body, maintain a consistency in the technique. To optimally
compare sounds from one region to another, keep the amount of pressure with the pleximeter
finger, the force with the plexor, the strike spot, and the part of the plexor finger used, all the
same throughout the exam.
You've just watched JoVE's video on percussion performed during a physical examination.
This presentation covered the types of percussion procedures, the commonly witnessed
percussion notes, the technique and factors that may affect the findings of this procedure.
Percussion revolutionized bedside diagnostics in the eighteenth and nineteenth centuries and it
still remains an important method that enables clinicians to evaluate deep anatomic structures
that cannot be visually inspected. As always, thanks for watching!

AUSCULTATION
Overview
Through auscultation, the clinician is able "to eavesdrop on the workings of the body" to gain
important diagnostic information.1Historically, the term "auscultation" was synonymous with
"immediate auscultation," in which the examiner's ear was placed directly against the patient's
skin. Although this was standard practice for centuries, the method proved inadequate in
nineteenth-century France, due to social norms and suboptimal diagnostic yield. This led René
Laënnec to invent the first stethoscope in 1816 (Figure 1), a tool that has since become
inseparable from auscultation in modern clinical practice, and patients hold it as a symbol of
honor and trustworthiness among those who carry them.2
Figure 1. A representative illustration of the first stethoscope invented by René Laënnec.
The stethoscope has undergone many technologic advances since Laënnec's initial hollow
wooden tube. Practically speaking, the provider must understand the difference between the
two sides of the modern stethoscope's chest piece: the diaphragm and the bell (Figure 2).

Figure 2. Parts of a modern stethoscope.
When applied firmly against the patient's skin, the diaphragm transmits high frequency sounds.
Sounds from within the patient vibrate the membrane of the diaphragm. These vibrations result
in the propagation of sound through the column of air inside the stethoscope and into the
examiner's ears. Conversely, when applied lightly, the bell transmits low frequency sounds.
The bell acts as a cup that directly transmits sounds from within the patient through the tubing
of the stethoscope. Pressing more firmly with the bell can stretch the underlying skin,
essentially turning it into a diaphragm. Auscultation is used in a wide variety of clinical
settings. It most commonly plays a role in the examination of the chest, heart, abdomen, and
vasculature.

Procedure
1. Throughout the entirety of the patient encounter, use your un-aided sense of hearing to
identify findings that may be diagnostically useful (e.g., hoarse voice or grunting with
expiration).
2. Before patient contact, decontaminate the stethoscope by wiping it with a 70% alcohol
pledget, a standardly available antiseptic rinse used for hand hygiene, or a hospital
surface disinfectant.3
3. Positioning of the stethoscope
1. Place the stethoscope ear buds in your ears with the tips pointing forward in
order to create a seal that drowns out ambient noise.
2. Confirm which side of the chest piece (i.e., the bell or the diaphragm) is active
by gently tapping on one side or the other.
3. Rotate the chest piece until you hear and feel a click to switch between the bell
and diaphragm as needed. Certain stethoscopes have only one side to the chest
piece, which can be used as a diaphragm and a bell depending on the amount of
pressure applied against the patient's skin. Firm pressure makes the chest piece
a diaphragm, while light pressure makes it a bell.
4. Hold the chest piece in your dominant hand. There are two commonly used
handgrips for the chest piece:
1. Support the chest piece between the middle phalanges of your second
and third fingers, with your thumb tucked under the tubing to keep it off
of the patient's skin, which can potentially reduce noise artifacts.
2. Support the chest piece between the distal phalanges of your thumb and
second finger. When using this grip, tuck the remaining fingers under
the tubing to keep it off the patient's skin, though in certain maneuvers,
these fingers need to be held in slight extension to keep the fingers
themselves off of the patient's skin (e.g., auscultation at the base of the
heart).
5. Refer to the dedicated videos on the cardiac, pulmonary, abdominal, and
vascular examinations for specific details on the techniques of auscultation for
these areas.
6. As you listen, especially to heart sounds, consider the physiology and mentally
picture the anatomy which may help to parse the variety of sounds that are heard
simultaneously.

7. Train the mind to form a visual representation of the sounds being heard, as this
may help to better clinically characterize the sounds. Certain electronic
stethoscopes allow examiners to record sounds and actually create visual
representations of the findings.
This video covered the general considerations related to auscultation during the physical
examination. Auscultation is typically done with the aid of a stethoscope, though certain
findings, especially on the respiratory examination, may be evident to the un-aided ear. While
specific stethoscope techniques vary based on each individual portion of the exam, in all
circumstances, the clinician must hold the stethoscope properly and recognize the difference
between the bell and the diaphragm in order to optimize the diagnostic utility of auscultation.
Additionally, in the interest of reducing nosocomial spread of infection, stethoscopes should
be decontaminated regularly. Making meaning out of the variety of sounds that one appreciates
with the stethoscope can seem daunting to the early learner. Through deliberate practice, with
consideration of anatomy and physiology of the structures being examined, and possibly the
use of visual representation of sound, auscultation becomes a powerful diagnostic tool for the
clinician.
References
1. Markel, H. The Stethoscope and the Art of Listening. New England Journal of
Medicine. 354: 551-553 (2006)
2. Jiwa, M., Millett, S., Meng, X., and Hewitt, V.M. Impact of the Presence of Medical
Equipment in Images on Viewers' Perceptions of the Trustworthiness of an Individual
On-Screen. Journal of medical Internet research. 14 (4), e100 (2012).
3. Makim, D.G. Stethoscopes and Health Care-Associated Infection. Mayo Clinic
Proceedings. 89: 277-280 (2014).
Transcript
Auscultation refers to the act of listening to the sounds produced by the body during a physical
examination.
Historically, the term "auscultation" was synonymous with "immediate auscultation," in which
the examiner's ear was placed directly against the patient's skin. Although this was standard

practice for centuries, the method proved inadequate in nineteenth-century France, due to social
norms and suboptimal diagnostic yield. Therefore, in 1816, René Laënnec invented the first
stethoscope. This was a hollow wooden tube with a flat surface on one end-to be placed on the
patient's skin, and an opening at the other end-to listen to the sounds transmitted. Since then,
stethoscope has undergone many technologic advances, but it still remains a tool that is
inseparable from clinical practice.
This video will illustrate the parts of the stethoscope and demonstrate how to use this
instrument during any physical examination.
First, let's review what are the different parts of a stethoscope and what is their function. The
basic parts include the ear buds, the tubing and the chest piece. Now-a-days commonly used
stethoscopes have two flat surfaces on the chest piece-one is the diaphragm and other is the
bell.
Usually, the diaphragm is applied firmly against the skin to listen to the high frequency sounds
such as S1 and S2. The firm application is necessary as this allows the high frequency sounds
from within the patient vibrate to the membrane of the diaphragm, which in turn results in
propagation of sound through the column of air inside the stethoscope and into the examiner's
ears. Conversely, when applied lightly, the bell transmits low frequency sounds such as S3 or
S4. The open bell acts as a cup that directly transmits sounds from within the patient through
the tubing. Pressing more firmly with the bell can stretch the underlying skin, essentially
turning it into a diaphragm. Certain stethoscopes have only one side to the chest piece, which
can be used as a diaphragm and a bell; firm pressure makes the chest piece a diaphragm, while
light pressure makes it a bell.
Now, let's go over some important steps related to auscultation that can be applied to any
physical examination. Throughout the entirety of the patient encounter, use your unaided sense
of hearing to identify findings that may be diagnostically useful, like hoarse voice or grunting
respirations.
Before patient contact, decontaminate the stethoscope with any of the standardly available
agents. Place the stethoscope ear buds in your ears with the tips pointing forward in order to
create a seal that drowns out ambient noise. By gently tapping on both surfaces, confirm which

side of the chest piece is active. To switch between the two sides, rotate the piece until you
hear a click, and then tap to confirm.
Hold the chest piece in your dominant hand. There are two commonly used handgrips for this.
One way is to support the piece between the middle phalanges of your second and third fingers
with your thumb tucked under the tubing to keep the tube off the patient's skin, which can
potentially reduce some noise artifacts. Another way is to support it between the distal
phalanges of your thumb and second finger. When using this grip, you should normally tuck
the remaining fingers under the tubing. Except, in certain maneuvers where these fingers need
to be held in slight extension to keep the fingers themselves off the patient's skin. For example,
during auscultation at the base of the heart.
There are specific techniques of auscultation for pulmonary, cardiac, abdominal, and vascular
examinations, which will be covered in the respective videos of these collections. As you listen,
consider the physiology and mentally picture the anatomy, which may help to parse the variety
of sounds that are heard simultaneously. Train the mind to form a visual representation of the
sounds being heard, as this may help in better clinical characterization of the underlying
pathology. Certain electronic stethoscopes allow examiners to record sounds and actually
create visual representations of the findings.
You've just watched JoVE's video on general approach to auscultation during a physical
examination. You should now understand the different parts of a stethoscope, and how to use
this instrument effectively.
Making meaning out of the variety of sounds that one appreciates with the stethoscope can
seem daunting to the early learner. Through deliberate practice, with consideration of anatomy
and physiology of the structures being examined, and possibly the use of visual representation
of sound, auscultation becomes a powerful diagnostic tool for the clinician. As always, thanks
for watching!

PROPER ADJUSTMENT OF PATIENT ATTIRE DURING THE PHYSICAL EXAM
Overview
Source: Jaideep S. Talwalkar, MD, and Joseph Donroe, MD, Internal Medicine and
Pediatrics, Yale School of Medicine, New Haven, CT
In order to optimize the predictive value of the physical examination, the provider must
perform maneuvers correctly. The proper use of drapes is an important component of correctly
performing physical examination maneuvers. Skin lesions are missed when "inspection" occurs
through clothing, crackles are erroneously reported when the lungs are examined through a t-
shirt, and subtle findings on the heart exam go undetected when auscultation is performed over
clothing. Accordingly, the best practice standards call for examining with one's hands or
equipment in direct contact with the patient's skin (i.e., do not examine through a gown, drape,
or clothing). In addition to its clinical value, the correct draping technique is important for
improving the patient's comfort level during the encounter.
Like all other aspects of the physical exam, it takes deliberate thought and practice to find the
right balance between draping, which is done to preserve patient modesty, and exposure, which
is necessary to optimize access to the parts that need examination. Individual provider styles
in the use of gowns and drapes vary considerably based on the site of practice, resource
availability, and discipline within medicine. This video provides a general overview of some
of the most common techniques used, combining techniques that utilize common draping
approaches.
Procedure
1. Maneuvers that can be performed while the patient is wearing street clothing
Note that some aspects of the physical exam can be performed on patients while they are
wearing street clothing that permits exposure of the region to be inspected. These maneuvers
include the measurement of the vital signs, general appearance, the HEENT (Head, Eyes, Ears,
Nose, and Throat) exam, the neck exam, the abdominal exam, the vascular exam, and the
neurological exam.

1. To take a measurement of the vital signs, make sure to have access to the patient's arms.
2. In order to perform the basic HEENT maneuvers, instruct the patient to remove any
hats, dentures (if a thorough exam of a patient's oral mucosa is necessary), eyeglasses
(while examining the eyes), and hearing aids (if a thorough ear exam is necessary). The
HEENT exam can be performed regardless of what a patient is wearing from the neck
down. Keep in mind that functional assessment of speech, visual acuity, and hearing is
done best with dentures, glasses, and hearing aids in place.
3. Make sure the clothing permits the ability to inspect and palpate the neck and
supraclavicular regions (an adequate neck examination can be performed in a patient
who's wearing a loose-fitting shirt or a tank top).
4. The clinician can examine the abdomen in a patient wearing loose-fitting clothing.
Instruct the patient to have their pants rolled down to expose the lower abdomen and
their shirt raised up to provide optimal exposure.
5. For the vascular exam, make sure to have access to the site where each pulse is located.
For all upper and lower extremity pulses other than femoral, loose-fitting sleeves or
pant legs can be raised up when needed. Socks must be removed for pedal pulses.
6. All aspects of the neurologic examination can be performed on a patient who's wearing
clothing that permits inspection and palpation of the extremities. Be sure to remove a
patient's shoes and socks.
7. Most musculoskeletal regions can be examined in patients wearing t-shirts and shorts.
The shoulder examination is best done in a patient who is shirtless (or in a bra only) or
wearing a tank top, as visual inspection and provocative range of motion testing cannot
be easily done simultaneously in a patient wearing a gown.
2. Offering the gown and drape
1. Certain patients may find it acceptable to be examined while shirtless, which provides
optimal access to the structures in the neck, thorax, and abdomen. In the interest of
avoiding unnecessary exposure of women's breasts, clinicians often conduct the
examination with the patient wearing a bra or by using draping techniques with a gown.
This video demonstrates the draping technique for a patient who has been instructed to
remove their bra.
2. Provide instructions on what to do with the gown and drape (e.g., "In order to examine
you today, I'm going to ask you to change into this gown. Keep it open in the back. You

can leave your underwear on, but please remove your other clothing including your bra.
You can cover yourself with this drape to keep warm.").
3. Step out of the room while the patient changes, unless the patient needs help getting
changed due to mobility limitations, and let the patient know how long you'll be gone.
Experienced providers may tend to another task while the patient is changing, which
patients typically don't mind, as long as they know when to expect your return.
3. The sensitive use of gown and drape in various physical exam maneuvers
1. With the patient seated on the exam table, start the exam with the gown fastened,
typically in the back, and offer a drape to cover the patient's lap and legs for warmth
and use in subsequent maneuvers.
2. Examination of the neck, anterior chest, and heart in a patient wearing a hospital gown
- draping techniques are similar for all of these maneuvers in the seated, supine, and
standing positions.
3. Untie the gown at the back of the neck.
4. Instruct the patient to lower the gown slightly at the shoulders to allow optimal
examination of the lower neck and clavicles.
5. Cardiac and Respiratory Exam
1. Ask the patient to lower the gown a few inches further, while keeping their
breasts covered. This allows for adequate exposure for inspection, percussion,
palpation, and auscultation on the anterior chest and anterior lung zones, as well
as inspection, palpation, and auscultation of the pulmonic and aortic regions of
the heart.
2. Slightly lower the gown at the sternum to allow for auscultation at Erb's point
and the tricuspid area. Examination of the tricuspid area can also be done via an
alternative approach, as described below.
3. Replace the gown over the shoulders when this portion of the exam is finished.
4. After informing the patient that the "bottom part of their heart" is to be examined
next, raise their gown, or instruct the patient to raise it, to expose the left flank
and left upper quadrant of the abdomen to gain access to the fifth left intercostal
space at the mid-clavicular line (mitral area). If the patient's left breast is
impeding access to this area, use the back of your left hand to displace the breast
or ask the patient to lift the bottom of their left breast out of the way.

5. For an alternative approach to examining the tricuspid area, with the left upper
quadrant, slightly lift the gown at the inferior border of the sternum.
6. With the flank and left upper quadrant exposed, and the patient holding their
left breast and gown out of the way with their right hand, examine the mitral
area with the patient in the left lateral decubitus position.
7. To examine the posterior and lateral thorax in a seated position, move the folds
of the gown laterally to allow for adequate exposure for the inspection,
percussion, palpation, and auscultation of the posterior chest, back, and
posterior lung zones.
8. Displace the gown further, laterally and one side at a time, as needed to allow
for the examination of the lateral chest walls.
9. Examination of the back can be performed in a patient who is shirtless (or only
in a bra) or wearing a gown that's open in the back. If the patient is wearing a
gown, perform the seated inspection as described previously.
6. Gait and Standing Range of Motion Testing
1. During gait or standing range of motion (e.g., forward flexion) testing, hold the
back of the gown together, so the patient can concentrate on the movement
(rather than on worrying about the gown falling off).
2. Replace the gown to cover the back and retie the neck straps when this portion
of the exam is finished.
7. Abdominal examination
1. Place the drape over the patient's legs and pelvis.
2. With the patient in the supine position, lift (or have the patient lift) the gown
just below the level of the breasts, simultaneously securing the drape, so it keeps
the patient's pelvis covered. This technique is called "double draping," or
simultaneous use of the gown and drape to leave the chest, legs, pubic, and
inguinal regions covered, while examining the abdomen or lower chest.
3. All standard aspects of the abdominal exam can be performed with this
exposure, except for the percussion of the liver from the superior approach,
which requires additional displacement of the gown on the right side of the
lower chest. The patient may need to lift their right breast superiorly to allow
access for percussion.

8. Femoral Artery and Inguinal Nodes
1. Palpation and auscultation of the femoral artery generally requires the patient
to be in a gown. While it is possible to palpate the pulse over a thin layer of
clothing, this is not optimal, and auscultation cannot be done this way.
2. To perform both palpation and auscultation, move the drape medially or lower
the drape or pants sufficiently to allow the examiner access from a superior
approach, examining one side at a time and replacing the drape before moving
to the other side.
3. Note that examination of the inguinal lymph nodes can be done in the same
way.
4. Replace the gown when these maneuvers are finished being performed.
9. Musculoskeletal System of the Lower Extremities
1. If a patient is wearing a gown and the lower extremities need to be examined
while the patient is supine, place the draping sheet between the patient's legs, so
each leg and hip can be easily uncovered and directly examined, which limits
the exposure of areas not being actively examined.
10. Skin
1. A complete skin examination requires sequential displacement of the gown to
expose all areas of interest, while keeping other regions covered with the gown
and drape. The skin of the breasts, pelvis, and gluteal regions are typically
examined in this process, as well. Refer to the videos on the genitourinary exam
and female breast exam for descriptions of draping techniques for these
components of the exam.

Figure 1: General considerations for the sensitive use of drapes and gowns
The sensitive use of gowns and drapes during the physical examination is important to strike a
balance between patient comfort and exposure (Figure 1). The examination should not be
compromised out of the clinician's concern for patient exposure, since the proper use of draping
allows for the proper exam to be performed in most clinical circumstances. Examination
through clothing, sheets, or gowns is incorrect technique, though only the areas of the body
being directly examined at a given time need to be exposed, and once an area has finished being
examined, a clinician should replace the drape or clothing before moving on to the next area.
An examiner shouldn't reach under a gown or clothing to examine a patient, and they should
enlist the patient's help in moving the gown or drape throughout the exam, as this allows the
patient to maintain some control over the degree of exposure. Letting the patient know what is
about to be done before moving a gown or drape is also important, as proper communication
puts the patient at greater ease. If a clinician has tied the gown during the exam, they should
retie it before asking the patient to step down from the table. The handful of draping techniques

demonstrated in this video can be used together for all the standard parts of the physical
examination. As with all the other aspects of the physical examination, developing comfort and
individual stylistic variations in draping technique takes deliberate practice.
Transcript
The proper usage of any attire, including hospital gowns and drapes is an important component
of correctly performing maneuvers during the physical exam.
Skin lesions can be missed when inspection occurs through clothing. Sounds can be misleading
if the lungs are percussed through a t-shirt. And subtle findings on the heart exam can go
undetected when auscultation is performed over apparel. Accordingly, the best practice
standards call for examining with one's hands or equipment in direct contact with the patient's
skin. Therefore, it takes deliberate thought and practice to employ appropriate usage of
clothing, such that it preserves patient modesty, and allows sufficient access to the parts that
need examination.
Certain regions can be examined while patient are wearing street clothing, while others regions
can be more comfortably investigated if the patient is wearing gown and drapes. In this video,
we'll demonstrate considerations for each of these scenarios using examples of a few routine
physical exams.
First, let's go over the steps, which can be performed on patients wearing street clothing. The
vital signs can be measured if you have access to the patient's arms. For basic HEENT
maneuvers, instruct the patient to remove any hats, eyeglasses, dentures-if a thorough exam of
a patient's oral mucosa in necessary, and hearing aids -if a thorough ear exam is necessary. But
other than that these exams can be performed regardless of what a patient is wearing from the
neck down.
If the patient is wearing loose-fitting clothing, the inspection and palpation of the neck and
supraclavicular regions can be easily performed. In order to examine the abdomen, instruct the
patient to lie down and ask them to roll down their pants and raise-up their shirt to provide
optimal exposure. During vascular exam, raise the sleeves and the pant legs as necessary to
access the pulse sites. Make sure that the footwear and socks are removed before testing the

pedal pulses. The femoral pulse is usually not accessible in patients wearing street clothing.
All aspects of the neurologic examination can be performed on a patient who's wearing clothing
that permits inspection and palpation of the extremities.
Now, let's go over the maneuvers to be performed while the patient is wearing a hospital gown.
First, provide instructions to the patient on what to do with the gown, "In order to examine you
today, I'm going to ask you to change into this gown. Keep it open in the back. You can leave
your underwear on, but please remove your other clothing including your bra." Let the patient
know how long you'll be gone and step out of the room while the patient changes. When you
come back, knock on the door and ask for the patient's permission to come in. Instruct the
patient to sit on the exam table. Offer a drape to cover lap and legs for warmth. This drape will
be used in subsequent maneuvers as well.
Now, let's go over the appropriate gown use for the neck, anterior chest, and heart exams. Untie
the gown at the back of the neck. Instruct the patient to lower the gown slightly at the shoulders
to allow optimal examination of the lower neck and clavicles. Next, ask the patient to lower
the gown a few inches further. This allows for adequate exposure of the anterior chest, lung
zones, as well as the pulmonic and aortic regions of the heart. Further lowering the gown at the
sternum allows for auscultation at the Erb's point and the tricuspid area. When this portion of
the exam is finished, replace the gown over the shoulders.
For examining the cardiac apex, instruct the patient to raise their gown to expose the left flank
and upper left quadrant of the abdomen. To examine the mitral area, place the stethoscope in
the fifth left intercostal space at the mid-clavicular line. Certain findings are best appreciated
with the patient lying in the left lateral decubitus position. If the patient's left breast is impeding
access to this area, ask the patient to displace it with their right hand or you can use the back
of your left hand to do the same. This position brings the left ventricle closer to the chest wall,
which can accentuate S3, S4 and the murmur of mitral stenosis when using the bell.
For adequate exposure of the back region, move the folds of the gown laterally with the patient
in the seated position. Displace the gown further, one side at a time, to allow for the lateral
chest wall examination. During gait or standing range of motion, like forward flexion testing,
hold the back of the gown together, so that the patient can concentrate on the movement and

not worry about the gown falling off. After this portion of the exam, replace the gown to cover
the back and retie the neck straps.
For abdominal, thigh and inguinal investigation, ask the patient to lie down at 0-30° angle, and
place the drape to cover the patient's legs and pelvis. Request the patient to lift the gown just
below the chest level, simultaneously securing the drape. This technique is called "double
draping," which means simultaneous use of a gown and a drape. All standard aspects of the
abdominal exam can be performed with this exposure, except for the percussion of the liver
from the superior approach, which requires additional displacement of the gown on the right
side to expose the lower chest. To assess the femoral artery and inguinal lymph nodes, move
the drape medially, examine one side at a time and replace the drape before moving to the other
side. Replace the gown when these maneuvers are finished being performed.
In order to examine the musculoskeletal system, ensure that the region of interest is exposed to
permit inspection, palpation, and provocative maneuvers simultaneously. Exposure should also
allow examination of the surrounding muscle groups and joints. For testing lower extremities,
place the draping sheet between the patient's legs, so that each leg and hip can be easily
uncovered and directly examined, which limits the exposure of areas not being actively
examined. Lastly, a complete skin examination requires sequential displacement of the gown
to expose all areas of interest, while keeping other regions covered with the gown or drape.
At the end of the physical exam, thank the patient for their cooperation. Ask patients to change
back into their clothing before initiating complicated discussions about diagnosis and
treatment.
You've just watched JoVE's video on sensitive and effective usage of attire during the physical
exam. Here, we presented a handful of techniques for effectively working with patient's
clothing-be it "street" or "hospital"-that can be can be applied to all the standard parts of the
physical exam.
It is extremely important to strike a balance between patient comfort, and exposure necessary
for a thorough examination, and as with all the other aspects of the physical exam, developing
the skill to appropriately manipulate the patient's attire takes deliberate practice. As always,
thanks for watching!

BLOOD PRESSURE MEASUREMENT
Overview
Source: Meghan Fashjian, ACNP-BC, Beth Israel Deaconess Medical Center, Boston MA
The term blood pressure (BP) describes lateral pressures produced by blood upon the vessel
walls. BP is a vital sign obtained routinely in hospital and outpatient settings, and is one of the
most common medical assessments performed around the world. It can be determined directly
with the intra-arterial catheter or by indirect method, which is a non-invasive, safe, easily
reproducible, and thus most used technique. One of the most important applications of BP
measurements is the screening, diagnosis, and monitoring of hypertension, a condition that
affects almost one third of the U.S. adult population and is one of the leading causes of the
cardiovascular disease.
BP can be measured automatically by oscillometry or manually by auscultation utilizing a

sphygmomanometer, a device with an inflatable cuff to collapse the artery and a manometer to
measure the pressure. Determination of the pulse-obliterating pressure by palpation is done
prior to auscultation to give a rough estimate of the target systolic pressure. Next, the examiner
places a stethoscope over the brachial artery of the patient, inflates the cuff above the expected
systolic pressure, and then auscultates while deflating the cuff and observing the manometer
readings. When the pressure in the cuff falls below the pressure in the brachial artery, the
turbulent blood flow in a partially squeezed artery produces the Korotkoff audible sounds. The
first audible Korotkoff sound signifies the maximum arterial pressure during systole. When the
pressure in the cuff is reduced further and falls below the minimal arterial pressure (during
diastole), the Korotkoff sounds become no longer audible. The reading at this point signifies
the diastolic blood pressure. The blood pressure is measured in mmHg and recorded as a
fraction (systolic BP/ diastolic BP).
In most instances, the vital signs are initially measured by a health care assistant or registered
nurse (RN). The physician may choose to repeat the vital signs and blood pressure
measurement after completion of the patient interview. Repeated measurement of blood
pressure is especially important given the potential measurement errors and blood pressure
variations.

Procedure
1. Preparation
1. Assess for any contraindications to BP measurement in the upper arm including

arteriovenous fistula, history of axillary lymph node dissection, or evident
lymphedema.
2. Make sure the patient has changed into a gown and rested for at least 5 min prior to
obtaining blood pressure and other vital signs.
3. Ask the patient to sit comfortably with their feet uncrossed and resting on the floor.
4. Have the stethoscope and sphygmomanometer ready.
5. Confirm proper sizing of the BP cuff (when wrapped around the limb the index line on
the cuff should fall within the marked arm circumference range limits). A small cuff
may falsely elevate the readings and potentially lead to misdiagnosis.
2. Determination of pulse-obliterating pressure by palpation
Obtaining the pulse-obliterating pressure prior to measurement of blood pressure by

auscultation allows avoiding measurement error due to the auscultatory gap. An auscultatory
gap is an intermittent disappearance of Korotkoff sounds after their initial appearance before
the true diastole, which may seriously underestimate the systolic pressure or overestimate the
diastolic pressure.
1. Place the cuff on the patient's arm about 2.5 cm above the antecubital fossa.
2. Make sure the patient's arm is free of clothing and resting at their side with the brachial
artery at the level of the heart.
3. Identify the radial pulse with your index and middle fingers.
4. Close the valve on the pressure bulb (by turning it clockwise with your thumb) and
inflate the cuff by squeezing the pressure bulb rapidly.
5. Inflate until the radial pulse cannot be felt anymore and note the measurement on the
manometer.
6. Continue to inflate until the pressure increases for an additional 30 mmHg. This is done
to avoid over-inflation of the cuff on subsequent readings.
7. Open the valve slowly by rotating it counterclockwise with your thumb.
8. Deflate the cuff at 2 mmHg/sec until the radial pulse returns.

9. Record the manometer reading when the radial pulse reappears (obliterating pressure)
on the vital signs flow sheet.
3. Obtaining blood pressure with auscultation
1. Place the stethoscope over the brachial artery (medial aspect of antecubital fossa).
2. Inflate the cuff again at a level of 30 mmHg above pulse-obliterating pressure and make
sure no sounds are present.
3. Slowly deflate the cuff at a rate of 2 mmHg/sec.
4. Note the value on the manometer when the Korotkoff sound, indicated by the first two
consecutive beats, can be heard. The manometer reading at that moment corresponds
to the systolic blood pressure.
5. Continue slowly deflating the cuff while listening for the sounds to completely
disappear, which signifies the diastolic blood pressure.
6. Make sure to deflate the cuff entirely so as not to miss the diastolic pressure.
7. Record the systolic and diastolic blood pressure measurements on the vital signs sheet.
8. Repeat the process in both arms (unless contraindicated).
4. Testing for pulsus paradoxus
Normally, the systolic blood pressure is lower on inspiration due to decreased intrathoracic
pressure. An abnormally large fall (more than 10 mmHg) in systolic blood pressure on
inspiration is defined as pulsus paradoxus and is most commonly associated with cardiac
tamponade or severe chronic obstructive pulmonary disease .
1. Inflate the cuff to 30 mmHg higher than the systolic pressure determined during blood
pressure measurement.
2. Deflate at 2 mmHg/sec until the first Korotkoff sound is audible on expiration (sound
should be intermittent rather than every heartbeat, corresponding to higher blood
pressure on expiration). Note the measurement.
3. Continue to deflate the cuff at 2 mmHg/sec until the Korotkoff sounds are audible on
both expiration and inspiration (every heartbeat). Lower blood pressure on inspiration
is due to a decrease in intrathoracic pressure.
4. Calculate the difference between systolic blood pressure on expiration and inspiration.

5. Orthostatic or Postural blood pressure measuring
An orthostatic hypotension is an abnormal decrease in systolic blood pressure of 20 mmHg or

a decrease in diastolic blood pressure of 10 mmHg within 3 min of standing compared with
blood pressure in supine or sitting position. This can result from compromised venous return
and subsequent decrease in cardiac output. Orthostatic hypotension can happen transiently in
people of all ages, but occurs most commonly in elderly patients. Some potential causes include
blood loss, medications, and disease of the autonomic nervous system.
1. Place the patient in a supine position. Wait for a minimum of 5 min before obtaining
the reading.
2. Obtain a blood pressure measurement as described.
3. Record the measurement on the vital signs sheet. Make sure to note the position of the
patient.
4. Have the patient stand and repeat the BP measurement after 3 min of standing.
5. Calculate the difference in pressures. If there is a decrease of 20 mmHg or greater in
the systolic pressure, or 10 mmHg or greater in the diastolic pressure, the patient has
orthostatic hypotension.
An accurate measurement of BP is essential for timely diagnosis and treatment of the

underlying condition. Although patients can sustain higher blood pressure (hypertension) for a
longer period of time, which is a key factor in developing cardiovascular disease or stroke, a
drastically low (hypotensive) or decreasing blood pressure can be fatal if not treated in time.
Despite being a simple and non-invasive measurement, obtaining accurate BP is a skill that
requires practice, and correct interpretation of the findings requires good understanding of
physiology and pathophysiology behind the principle of this procedure.
Transcript
Blood pressure is a vital sign obtained routinely in hospital and outpatient settings. The term
blood pressure describes the lateral pressure produced by blood upon vessel walls. One of the
most important applications of blood pressure measurement is the checking for increased blood

pressure-a condition termed hypertension. One in every three adults in the United States suffers
from hypertension and it is one of the leading causes of cardiovascular diseases.
This video will illustrate the principles behind traditional blood pressure measurement
technique and then it will review the critical steps to be followed during this procedure.
The equipment needed for traditional, indirect measurement of blood pressure includes a
stethoscope and a sphygmomanometer. The sphygmomanometer consists of a blood pressure
cuff containing a distensible bladder, a rubber bulb with an adjustable valve, which when
closed helps in cuff inflation and when open releases the built pressure. It also consists of
tubing - connecting the cuff to the bulb, and to the manometer, which displays the cuff's
pressure in mmHg.
In order to record the blood pressure reading, the examiner wraps the cuffs around the brachial
artery, places a stethoscope over this artery, inflates the cuff above the expected systolic
pressure and then deflates it while auscultating and observing the manometer simultaneously.
Initially, when the cuff is fully inflated the artery is squeezed and the blood flow is halted.
Thus, there is no sound upon auscultation. Upon deflation, the first appearance of the Korotkoff
sounds signifies the systolic pressure, which is audible due to the turbulent blood flow in the
partially squeezed artery. Further deflation causes a continual decrease in cuff pressure, and
the Korotkoff sounds remain audible throughout, up until the point when the cuff pressure is
below the minimal arterial pressure. This reading denotes the diastolic pressure. The fraction
of systolic over diastolic is recorded as the final blood pressure reading.
With this knowledge, now let's go through the step-wise procedure of obtaining accurate blood
pressure readings. If necessary, provide the patient with a gown and ensure that he or she is
rested for at least 5 minutes prior to obtaining the measurement. To guarantee an accurate
reading, ensure that the patient is sitting comfortably with their feet uncrossed and resting on
the floor. The cuff should be placed about 2.5 cm above the antecubital fossa. Confirm proper
sizing by looking at the index line on the cuff when wrapped around the arm, it should fall
within the marked arm circumference range limits. This is critical, as a smaller cuff may falsely
elevate the readings and potentially lead to misdiagnosis. Also, make sure that the patient's arm
is resting with the brachial artery at the level of the heart. This is also important, because if the

arm is below the heart level it may lead to an overestimation, and if it is above it might result
in underestimation of systolic and diastolic pressures.
Next, find the radial pulse with your index finger. Once the pulse is identified, close the valve
on the pressure bulb by turning it clockwise. Then, inflate the cuff by squeezing the pressure
bulb rapidly. Continue doing this until the radial pulse cannot be felt anymore, and note the
mercury level on the manometer. Inflate further until the pressure increases for an additional
30 mmHg. Try not to go beyond this mark as it might lead to unnecessary over inflation, which
is uncomfortable for a patient. Then, open the valve slowly by rotating it counterclockwise and
deflate the cuff at the rate of approximately 2 mmHg per second until the radial pulse returns.
Note the manometer reading when the radial pulse reappears and record it on the vital signs
flow sheet as the pulse-obliterating pressure.
After this, proceed to obtaining blood pressure with auscultation. Place the chest piece over the
brachial artery in the medial aspect of antecubital fossa. Inflate the cuff again to a level above
the pulse-obliterating pressure and confirm that no sound is present. Now, slowly deflate the
cuff at a rate of 2 mmHg per second. Listen carefully and note the value on the manometer
when the Korotkoff sound can be heard. The manometer reading at that moment corresponds
to the systolic blood pressure. Continue slowly deflating the cuff while listening for the sounds
to completely disappear. This signifies the diastolic blood pressure. Make sure to deflate the
cuff entirely. Record the systolic and diastolic measurements on the vital signs flow sheet.
Normally, the systolic blood pressure on inspiration tends to be lower than the one during
expiration due to decreased intrathoracic pressure. However, an abnormally large fall-more
than 10 mmHg-in systolic blood pressure on inspiration is defined as pulsus paradoxus, which
is most commonly associated with cardiac tamponade or severe chronic obstructive pulmonary
disease. To check for pulsus paradoxus, first inflate the cuff to approximately 30 mmHg higher
than the previously determined systolic pressure. Deflate at the rate of about 2 mmHg per
second. If pulsus paradoxus is present, the first Korotkoff sound is intermittent and occurs just
during expiration. Note the reading, which corresponds to higher systolic blood pressure on
expiration. Continue to deflate at the same rate until the Korotkoff sounds are audible on both
expiration and inspiration-that is with every heartbeat. Note this reading as well, which
corresponds to lower systolic blood pressure on inspiration. Calculate the difference between

systolic blood pressure on expiration and inspiration to determine if pulsus paradoxus is present
or absent.
Lastly, check for orthostatic hypotension. Place the patient in a supine position and wait for a
minimum of 5 minutes before obtaining the reading. Obtain a blood pressure measurement in
this position following the method described previously. Record the measurement on the vital
signs sheet and make sure to note the position of the patient. Next, request the patient to stand
and repeat the blood pressure measurement after 3 minutes of standing. Calculate the difference
in pressures. If there is a decrease of 20 mmHg or greater in the systolic pressure or 10 mmHg
or greater in the diastolic pressure, then the patient suffers from orthostatic hypotension.
You've just watched JoVE's video on how to accurately measure blood pressure. Despite being
a simple and non-invasive measurement, obtaining an accurate blood pressure reading is a skill
that requires practice. In addition, correct interpretation of the findings requires good
understanding of the physiology and the principles behind this procedure. As always, thanks
for watching!

MEASURING VITAL SIGNS
Overview
Source: Meghan Fashjian, ACNP-BC, Beth Israel Deaconess Medical Center, Boston MA
The vital signs are objective measurements of a patient's clinical status. There are five
commonly accepted vital signs: blood pressure, heart rate, temperature, respiratory rate, and
oxygen saturation. In many practices, pain is considered the sixth vital sign and should
regularly be documented in the same location as the other vital signs. However, the pain scale
is a subjective measurement and, therefore, has a different value according to each individual
patient.
The vital signs assessment includes estimation of heart rate, blood pressure (demonstrated in a
separate video), respiratory rate, temperature, oxygen saturation, and the presence and severity
of pain. The accepted ranges for vital signs are: heart rate (HR), 50-80 beats per minute (bpm);
respiratory rate (RR), 14-20 bpm; oxygen saturation (SaO2), > 92%; and average oral
temperature, ~98.6 °F (37 °C) (average rectal and tympanic temperatures are ~1° higher, and
axillary temperature is ~1° lower compared to the average oral temperature).
Vital signs serve as the first clue that something may be amiss with a patient, especially if the
patient is unable to communicate. Although there are quoted normal ranges, each patient should
be considered as an individual and not treated without taking into account the entire clinical
picture.
Procedure
Make sure the patient has been seated and resting for at least 5 minutes prior to obtaining vital
signs (VS) to accurately determine the baseline.
1. Heart rate
The radial artery is the most common site used to assess the pulse.
1. Explain to the patient that you are going to start by checking their pulse.
2. Place your index and middle fingers on the radial pulse (never use the thumb, as you
can sometimes feel your own pulse). To prevent occlusion, do not press or apply
pressure to the artery.

3. Assess the rhythm.
1. If the rhythm is regular, count the beats for 15 seconds, then multiply by 4.
2. If the rhythm is irregular, count the beats for a full 60 seconds. A regularly
irregular pulse may signal premature beats, whereas an irregularly irregular
rhythm may signal atrial fibrillation. Confirm any abnormalities with an
electrocardiogram (ECG).
4. Note the amplitude of the pulse (normal, bounding, diminished, or absent). Bounding
pulses may be observed at rest with atherosclerosis, congestive heart failure (CHF),
kidney disease, aortic insufficiency, or fever. Diminished pulses may be noted with
peripheral vascular disease (PVD) or sepsis. If absent, it may be due to occlusion of the
artery and should be further investigated.
5. Record HR, making a note of rhythm and amplitude on the VS flow sheet.
2. Respiratory rate
Attempt to calculate the respiratory rate without the patient becoming aware. This can be done
either by leaving the fingers on the patient's radial pulse or by counting during the
cardiovascular portion of the physical exam when they are breathing normally.
1. Count the respiratory rate for a full 60 seconds. One respiratory cycle includes both
inspiration and expiration. Note if slow breathing (bradypnea) or rapid shallow
breathing (tachypnea) is present.
2. Assess the regularity of breathing. Note if an irregularly irregular (ataxic or Biot's) or
regularly irregular (Cheyne-Stokes, characterized by long periods of apnea) pattern is
present.
3. Note the depth of breathing. Is the patient engaged in shallow or very deep breathing?
For example, rapid shallow breathing can be labeled as tachypnea, whereas deep rapid
breathing may be the Kussmaul breathing, which is associated with diabetic
ketoacidosis.
4. Note the work of breathing. Is the patient utilizing accessory muscles with respiration?
These include the trapezius, scalene, sternomastoid, and external intercostal muscles.
This often indicates if there is an issue with oxygen delivery or air trapping.
5. Record the rate and rhythm on the VS flow sheet. Also include depth and work of
breathing, if abnormal.

3. Temperature
An examiner can obtain oral, rectal, axillary, or tympanic membrane temperatures. Be familiar
with the differences in the expected normal values. In the office setting, the most common
method of checking the temperature is oral. If the patient is non-responsive or unable to
cooperate, oral is not the preferred method, and the examiner should use an alternate technique.
1. Explain to the patient that you are going to check their temperature.
2. Place a disposable plastic sheath on the thermometer.
3. If using a digital thermometer, insert under the patient's tongue and hold there until the
thermometer alerts you that the temperature has been calculated.
4. If using a glass thermometer, make sure it reads less than 96 °F and insert under the
patient's tongue. Hold there for 3 min.
5. Record the temperature and location obtained on the vital sign flow sheet.
4. Oxygen saturation
The oxygen saturation (SaO2) can be measured by a non-invasive method called pulse
oximetry. The oximeter is a small, usually portable, device that consists of a monitor and a
probe, which is placed on the patient's finger, toe, or earlobe. The probe allows two
wavelengths of light to pass through the body to a photodetector. The changes in absorbance
indicate the percentage of saturated hemoglobin in the arterial blood. Most oximeters display
the patient's pulse rate, too. Be advised: if a patient's fingertip is cold or if the patient is wearing
nail polish, this may interfere with the reading. There are also conditions that falsely elevate
the readings including carbon monoxide poisoning.
1. Explain to the patient that you are going to check their oxygen saturation.
2. Place the oximeter probe onto the patient's finger. Finger probes are often a single
rubber piece that can be hinged and slipped onto the fingertip. There are alternative
probes that can be placed on other body parts, if unable to obtain a read from the finger.
3. Record the oximeter reading on the vital sign flow sheet.
5. Pain
In most instances , a numeric scale (1-10, 10 being the worst pain imaginable) is utilized to
estimate presence and the level of pain. In non-verbal patients, children, or those who do not

speak English, severity of pain is assessed by using the visual Wong-Baker FACES® scale.
Always remember to reassess pain after any intervention taken.
1. Ask the patient if they are having pain.

2. If the patient expresses comprehension and does have pain, ask them to quantify it on
a scale of 1-10.
3. If the patient is unable to comprehend, but appears to have pain, show them the Wong-
Baker FACES® scale to determine the severity of pain.
4. Record on the vital sign flow sheet.
The vital signs - blood pressure, heart rate, respiratory rate, temperature, oxygen saturation,
and "the 6th vital sign", pain - are often the first pieces of objective evidence gathered before
formal evaluation of the patient. These simple non-invasive measurements provide essential
(i.e., vital) insight into a patient's clinical status, as they can indicate early objective changes
prior to the onset of symptoms.
A medical practitioner should be familiar with accepted variations in normal ranges of

measurements based on age, weight, and gender. Abnormality in vital signs can indicate an
acute medical problem or a change in chronic disease state. If these have been obtained prior
to the examiner's first encounter with the patient, but are abnormal, it is advised to perform
repeated measurement. The vital signs help guide the evaluation of the patient and to formulate
the assessment and plan.
Transcript
Vital signs are objective measurements of a patient's clinical status. The commonly
documented vital signs are blood pressure, heart rate, temperature, respiratory rate, oxygen
saturation and the presence and severity of pain.
The principles and procedure of blood pressure measurement have been covered in detail in
another video of this collection. Here, we will illustrate how to measure and record the rest of
the vital signs.

Before starting with the procedure, ensure that the patient has been seated and resting for at
least 5 minutes. In the meantime, wash your hands thoroughly with soap and warm water. Upon
entering the room, introduce yourself to the patient, briefly explain what you are going to do,
and obtain their consent, "Now I am going to check your vital signs, will that okay?"
Start by assessing the heart rate also known as the pulse rate. The radial artery is the most
common site used to assess this parameter. Place your index and middle fingers on the radial
pulse. Do not apply pressure, and never use the thumb, as with thumb you may sometimes feel
your own pulse. Assess the rhythm and note if it is regular. Count the beats for 15 seconds, and
then multiply by 4 to calculate the pulse rate in beats per minute. If the rhythm is irregular,
count the beats for a full minute. Simultaneously, assess the amplitude of the pulse, and note
whether it is normal, bounding, diminished, or absent. Record the heart rate, making a note of
the rhythm and amplitude on the vital signs flow sheet. The accepted range for a normal heart
rate is 50-80 beats per minute.
The next vital sign to be recorded is the respiratory rate. Attempt to calculate this without the
patient becoming aware. Count the respiratory cycles for at least one full minute. One
respiratory cycle includes both inspiration and expiration. Note the rate, regularity, depth, and
work of breathing. The work of breathing refers to the utilization of accessory muscles of
respiration. These include neck muscles like scalene and sternomastoid. The constant
utilization of these muscles indicates difficulty with breathing. Record the rate and rhythm on
the vital signs sheet. Also include the depth and work of breathing, if abnormal. The normal
respiratory rate is about 14 to 20 breaths per minute.
After obtaining the respiratory rate, check the temperature, most commonly done by using a
digital oral thermometer. Place a disposable plastic sheath on the thermometer, and insert it
under the patient's tongue and hold there until the thermometer alerts you that the temperature
has been calculated. Other than the oral temperature, an examiner can obtain axillary, rectal,
or tympanic membrane temperatures. However, remember that there is a difference in the
expected normal values based on the location. Record the temperature and the location where
it was obtained.
Next, measure the oxygen saturation, commonly known as SaO2, which refers to the fraction
of oxygen-saturated hemoglobin relative to total hemoglobin. This can be measured by a non-

invasive method called pulse oximetry. The pulse oximeter is a small, usually portable device
that consists of a monitor and a probe, which is usually placed on the patient's finger. One side
of the probe has the light sources, which emit two different types of lights-infrared and red,
which are transmitted through the finger to the detector on the other side. The oxygen-rich
hemoglobin absorbs more of the infrared light and the deoxygenated hemoglobin absorbs more
of the red light. The microprocessor calculates the differences and converts the information
into a digital readout of the percentage oxygen-saturated hemoglobin in the arterial blood,
which is nothing but SaO2. To obtain this value, simply place the oximeter probe, which is
often a single rubber piece that can be hinged and slipped onto the patient's fingertip. After a
few seconds, record the display reading, which should normally be more than 92 percent. In
case if the patient's fingertip is cold or if the patient is wearing nail polish, which might interfere
with the fingertip reading, consider using a probe for the ear lobe.
Lastly, ask the patient if they are experiencing any type of pain. If the patient expresses
comprehension and does have pain, ask them to quantify it on a scale. If the patient is unable
to comprehend, but appears to have pain, show them the Wong-Baker FACES® scale to
determine the severity of pain.
You've just watched JoVE's demonstration of the principles and procedures associated with
obtaining the commonly required vital signs.
These simple non-invasive measurements provide essential insight into a patient's clinical
status, as they can indicate early objective changes prior to the onset of symptoms. Therefore,
every examiner should be aware about the methods used to record these and the accepted
variations in the readings. As always, thanks for watching!

RESPIRATORY EXAM I: INSPECTION AND PALPATION
Overview
Source: Suneel Dhand, MD, Attending Physician, Internal Medicine, Beth Israel Deaconess
Medical Center
Disorders of the respiratory system with a chief complaint of shortness of breath are among the
most common reasons for both outpatient and inpatient evaluation. The most obvious visible
clue to a respiratory problem will be whether the patient is displaying any signs of respiratory
distress, such as fast respiratory rate and/or cyanosis. In a clinical situation, this will always
require emergent attention and oxygen therapy.
Unlike pathology in other body systems, many pulmonary disorders, including chronic
obstructive pulmonary disease (COPD), asthma, and pneumonia, can be diagnosed by careful
clinical examination alone. This starts with a comprehensive inspection and palpation. Keep in
mind that in non-emergency situations the patient's complete history will have been taken
already, gaining important insight into exposure histories (e.g., smoking), which could give
rise to specific lung diseases. This history can then confirm physical findings as the
examination is performed.
Procedure
1. Preparation for exam
1. Before examining the patient, wash hands thoroughly with soap and water or clean
them with antibacterial wash.
2. Explain to the patient that you are going to perform a lung examination.
2. Positioning the patient
1. Make sure the patient is undressed down to the waist (females keeping on underwear
and exposing each hemithorax one at a time).
2. Position the patient on the examination table at a 30- to 45-degree angle and approach
the patient from the right side. Examining the posterior of the lung requires that the
patient be leaning forward or sitting on the edge of the bed.

3. General observation
1. Have a general look at the patient first. By this time, the patient's vital signs should
have already been obtained. Pay particular attention to the patient's respiratory rate and
oxygen saturation.
2. Note the signs of obvious respiratory distress. These include:
1. Fast respiratory rate (normal respiratory rate is around 14-20 breaths per
minute)
2. Cyanosis (blue or purple coloration of the skin or mucous membranes)
3. Unusual posturing to maximize air entry (patient may lean forward on
outstretched arms [tripod position])
4. Breathing using accessory muscles (scalene, sternocleidomastoid, and trapezius
muscles) in addition to the diaphragm
5. Inward movement of intercostal muscles (intercostal retractions)
3. Note if the patient is coughing. If the patient is producing sputum, this can also provide
an important diagnostic clue that there is an underlying respiratory infection.
4. Note if the patient's voice sounds hoarse when speaking. A hoarse voice may be a sign
of upper airway inflammation, infection, or malignancy.
5. Note if wheezing is present.
6. Observe carefully for any other specific abnormal breathing patterns.
4. Peripheral examination
1. Hand examination
1. Ask the patient to stretch out the arms and extend the wrists. Assess for flapping
tremor (asterixis), sometimes caused by carbon dioxide retention). Note that
patients can also exhibit tremors if they've just received bronchodilator therapy.
2. Note if nicotine staining on the nails is present.
3. Ask the patient to put both thumbnails side-by-side. Note if a diamond-shape is
formed on the inside. If clubbing (a decrease in angle between the nail and nail
bed) is present, this doesn't happen. This can be a sign of pulmonary fibrosis,
cystic fibrosis, or bronchogenic carcinoma.
4. Examine the skin for erythema nodosum (red, painful, tender lumps or nodules
associated with sarcoidosis).

5. Palpate the radial pulse at the wrist. A bounding or abnormally strong pulse can
be a sign of carbon dioxide retention.
2. Head examination
1. Inspect for a facial flushing, a potential indication of carbon dioxide retention.
2. Inspect the nose for nasal polyps or evidence of epistaxis. Ask the patient to tilt
head upwards and look into each nostril, using a flashlight.
3. Ask the patient to open mouth and stick out the tongue. The color of the tongue
should be pink/red. If it is a bluish discoloration, this indicates central cyanosis.
4. Inspect the throat for pharyngitis or tonsillar inflammation. Ask the patient to
phonate by saying, "Ahhhhh". Using a flashlight, look at the back of the patient's
throat. You may use a tongue depressor to get a good view of the back of the
mouth.
5. Observe patient's face for the signs of Horner's syndrome (the triad of miosis
(constricted pupil), ptosis, and hemifacial anhidrosis (decreased sweating on
that side of the face). Horner's syndrome can be caused by brachial plexus
compression from a Pancoast (apical lung) tumor.
3. Assess for lymphadenopathy
1. Palpate the cervical lymph nodes with both hands, one on each side of the
patient's face.
2. Start at the preauricular glands and then work down, palpating with the ends of
your fingers: jugulodigastric, submandibular, submental, anterior cervical,
supraclavicular, posterior cervical, posterior auricular, occipital lymph nodes.
3. Assess for axillary lymphadenopathy by holding the patient's arm near the
elbow with one hand and palpating in the axilla with your other hand.
5. Chest inspection
1. Inspect the chest wall for scars that would be evidence of a prior thoracotomy.
2. Inspect the chest shape and look for any visible chest deformities. The anterioposterior
diameter of the chest is normally smaller than its lateral diameter (Figure 1).
3. A "barrel" chest (Figure 2) is a bulging chest with an abnormal increase in
anteroposterior diameter and decreased movement in respiration, observed in COPD
and emphysema.

4. Also look for pectus excavatum (Figure 3) (sunken or caved-in chest, usually
congenital) versus pectus carinatum (Figure 4) (a protruding or "pigeon" chest, again,
usually congenital).
5. Note if kyphoscoliosis (Figure 5), an outward and lateral curvature of the spine which
can impair respiration, is present.
6. Note if the chest movements are symmetrical with equal expansion of both
hemithoraces.
Figure 1. Thorax of a normal adult. A transverse section of a thorax (left); a torso (right).
The anteroposterior chest diameter is smaller than lateral diameter.

Figure 2. Barrel chest. A transverse section of thorax (left); a torso (right) with signs of barrel
chest (increased anteroposterior diameter)
Figure 3. Pectus Excavatum (funnel chest). A transverse section of thorax (left); a torso
(right) with signs of pectus excavatum (depression of the lower portion of sternum)

Figure 4. Pectus Carinatum (pigeon chest). A transverse section of thorax (left); a torso
(right) with signs of pectus carinatum (increased anteroposterior chest diameter, anteriorly
displaced sternum, and depression of the costal cartilages)
Figure 5. Thoracic Kyphoscoliosis. A transverse section of thorax (left); a torso (right) with
signs of kyphoscoliosis (abnormal spinal curvatures and vertebral rotation).
6. Palpation
1. Palpate the trachea

1. Position yourself in front of the patient.

2. Place your right index finger in the sternal notch.
3. Palpate the lateral borders of the trachea to determine if it is in normal (midline)
position. A deviated trachea can indicate lung pathology either away or towards
the side of deviation. The trachea will be deviated away from the side of an
effusion or lung mass, and towards the side of a pneumothorax, collapsed lung,
or atelectasis.
2. Palpate the chest wall.
1. Use the palm of your right or left hand to assess for any obvious point
tenderness, masses, or rib deformities.
2. Palpate at 4-5 levels up the chest anteriorly and posteriorly. Any differences
between right and left can indicate abnormal underlying lung tissue.
3. Note any evidence of subcutaneous emphysema, which feels like a crackly
tactility under the skin. This is observed when air gets into the subcutaneous
tissues, and is associated with lung collapse secondary to trauma or a ruptured
bronchial tube.
3. Assess chest expansion
1. Place your hands, with thumbs touching, in the midline and extend your fingers
to make contact with the lateral edges of the chest anteriorly, just below the
level of the nipples.
2. Ask the patient to take a deep breath. The thumbs should separate by
approximately 5 cm or more in normal chest expansion (this technique can also
be utilized posteriorly).
4. Assess tactile vocal fremitus. Typically, tactile vocal fremitus is increased over areas
of consolidation and decreased over pleural effusion in the case of lung collapse.
1. Place your hands at the lower anterior part of the chest with the hypothenar
(ulnar) sides of each hand touching the chest at the same level on the right and
left.
2. Ask the patient to say "99" or "1-2-1". The vibration felt against your hand
should be the same in each hand.
Look first and foremost for any signs of respiratory distress in a patient and unique breathing
pattern. Severe underlying pulmonary illnesses will often be apparent from simply glancing at

patients. Conditions such as COPD and emphysema can reveal themselves in a patient's
appearance and body habitus. These patients can loosely be classified as either "pink puffers"
or "blue bloaters." "Pink puffers" are usually thin and have emphysema. They have a hyper-
inflated chest, usually have a fast respiratory rate in order to maintain their oxygen saturations,
and are mildly hypoxemic. "Blue boaters" are obese and more severely hypoxic, relying on
hypoxia for their respiratory drive. They typically have COPD and carbon dioxide retention
with signs of heart failure.
Remember that crucial diagnostic clues will be provided by simply listening during the process
of inspection and palpation (without using a stethoscope). For instance, if a patient sounds
hoarse, congested, wheezy, or is coughing, this can give insight into the diagnosis in many
cases. Palpation will then confirm what has already been found through careful visual
inspection. Lymphadenopathy can indicate a respiratory tract infection, and decreased chest
expansion is a sign of chronic underlying lung disease. Take the time to go through this entire
process on every patient during your examination.
Transcript
Disorders of the respiratory system with a chief complaint of shortness of breath are among the
most common reasons for both outpatient and inpatient evaluation.
The air we breathe in travels through our trachea into our lungs through the bronchi. Inside the
lungs, it passes through the bronchioles to ultimately enter the specialized air sacs called
alveoli. The alveoli are surrounded by blood capillaries, which allow diffusion of inhaled
oxygen into our blood stream and facilitate excretion of carbon dioxide; thus maintaining our
system's homeostasis.
Dysfunctioning of lungs, which occurs in diseases like asthma, emphysema or chronic

obstructive pulmonary disorder, commonly known as COPD, can be diagnosed with the help
of a simple respiratory exam. This assessment involves inspection, palpation, percussion and
auscultation. This presentation will focus on the inspection and palpation aspect only; the rest
will be covered in another video of this collection.
First, let's briefly review what to look for during inspection and palpation of the respiratory
system. Unlike pathology in other body systems, many pulmonary disorders can be diagnosed

by careful inspection alone. For example, simply by checking the respiration rate, one can
diagnose respiratory distress. Similarly, observing the muscles used in respiration can also
provide some insight. Normal or quiet breathing is accomplished just by the use of diaphragm
and external intercostal muscles, while forced expiration involves the internal intercostal and
abdominal muscles. Other than these primary muscles, there are accessory muscles for
inspiration, such as scalene, sternocleidomastoid, pectoralis minor and trapezius. A constant
use of these muscles, which can be observed during inspection, indicates difficulty in breathing.
Another parameter that can be inspected is the chest's anteroposterior diameter, which is
normally smaller than its lateral diameter. Therefore, a "barrel" chest, which is indicated by
bulging chest with an abnormal increase in anteroposterior diameter, is indicative of conditions
such as COPD and emphysema. Some chest deformities like pectus excavatum signified by
sunken or caved-in chest, or pectus carinatum, which refers to a protruding or "pigeon" chest,
are due to congenital defects. By inspection, one can also detect kyphoscoliosis, which is an
outward and lateral curvature of the spine; this can severely impair respiration.
Coming to palpation, palpating the lateral borders of the trachea via the sternal notch helps in
determining if the trachea is in normal, midline position or not, as a deviated trachea can
indicate lung pathology. Other major areas of palpation include all of the head, neck and
axillary lymph nodes. Lymphadenopathy, which is abnormal number or size of lymph nodes,
can indicate a respiratory tract infection.
Taken together, careful inspection and palpation can provide great deal of information
regarding the physiology and pathophysiology of a patient's respiratory system.
After reviewing what to look for during a respiratory exam, let's walk through the detailed steps
of general observations and inspection. Before every examination, wash your hands thoroughly
with soap and warm water. Enter the room, where the patient is already seated. Introduce
yourself and briefly explain the exam you are going to perform. Make sure that the patient is
undressed down to their waist. Females should keep their underwear on and expose one
hemithorax at a time as requested. Position the patient on the examination table at a 30-45°
angle and approach them from their right side.

First, note the signs of obvious respiratory distress. These include: hoarse voice, fast respiratory
rate, unusual posturing to maximize air entry like tripoding, breathing using accessory muscles,
inward movement of intercostal muscles, coughing with sputum, wheezing, and cyanosis.
Next, ask the patient to stretch out their arms and extend the wrists. Inspect for the presence of
tremor and also note if nicotine staining of nails is present. Ask the patient to put their two
thumbnails side by side. Note if a diamond-shape is formed on the inside. If clubbing is present,
this doesn't happen, and it can be a sign of pulmonary fibrosis, cystic fibrosis, or bronchogenic
carcinoma.
Examine the skin on the anterior tibial surface for erythema nodosum, which is inflammation
of the skin, or panniculitis that typically causes painful red nodular areas. Inspect the patient's
face for obvious facial flushing, and for the signs of Horner's syndrome, which includes the
triad of miosis, ptosis, and hemifacial anhidrosis-that is decreased sweating on one side of the
face. Ask the patient to tilt their head upwards and look into each nostril with the help of a
flashlight. This is to inspect for nasal polyps or evidence of epistaxis. Next, instruct the patient
to open their mouth and stick out their tongue. The color of the tongue should be noted-pink or
red represent normal, while bluish discoloration suggests central cyanosis. Then, ask the patient
to phonate by saying, "Ahhhhh", and using a tongue depressor, inspect the throat for
pharyngitis or tonsillar inflammation.
After this, move to the chest region and inspect the chest wall for scars that would be an
evidence of a prior thoracotomy. Also inspect the chest shape and look for any visible
deformities.
Now, let's review the palpation steps of the respiratory physical exam. Start with palpating the
radial pulse. A bounding or abnormally strong pulse can be a sign of carbon dioxide retention.
Next, assess for lymphadenopathy in the cervical region. Palpate the nodes with on both sides
simultaneously. Start at the preauricular glands followed by jugulodigastric, submandibular,
submental, anterior cervical, supraclavicular, posterior cervical, posterior auricular, and
occipital lymph nodes. Assess for axillary lymphadenopathy by holding the patient's arm near
the elbow with one hand and palpating in the axilla with your other hand. Next, feel the trachea
by placing the right index finger in the sternal notch. Palpate the lateral borders of the windpipe
to determine if it is in the normal, midline position.

Following that, palpate the chest wall by using the palm of your hand to assess for any obvious
point tenderness, masses, or rib deformities. Perform the palpation at four to five different
levels anteriorly and posteriorly, and any differences between the right and left sides can
indicate abnormal underlying lung tissue. Next, assess chest expansion, place your hands just
below the level of the nipples, with thumbs touching in the midline and fingers extended to
make contact with the lateral edges. Ask the patient to take a deep breath. The thumbs should
separate by approximately 5 cm or more in normal chest expansion. This technique can be also
utilized posteriorly.
Lastly, to assess tactile vocal fremitus, place the hypothenar sides of your hands at the lower
anterior part of the chest. Then ask the patient to say "99" every time you change the position.
The vibration felt against your hand should be the same for each position on both sides. Same
test can be performed on the posterior surface.
You've just watched JoVE's video on inspection and palpation during a respiratory exam.
Severe pulmonary illnesses will sometimes be apparent from simply glancing at the patient.
Gaining important clues related to smoking and other exposure history could further aid in the
diagnosis of specific lung disease. In addition, careful inspection and palpation can help detect
disorders that are not apparent and therefore one should take the time to go through this entire
process on every patient with a respiratory complaint. As always, thanks for watching!

RESPIRATORY EXAM II: PERCUSSION AND AUSCULTATION
Overview
Medical Center
Learning the proper technique for percussion and auscultation of the respiratory system is vital
and comes with practice on real patients. Percussion is a useful skill that is often skipped during
everyday clinical practice, but if performed correctly, it can help the physician to identify
underlying lung pathology. Auscultation can provide an almost immediate diagnosis for a
number of acute pulmonary conditions, including chronic obstructive pulmonary disease
(COPD), asthma, pneumonia, and pneumothorax.
The areas for auscultating the lungs correspond to the lung zones. Each lung lobe can be
pictured underneath the chest wall during percussion and auscultation (Figure 1). The right
lung has three lobes: the superior, middle, and inferior lobes. The left lung has two lobes: the
superior and inferior lobes. The superior lobe of the left lung also has a separate projection
known as the lingual.
Figure 1. Anatomy of lungs with respect to the chest wall. An approximate projection of

lungs and their fissures and lobes to the chest wall anteriorly. RUL - right upper lobe; RML -
right middle lobe; RLL - right lower lobe; LUL - left upper lobe; LLL - left lower lobe.
Procedure
1. Positioning
1. Make sure the patient is undressed down to the waist.

2. Position the patient on the examination table at a 30- to 45-degree angle and approach
from the right side. Examining the posterior of the lung requires the patient to be leaning
forward or sitting on the edge of the bed.
2. Percussion
1. Percuss both posteriorly and anteriorly, starting on the back.

2. Place non-dominant hand with middle finger (pleximeter finger) pressed and
hyperextended firmly on the patient's right or left mid-back area (lower levels of lungs
posteriorly). The firmer the finger is pressed to the chest wall, the louder the percussion
note tends to be.
3. Make sure the other fingers and palm are not pressed against the patient's chest.
4. Use the tip of the middle finger (plexor finger) of the dominant hand to tap firmly on
the top third (middle or distal phalanx) of the pleximeter finger of the non-dominant
hand at least twice (it is advisable to keep fingernails short). The sound should be
hollow, representing an air-filled lung.
5. Repeat the percussion at four and five levels, comparing each lung level side by side,
working up to the chest wall, starting at the inferior lung borders. On expiration, the
lower border of the lungs is at the level of the sixth rib at the midclavicular line and the
eighth rib at the midaxiallary line anteriorly, approximately at the level of the T10
spinous process posteriorly.
6. Percuss anteriorly and posteriorly, placing the finger on the chest in the intercostal
spaces.
7. Appreciate the quality of percussion sounds. The normal findings on the chest
percussion are:
1. Resonant percussion note: heard over a normal air-filled lung.

2. Dull percussion note (the sound heard over solid tissues): over the liver in the
right lower anterior chest and over the heart in the left anterior chest. When
percussion of the lungs elicits this sound, it is indicative of consolidation.
3. Tympanic percussion note (a drum-like sound when percussing over hollow
organs): over the Traube's space, an area overlying the gastric bubble and
bordered by the sixth rib, anterior axillary line, and left costal margin. Left
pleural effusion produces a dull percussion sound over Traube's space.
8. Note the presence of pathological percussion sounds. A "stony dull" or flat percussion
note sounds duller than the "standard" dull sound. It resembles the percussion note
heard over the thigh and is indicative of a pleural effusion. A hyper-resonant percussion
note is a pathological percussion sound indicative of hyper-inflated lungs from
advanced COPD, emphysema, or a pneumothorax.
3. Auscultation
1. Position the patient: ask the patient to lean forward or sit upright in order to examine
posteriorly. Asking the patient to fold arms or place hands on opposing shoulders also
helps to get maximal exposure to the lung fields.
2. Place the diaphragm of the stethoscope on the patient's chest, and ask the patient to take
deep breaths in and out through the mouth.
3. Auscultate at five levels posteriorly and anteriorly, comparing side by side.
4. Normal breath sounds are called vesicular breath sounds, which are low-pitched sounds
louder on inspiration and softer on expiration. They should be symmetrical posteriorly.
5. Note the presence and location of abnormal (adventitious) extra breath sounds, such as
crackles, wheezing, rhonchi, stridor, or pleural friction rub (Table 1).
6. Note the following characteristics of any abnormal breath sounds (if present): loudness,
quality, duration, and whether they occur during inspiration or expiration (i.e., timing
in the respiratory cycle). Many abnormal breath sounds are best heard after asking the
patient to cough.
7. Assess for bronchophony, an increased sound transmission over the consolidated lung,
when asking the patient to say "99" or "1-2-1." Egophony is when an "E" sound changes
to an "A" over consolidated lung.

8. Assess for whispering pectoriloquy. While auscultating with the stethoscope, ask the
patient to whisper "99" or "1-2-1." In the consolidated lung, the sound will actually be
heard better and more clearly with the stethoscope.
Breath sounds Description
Harsh or hollow breath sounds, similar to what you would hear if you
Bronchial placed your stethoscope over the trachea or main bronchi. In other areas
they can be a sign of underlying consolidation
Bronchovesicular Normal over the large airways and sternum, abnormal in other areas
Caused by fluid in the airways and are more commonly heard during
inspiration at the bases of the lungs. They can be classified as fine; which
Crackles or are soft, brief high-pitched sounds or "pops", or coarse; which are louder
Crepitations or and lower pitched than fine crackles. Fine crackles can be heard in
Rales pulmonary fibrosis and course crackles in COPD and pneumonia. Note
the timing of the crackles. Congestive heart failure typically produces
late crackles
Wheeze Distinctive high-pitched continuous sound heard in asthma and COPD
Low-pitched "snoring" sound that can be auscultated in any condition

Rhonchi causing reactive airways disease, including pneumonia, COPD, and
CHF
An abnormal high-pitched sound generated from the upper airways,

Stridor
usually during inspiration (this is often a medical emergency)

Caused by pleural surfaces rubbing against each other (pleural friction
Rub rub), and heard more in pleurisy as well as other conditions, such as
pericarditis
Table 1. A table summarizing potential findings during auscultation of the lungs.
Percussion and auscultation should always be done in sequence whenever performing a full
respiratory examination. Learning how to percuss correctly takes time and practice (practice
can be done on yourself or other surfaces, such as a table). Note how the percussion note
changes naturally over air-filled lung, ribs, and solid organs, such as the heart.
Auscultation must be performed over each lung zone to give the physician the best chance of
identifying the focus of any lung pathology. Abnormal breath sounds should be easily
recognizable when occurring in a patient. Allow enough time to classify the breath sounds.
Listen for several breathing cycles in one area, if necessary, to hear the exact nature of the
crackles, wheezes, rhonchi, or other pathological findings. Distinguishing between certain
breath sounds can occasionally seem subjective, but will become easier with practice, leading
to a "spot diagnosis" for many pulmonary conditions.
Transcript
Learning the proper technique for percussion and auscultation of the respiratory system is vital
for the bedside diagnosis of lung disorders. Percussion is a simple yet useful skill, which, if
performed correctly, can help the physician identify the underlying lung pathology. On the
other hand, auscultation can provide an almost immediate diagnosis for a number of pulmonary
conditions including chronic obstructive pulmonary disease, asthma, pneumonia, and
pneumothorax.
In another video, we covered how to perform inspection and palpation of the respiratory
system. This video will focus on the percussion and auscultation steps of this exam.

Before going into the details of the clinical exam, let's review the lung lobes and breath sounds.
This will help us better understand the anatomical locations and results of percussion and
auscultation.
The areas for percussion and auscultation of lungs correspond to the lung lobes and each lung
lobe can be pictured underneath the chest wall. The right lung, which is the larger of the two,
has three lobes-superior, middle, and inferior. The horizontal fissure separates the superior
from the middle lobe, whereas the right oblique fissure separates the middle from the inferior.
The left lung only has two lobes- superior and inferior-separated by the left oblique fissure.
Since lungs are mostly filled with air that we breathe in, percussion performed over most of
the lung area produces a resonant sound, which is a low pitched, hollow sound. Therefore, any
dullness or hyper-resonance is indicative of lung pathology, such as pleural effusion or
pneumothorax, respectively.
Breath sounds heard through the stethoscope during auscultation are peculiar as well. The two
sounds heard during normal breathing are bronchial and vesicular. Bronchial sound, which is
more tubular and hollow, is heard over the large airways in the anterior chest. Whereas,
vesicular sound, which is soft, low-pitched and rustling, can be heard over most of the lung
tissue area. Abnormal breath sounds include crackles also known as rales,which are indicative
of fluid in small airways. On the other hand, wheezes or rhonchi suggest airway constriction
or swelling, which causes partial airway obstruction. Pleural rubs occur when inflamed pleural
surfaces slide against one another during respiration, and lastly stridor is caused by obstruction
of the upper airway.
With this knowledge of where and what to look for during respiratory percussion and
auscultation, let's discuss the procedural steps starting with percussion. Ask the patient to sit
straight or lean forward. Start with the percussion of the posterior surface. Place your non-
dominant hand with middle finger pressed and hyperextended firmly over the patient's mid-
back area. Use the tip of the middle finger of the dominant hand to tap firmly on the top third
phalanx of the middle finger of the pressing hand at least twice. Repeat this at four to five
levels, comparing side-to-side.
Perform the same procedure on the anterior chest wall, working from the inferior lung borders.
Both anteriorly and posteriorly, make sure the middle finger of the pressing hand is placed in

the intercostal spaces and not on the ribs. Appreciate the percussion sound quality. Tapping
over normal air-filled lung should produce a resonant percussion note. On the contrary
percussion over solid tissues such as the liver or the heart should produce a dull note. And
percussion over hollow spaces, like the Traube's space should yield a Tympanic note, which is
a drum-like sound.
Lastly, let's move to auscultation, which is listening to breath sounds using a stethoscope. To
start, instruct the patient to lean forward or sit upright in order to examine posteriorly. Request
the patient to place their hands on opposing shoulders to get maximum exposure to the lung
fields. Place the diaphragm on the patient's mid-back area and ask them to take deep breaths in
and out through their mouth. Auscultate at five levels posteriorly, and then repeat the same
procedure anteriorly, comparing side-to-side. Normal breath sounds should be symmetrical
both posteriorly and anteriorly; any deviation is a possible indicator of a lung disease.
The last three steps of auscultation are tests aiming to identify lung consolidation. First of these
tests is to assess for bronchophony. Ask the patient to say "99", while auscultating the chest
area. An increased sound transmission indicates a consolidated lung. Second is to assess for
egophony. Ask the patient to say "E". When an "E" sound changes to an "A" through the
stethoscope, it is an indication of a consolidated lung. Lastly, assess for whispering
pectoriloquy. Ask the patient to whisper "99". In case of a consolidated lung, the sound will
actually be heard better and more clearly through the stethoscope. All these steps should also
be performed posteriorly at different locations in order to cover the entire lung area. At the end
of the examination, thank the patient and have them change back.
You've just watched JoVE's video on percussion and auscultation for respiratory evaluation.
Distinguishing between sounds heard during this portion of the exam can occasionally seem
subjective, but the assessment becomes clearer and easier with practice, leading to a "spot
diagnosis" for many pulmonary conditions. As always, thanks for watching!

CARDIAC EXAM I: INSPECTION AND PALPATION
Overview
Medical Center
The cardiac assessment is one of the core examinations performed by almost every physician
whenever encountering a patient. Disorders of the cardiac system are among the most common
reasons for hospital admission, with conditions ranging from myocardial infarction to
congestive heart failure. Learning a complete and thorough cardiac examination is therefore
crucial for any practicing physician.
If there is pathology in the heart or circulatory system, the consequences can also be manifested
in other bodily areas, including the lungs, abdomen, and legs. Many physicians instinctively
reach straight for their stethoscopes when performing cardiac exams. However, a large amount
of information is gained before auscultation by going through the correct sequence of
examination, starting with inspection and palpation.
Procedure
1. Introduction
1. As always, before examining any patient, wash hands thoroughly with soap and water
or clean them with antibacterial wash.
2. Enter the examination room and introduce yourself to the patient, explaining that you
are going to perform a cardiac examination.
2. Positioning
1. Have the patient undress down to the waist (females keeping on their underwear).
2. Position the patient on the examination table at a 30- to 45-degree angle, and approach
the patient from the right side.
3. Have a general look at the patient first. Note whether the patient is comfortable or in
any distress.

3. Peripheral examination
1. Ask the patient to hold his/her hands up and assess for the following:
1. Capillary refill: Press on the patient's thumbnail with your first finger while
holding the other side of the patient's finger with your thumb. The skin under
the nail will blanch (turn a white color). Measure the amount of time it takes to
turn back to red. This should be less than 2 sec, which indicates good peripheral
circulation.
2. Clubbing, which is defined as a decrease in angle between the nail and nail bed.
Clubbing can be a sign of right-to-left shunt disease or bacterial endocarditis
(infection of the heart valves): Ask the patient to put both thumbnails side-by-
side. Note if a diamond-shape is formed on the inside. If clubbing is present,
this doesn't happen.
3. Signs of bacterial endocarditis: splinter hemorrhages (tiny red hemorrhages
under the nails), Osler's nodes (painful red papules often found on the ends of
the fingers), Janeway lesions (painless red macules often found on the palms).
2. Palpate the radial pulse with the index and middle finger, and assess for the rate per
minute, rhythm regularity, volume, and character. Low volume or faint pulses are a sign
of a low flow state such as sepsis. An abnormally strong "bounding" pulse can be found
in conditions such as anemia and congestive heart failure.
3. Examine the skin on the arms for xanthoma deposits, which may be observed near the
elbows and can be a sign of hyperlipidemia.
4. Inspect the patient's head for any signs of cardiac disease:
1. de Musset's sign: a "bobbing" head movement associated with aortic
regurgitation.
2. Malar flush: a flushing or red facial appearance indicative of mitral stenosis.
3. Inspect the cornea for corneal arcus, a gray-white discoloration around the
cornea that is a sign of hyperlipidemia.
4. Inspect the skin around the eyes for yellow cholesterol deposits known as
xanthelasma.
5. Inspect the fundus for retinopathy (which often occurs with cardiovascular
disease and diabetes) and Roth's spots (pale-centered retinal hemorrhages that
occur with bacterial endocarditis).

6. Ask the patient to open mouth and stick out tongue. The color of the tongue
should be pink/red. If it is a bluish discoloration, this is a sign of central
cyanosis.
5. Palpate the carotid pulse gently with your first two fingers, and assess the volume and
character of the pulse. A slow rising pulse is a sign of aortic stenosis.
6. The jugular venous pressure (JVP) is nature's manometer of right atrial pressure and is
elevated in congestive heart failure.
1. To measure the JVP, ask the patient to turn the head to the left while the patient
is positioned at 45 degrees.
2. Observe for a double pulsation from the right internal jugular vein between the
two heads of sternocleidomastoid (the sternal head and the clavicular head). The
carotid pulse that sometimes can be seen in thin patients has a single pulsation
and is palpable, while the jugular vein pulsation is not.
3. Locate the angle of Louis (manubriosternal joint), which is positioned about 5
cm above the center of the right atrium.
4. Extend a long rectangular object (such as a paper card) horizontally from the
highest point at which the internal jugular vein pulsation can be seen.
5. Using a vertically positioned ruler measure the distance from the angle of Louis
to the card and calculate the JVP by adding 5 cm (the distance from the angle
of Louis to the right atrium) to that number.
6. Another way to visualize the internal jugular vein is to press gently in the right
upper quadrant of the abdomen, just below the costal margin. This maneuver
induces so-called hepatojugular reflux (blood shift from abdominal vessels into
the right atrium). Normally, a transient increase in JVP can be observed before
a decrease. Sustained increase in JVP is seen in congestive heart failure and
other conditions, such as tricuspid regurgitation and constrictive pericarditis.
4. Chest inspection
1. Inspect the patient's chest anteriorly and posteriorly for any visible scars. Look for any
evidence of a median sternotomy scar (a sign of coronary artery bypass surgery or aortic
valve surgery). A more lateral scar below the left nipple would be indicative of prior
mitral valve surgery.

5. Palpation
1. The apex beat, also known as the point of maximal impulse (PMI), corresponds to the
lower left heart border. It is the most inferior and lateral position that the cardiac
impulse can be felt.
1. Locate the PMI in the fifth intercostal space in the mid-clavicular line by
counting down from the second intercostal space adjacent to the angle of Louis.
2. Palpate with your first two fingers.
3. If this cannot be palpated, ask the patient to lie on his/her left side. The apex
beat will be displaced laterally if the heart is enlarged (cardiomegaly).
2. Next, palpate for heaves and thrills (a thrill is a palpable murmur).
1. Place the palm of your hand in each of the four heart zones in the precordium
and then on the upper left and right chest wall. A thrill feels like a vibration or
buzzing underneath your hand.
2. Place your hand at the left sternal edge. A parasternal heave is a sign of right
ventricular enlargement and feels like a "lifting feeling" under your hand.
6. Percussion of heart
1. Unlike many other examinations, percussion is rarely employed for the cardiac system;
however, a few generations ago, physicians would use percussion of the borders of the
heart to assess for cardiomegaly.
7. Other inspection and palpation
1. Palpate for an abdominal aneurysm in the midline of the abdomen using both hands
placed parallel with each other.
2. Look at the legs and assess for any signs of edema.
3. Feel the peripheral pulses at the femoral, popliteal, anterior tibial, and dorsalis pedis
locations.
A significant amount of clinical information is to be gained with a thorough comprehensive

inspection and palpation of the cardiac system. The examiner should be able to tell whether a
patient has a number of likely conditions, including atrial fibrillation, valvular heart disease,

cardiomegaly, hyperlipidemia, and bacterial endocarditis. Unfortunately, during everyday
clinical practice, these steps are often abbreviated or skipped. By learning the full examination
technique, medical professionals gain a solid foundation on which to build their clinical skills,
as they see more cardiac pathology. Going through a stepwise fashion of the cardiovascular
system can lead physicians to diagnoses even before placing their stethoscopes on patients.
Transcript
The cardiac assessment is one of the core physical examinations performed by every physician
whenever they encounter a patient. Proper functioning of the cardiac system is vital for living,
and disorders associated with it are among the most common reasons for hospital admissions
across the globe. Therefore, learning how to perform a complete and thorough cardiac
examination is crucial for any practicing clinician.
Many physicians instinctively reach straight for their stethoscope when performing a cardiac
exam. However, a lot of information can be gained before auscultation by conducting thorough
inspection and palpation. This video will review these two aspects of the cardiac exam in
detail.
Let's go over the sequence of inspection and palpation steps for the cardiac system evaluation
along with the expected findings. Before the exam, wash your hands thoroughly. Upon entering
the room, introduce yourself to the patient and briefly explain the procedure you will perform.
Have the patient undress down to their waist. Instruct them to lie down on the exam table
positioned at a 30-45° angle, and approach the patient from their right side.
Start by inspecting the periphery. Ask the patient to hold one hand up, press on the thumbnail
and watch the nail bed blanch. Then, release the pressure and estimate the time it takes to turn
back to red. This is the capillary refill time, which serves as an indicator of peripheral
circulation. Following the capillary refill test, instruct the patient to put their thumbnails side
by side to check for nail clubbing. Note that a diamond-shape aperture is formed, which means
clubbing is absent. If no aperture is formed, then it may suggest presence of chronic hypoxia
conditions such as right-to-left shunt disease or bacterial endocarditis. To examine for other
signs of bacterial endocarditis, inspect for red hemorrhages under the nails, referred to as the
splinter hemorrhages. Then, look for the Osler's nodes, which are painful red papules on the
finger ends. Also check if you can see the Janeway lesions, which are painless red macules on

the palms. Moving to the wrist, palpate the radial pulse with the index and middle finger, and
evaluate the pulse rate, rhythm regularity, pulse volume, and character. Next, inspect the skin
on the arms, especially near the elbows, and look for yellowish deposits known as the xanthoma
deposits, which is a sign of hyperlipidemia.
After examining the periphery, inspect the patient's head for the de Musset's sign, which is
represented by rhythmic head nodding in synchrony with the heartbeats. This is associated with
aortic regurgitation. Check the patient's face for Malar flush, which is a red facial appearance
indicative of mitral stenosis. Next, inspect the skin around the eyes for yellow cholesterol
deposits known as xanthelasma. Then examine the corneas for corneal arcus-a gray-white
discoloration indicative of hyperlipidemia. To finish the facial inspection, ask the patient to
open their mouth and stick out their tongue. Note the color to check for cyanosis.
Proceed to the neck region. First palpate the carotid arteries, which are right next to the trachea
and can be felt about 2 cm below the angle of the mandible. Gently press at this spot with your
first two fingers, and assess the pulse volume and character. Subsequently, measure the jugular
venous pressure or JVP. To do that, you'll need to locate the right internal jugular vein and the
Angle of Louis, which is the anterior angle formed at the manubriosternal joint. The internal
jugular veins run between the two heads-sternal and clavicular- of the sternocleidomastoid
muscle, which form a triangle with the clavicle at the bottom edge. In order to locate this vein,
ask the patient to turn their head to the left. Observe for a double pulsation, which is produced
by the right internal jugular vein. Next, locate the Angle of Louis by palpation, which is
approximately 5 cm above the center of the right atrium and next to the second intercostal
space. After locating the angle of Louis, extend a long rectangular object, such as a paper card,
horizontally from the highest point at which the internal jugular vein pulsation can be seen, and
then using a ruler measure the distance in cm from the angle of Louis to the paper card. The
measured distance plus 5 equals JVP, which is normally 6 to 8.
Following JVP measurement, inspect the patient's chest anteriorly and posteriorly for any
visible scars indicative of prior heart surgeries. Next step is to locate the point of maximal
impulse or PMI. Using the Angle of Louis as the reference point, count down to the 5th
intercostal space to palpate the PMI in the mid-clavicular line. If this cannot be palpated in
seated position, request the patient to lie on their left side and then palpate. Note that the apex
beat will be displaced laterally in cases of cardiomegaly. Next, use your palm to palpate the

four heart zones in the precordium, and the upper left and right chest wall. Note any vibrations
or buzzing underneath your hand, which could indicate thrills. To complete chest palpation,
place your hand at the left sternal edge. If you experience a "lifting feeling" under your hand,
it indicates a parasternal heave, which is a sign of right ventricular enlargement.
Moving down from the chest, palpate the abdomen for an aneurysm in the midline using both
hands placed parallel with each other. Next, inspect and palpate the legs for any signs of edema.
Finally, feel the peripheral pulses at the femoral, popliteal, posterior tibial, and dorsalis pedis
locations. This concludes the inspection and palpation aspect of the cardiac exam.
You've just watched JoVE's video on inspection and palpation of the cardiac system. A
significant amount of clinical information can be gained if a clinician performs all these steps
in a careful, precise and thorough manner. By learning the full examination technique, a
medical professional gains a solid foundation for building clinical skills in order to predict
cardiac pathology in advance. As always, thanks for watching!

CARDIAC EXAM II: AUSCULTATION
Overview
Medical Center
Proficiency in the use of a stethoscope to listen to heart sounds and the ability to differentiate
between normal and abnormal heart sounds are essential skills for any physician. Correct
placement of the stethoscope on the chest corresponds to the sound of cardiac valves closing.
The heart has two main sounds: S1 and S2. The first heart sound (S1) occurs as the mitral and
tricuspid valves (atrioventricular valves) close after blood enters the ventricles. This represents
the start of systole. The second heart sound (S2) occurs when the aortic and pulmonary valves
(semilunar valves) close after blood has left the ventricles to enter the systemic and pulmonary
circulation systems at the end of systole. Traditionally, the sounds are known as a "lub-dub."
Auscultation of the heart is performed using both diaphragm and bell parts of the stethoscope
chest piece. The diaphragm is most commonly used and is best for high-frequency sounds (such
as S1 and S2) and murmurs of mitral regurgitation and aortic stenosis. The diaphragm should
be pressed firmly against the chest wall. The bell best transmits low-frequency sounds (such as
S3 and S4) and the murmur of mitral stenosis. The bell should be applied with a light pressure.
Procedure
1. Position the patient at 30-45 degrees.
2. Make sure the area being examined is exposed, and never auscultate through the gown.
3. Place the stethoscope in the defined anatomical landmarks (Figure 1). A good rule of thumb
to find the second intercostal space is to locate the angle of Louis (manubriosternal joint),
which is at this level. Palpate across and down with your fingers to locate the other intercostal
spaces described.

Figure 1. Auscultation surface landmarks.
1. Aortic area
1. Place the diaphragm of the stethoscope at the 2nd intercostal space, right sternal
edge. This is the anatomical landmark for the aortic valve.
2. Listen for at least 5 sec for the second heart sound, which represents the aortic
valve closing.
2. Pulmonic area
1. Place the diaphragm of the stethoscope at the 2nd intercostal space, left sternal
edge. This is the anatomical landmark for the pulmonary valve.
2. Listen for at least 5 sec for the second heart sound, which represents the
pulmonary valve closing.
3. Tricuspid area
1. Place the diaphragm of the stethoscope at the 4th - 5th intercostal space, left
sternal edge. This is the anatomical landmark for the tricuspid valve.
2. Listen for at least 5 sec for the first heart sound, which represents the tricuspid
valve closing.

4. Mitral area
1. Place the diaphragm of the stethoscope at the 5th intercostal space, mid-
clavicular line (same area as the apex beat). This is the anatomical landmark for
the mitral valve.
2. Listen for at least 5 sec for the first heart sound, which represents the mitral
valve closing.
4. Other auscultation areas:
Auscultation of the lungs and major arteries also provides essential information of the function
of the cardiovascular system.
1. Auscultate with the diaphragm of the stethoscope at the bases of the lungs. Listen for
any crepitations or crackles, which indicate fluid in the lungs (pulmonary edema), a
sign of heart failure.
2. Auscultate with the bell of the stethoscope at the carotid arteries. Frequently, a murmur
that is present from the aortic valve may be heard. Also, auscultate here for a bruit (a
swishing sound produced by turbulent blood flow), which is a sign of carotid artery
stenosis.
3. Auscultate for abdominal bruits at the renal arteries and femoral arteries to assess for
peripheral vascular disease.
Auscultation of the heart remains one of the fundamental skills for any clinician to master, and
it provides vital diagnostic clues to many cardiac abnormalities. Learning the correct technique
for auscultation is essential in order to distinguish the normal from the pathological. All cardiac
areas must be auscultated in a structured and methodical fashion. The physical findings should
be interpreted with respect to the cardiac cycle, and the intensity, duration, pitch, and timing of
each sound should be noted. It is essential to memorize the anatomical landmarks where the
stethoscope should be placed on the patient's chest, and always examine the patient in a quiet
environment. It is important to listen for at least 5 sec, while the patient is breathing normally,
to avoid one of the common mistakes made during the physical exam - not allowing adequate
time to listen to the heart sounds. Physicians must be familiar with their stethoscopes and
engage both the diaphragm and the bell during the heart auscultation.

Transcript
Proficiency in the use of a stethoscope to listen to heart sounds and the ability to differentiate
between normal and abnormal heart sounds are essential skills for any physician.
The heart has two main sounds, S1 and S2. The first sound - S1- occurs as the mitral and
tricuspid valves close, after blood enters the ventricles. This represents the start of a systole.
The second heart sound - S2 - occurs when the aortic and pulmonary valves close, after blood
has left the ventricles to enter the systemic and pulmonary circulation systems at the end of a
systole. Together, they sound as "lub-dub"… "lub-dub".
In this video, we'll first review the surface landmarks for auscultation, and then we'll go through
the essential steps for this exam. The discussion related to the abnormal heart sounds such as
murmurs and gallops will be covered in a separate video of this collection.
Let's begin by reviewing the surface landmarks for auscultation. As discussed,
The aortic area corresponding to the aortic valve is along right sternal edge of the 2nd
intercostal space, abbreviated as the 2nd ICS. Similarly, at the left sternal edge of the same ICS
is the pulmonic area associated with the pulmonic valve. Travelling down the left sternal edge,
in the 4th or 5th ICS is the tricuspid area corresponding to the tricuspid valve. And in the 5th
ICS along the mid-clavicular line is the mitral area linked to the mitral valve.
Now that you're familiar with the landmarks, let's review the sequence of steps for this exam.
Before starting the procedure wash your hands thoroughly and make sure that the stethoscope
has been cleaned with a disinfectant wipe.
First, familiarize yourself with the stethoscope chest piece. The auscultation of the heart is
performed using both - the diaphragm and the bell. The diaphragm is best for high frequency
sounds, such as S1 and S2. The bell best transmits low frequency sounds, such as S3 and S4.
Begin by ensuring that the area to be examined is exposed, and request the patient to lie down
at a 30-45° degree angle on the exam table. Before placing the stethoscope, a good rule of
thumb is to locate the 2nd ICS by palpating for the Angle of Louis, which is at the level of the
2nd ICS. Next, place the diaphragm at the right sternal edge of this ICS, which is the aortic

area. Listen at each auscultation spot for at least 5 seconds to ensure that you're not missing
any subtle sounds. In addition, throughout the exam ask the patient to breathe in and out,
because in presence of an abnormal sound, the timing in the respiratory cycle can provide a
vital diagnostic clue. While auscultating the aortic area, listen for S2, which represents the
aortic valve closing. Next, move to the pulmonic area, which is on the left sternal edge of the
2nd ICS. Here, again you can clearly distinguish the second heart sound, which represents the
pulmonic valve closure. Subsequently, using the diaphragm, auscultate the tricuspid area at the
4th or 5th ICS on the left sternal edge. Here, listen for the first heart sound due to the tricuspid
valve closing. Lastly, place the diaphragm in the mitral area and listen for S1, which represents
the mitral valve closure.
In addition to the four valve-associated landmarks, auscultation of the lungs and major arteries
can provide essential information regarding the cardiovascular functioning. Using the
diaphragm, auscultate at the base of the lungs to listen for any crepitations or crackles, which
indicate pulmonary edema, a sign of heart failure. Next, with the bell, auscultate the carotid
arteries. Frequently, a murmur that is present from the aortic valve may be heard in this area.
Also, auscultate here for a bruit, which is a swishing sound produced by turbulent blood flow,
a sign of carotid artery stenosis. Finally, to assess for peripheral vascular disease, auscultate
for abdominal bruits at the aorta area, renal arteries, and femoral arteries.
You've just watched JoVE's presentation on cardiac auscultation. The video reviewed
important auscultation landmarks and illustrated how to perform the steps of this exam in a
structured fashion.
Auscultation of the heart remains one of the fundamental skills for any clinician to master, and
it provides vital diagnostic clues to many cardiac abnormalities. Therefore, learning the correct
technique for auscultation is essential in order to be able to distinguish normal from
pathological. As always, thanks for watching!

CARDIAC EXAM III: ABNORMAL HEART SOUNDS
Overview
Medical Center
Having a fundamental understanding of normal heart sounds is the first step toward
distinguishing the normal from the abnormal. Murmurs are sounds that represent turbulent and
abnormal blood flow across a heart valve. They are caused either by stenosis (valve area too
narrow) or regurgitation (backflow of blood across the valve) and are commonly heard as a
"swishing" sound during auscultation. Murmurs are graded from 1 to 6 in intensity (1 being the
softest and 6 the loudest) (Figure 1). The most common cardiac murmurs heard are left-sided
murmurs of the aortic and mitral valves. Right-sided murmurs of the pulmonary and tricuspid
valves are less common. Murmurs are typically heard loudest at the anatomical area that
corresponds with the valvular pathology. Frequently, they also radiate to other areas.
Figure 1. The Levine scale used to grade murmur intensity.
In addition to the two main heart sounds, S1 and S2, which are normally produced by the
closing of heart valves, there are two other abnormal heart sounds, known as S3 and S4. These
are also known as gallops, because of the "galloping" nature of more than two sounds in a row.
S3 is a low-pitched sound heard in early diastole, caused by blood entering the ventricle. S3 is
a sign of advanced heart failure, although it can be normal in some younger patients. S4 is

heard in late diastole and represents ventricular filling due to atrial contraction in the presence
of a stiff ventricle. S4 is also heard in heart failure and left ventricular hypertrophy.
Procedure
1. Murmurs
1. Position the patient at a 30- to 45-degree angle on the examination table.

2. When auscultating a murmur, ask the patient to breathe in and out, as it can provide a
vital diagnostic clue. Right-sided murmurs (pulmonary and tricuspid) are best heard on
inspiration, as blood flows into the right ventricle when intrathoracic pressure
decreases. Conversely, left-sided murmurs are heard best on expiration.
3. Categorize murmurs according to the following criteria: intensity (loudness), pitch
(e.g., high or low, harsh or blowing), configuration (e.g., crescendo-decrescendo),
location, and timing in the cardiac cycle (e.g., early systolic/diastolic).
4. Remember that not all murmurs are abnormal, and that systolic murmurs can be benign
in younger people.
5. Also remember that each murmur is usually loudest at the anatomical area that
corresponds with the valvular pathology.
6. Aortic stenosis: Auscultate with the diaphragm of the stethoscope on the aortic area,
with the patient in supine position. Aortic stenosis is a harsh-sounding ejection systolic
or crescendo-decrescendo murmur that occurs during systole, as the blood passes across
the stenotic aortic valve. This murmur classically radiates to the carotid arteries and can
be heard in the carotid area of the neck.
7. Aortic regurgitation: Auscultate with the diaphragm of the stethoscope at the lower left
sternal border, close to the tricuspid area, with the patient leaning forward. The murmur
of aortic regurgitation is a soft-blowing early diastolic decrescendo murmur. It can be
associated with a number of other physical examination findings (described in step 5
below).
8. Mitral regurgitation: Place the diaphragm of the stethoscope on the mitral area. This
murmur is a blowing pansystolic (or holosystolic) murmur. It classically radiates
toward the axilla. Mitral valve prolapse can also be associated with a "mid-systolic
click" sound.
9. Mitral stenosis: Auscultate with the bell of the stethoscope in the mitral area. It is a low-
frequency rumbling mid-diastolic murmur and can be accentuated by laying the patient

on his/her left side. Mitral stenosis is a very rare murmur that is almost always the result
of prior rheumatic fever.
10. Right-sided murmurs: Remember that murmurs associated with the tricuspid and
pulmonary valves are rare. Pulmonary stenosis, tricuspid regurgitation, and
hypertrophic cardiomyopathy manifest as systolic murmurs. Tricuspid regurgitation
occurs in association with longstanding lung disease, such as emphysema or pulmonary
hypertension. Pulmonary regurgitation and tricuspid stenosis are diastolic murmurs.
Congenital heart disorders, such as patent ductus arteriosus (PDA), can also cause loud
murmurs. In the case of PDA, a continuous "machinery-like" murmur is auscultated.
2. Gallops (S3 and S4)
1. Auscultate for S3 and S4 in the mitral and tricuspid areas with the bell of the
stethoscope pressed lightly on the patient's chest, and the patient lying on his/her left
side.
3. Splitting of heart sounds:
The second heart sound can be "split" when the closure of the aortic and pulmonary valves do
not occur together. The splitting of S2 during inspiration is normal and is known as
physiological splitting (P2 occurs after A2). Fixed splitting can be heard with an atrial septal
defect. If the splitting occurs during expiration, it is known as paradoxical splitting, which
occurs when there is a prolonged left ventricular phase, such as in left bundle branch block or
hypertrophic cardiomyopathy.
1. Ask the patient to breathe in and out, and auscultate over the second intercostal space
at the left sternal edge.
2. Note at which phase of respiratory cycle the splitting occurs.
4. Rubs:
A pericardial friction rub, as seen in pericarditis, resembles a rubbing sound of two surfaces
rubbing or grating against each other.
1. Auscultate at the lower left sternal edge with the patient leaning forward.
5. Note if the following signs of valvular pathology are present:

1. Quincke's pulse: seen in aortic regurgitation, resulting in alternating blanching and
flushing of the nail bed.
2. Corrigan's pulse, also known as Watson's water hammer pulse: a collapsing pulse that
occurs in aortic regurgitation.
3. de Musset's sign: a "bobbing" movement of the head, as seen with aortic regurgitation.
4. Blood pressure: a small gap between the systolic and diastolic blood pressure (narrow
pulse pressure), frequently found in aortic stenosis. A wide pulse pressure is
characteristic of aortic regurgitation.
The ability to recognize and distinguish between the different cardiac murmurs develops with
time and practice. The first step is to identify normal from abnormal. When a murmur is heard,
an examiner should think about the following questions: What part of the cardiac cycle does it
occur in - systolic or diastolic? Where is the murmur loudest? Where does the murmur radiate
to? Is it loudest on inspiration or expiration?
An examiner should make sure the environment is quiet and that there is ample time to hear
the murmur. Loud murmurs are often heard across the precordium, in which case, ascertaining
where it is loudest and where it radiates to is crucial. Whenever a murmur is heard, the clinician
should get into the habit of going through this systematic approach in order to correctly
diagnose the underlying pathology.
Transcript
Having a fundamental understanding of normal and abnormal heart sounds is the first step
toward distinguishing between them. Murmurs and gallops present two broad categories of
abnormal heart sounds. Murmurs are sounds that represent turbulent and abnormal blood flow
across a heart valve. On the other hand, gallops refer to the occurrence of more than two heart
sounds in a row.
In this video, we'll first review the phonocardiograms of, and the mechanism behind different
abnormal heart sounds. Then, we'll discuss the auscultation landmarks and the essential steps
useful for identifying underlying cardiac pathologies

Murmurs are caused either by stenosis, that is valve area narrowing, or due to regurgitation,
which refers to the backflow of blood across a valve. However, not all murmurs are
pathological; systolic murmurs can be benign in younger people.
All murmurs are categorized according to the intensity or loudness, pitch-high or low, harsh or
blowing, configuration-crescendo decrescendo, location, and timing in the cardiac cycle-
systolic or diastolic. The murmur intensity is graded from 1 to 6 on the Levine scale, 1 being
the softest referring to the murmur only audible on listening carefully for some time, and 6
refers to the loudest murmur with a palpable thrill, which is audible with the stethoscope not
touching the chest but lifted just off it.
The most common cardiac murmurs heard are the left-sided murmurs of the aortic and mitral
valves. Aortic stenosis is a harsh-sounding, systolic, crescendo-decrescendo murmur that
sounds like this… This murmur classically radiates to the carotid arteries and can be heard in
the carotid area of the neck. The murmur of aortic regurgitation is a soft-blowing, early
diastolic, decrescendo murmur; take a listen... On the other hand, mitral regurgitation is a
blowing, pansystolic or holosystolic murmur that sounds like this… This murmur usually
radiates towards the axilla. Lastly, mitral stenosis produces a low frequency, rumbling, and
mid-diastolic murmur… The right-sided murmurs, which are related to the tricuspid and
pulmonary valves, are rare. Additionally, hypertrophic cardiomyopathy, which is a genetic
disorder leading to an abnormal thickening of the cardiomuscular wall, produces a systolic,
crescendo-decrescendo murmur… Likewise, Patent Ductus Arteriosus-a congenital heart
disorder in which the ductus arteriosus does not close-induces a continuous machine-like
murmur…
Except murmurs, other atypical heart sounds include gallops S3 and S4. This is the S3
gallop…which is a low-pitched sound, heard in early diastole, caused by blood entering the
ventricle. Whereas S4, which sounds like this…is heard in late diastole, and represents
ventricular filling due to atrial contraction in the presence of a stiff ventricle. S3 is a sign of
advanced heart failure, although it can be normal in some younger patients. And S4 is also
heard in heart failure and in presence of left ventricular hypertrophy.
In addition to murmurs and gallops, splitting of normal heart sounds may occur. Each normal
heart sound-S1 and S2-is composed of two components referring to the closing of the two

valves, which make up that sound. Therefore, S1 is composed of tricuspid T1 and mitral M1
components. Similarly, S2 is composed of aortic A2 and pulmonary P2 elements. It's hard to
distinguish between the sounds produced by individual valves, as they close almost together.
But if the pair of valves is not closing together, then a "split" might appear on auscultation.
S2 split during inspiration that sounds like this…is normal. It is referred to as the
"physiological" split. However, if S2 split occurs during expiration, it called "paradoxical"
split…which occurs when there is a prolonged left ventricular phase, such as in left bundle
branch block or hypertrophic cardiomyopathy. And if the split occurs throughout the
respiratory cycle, then it is known as "fixed" split…which can be heard in case of an atrial
septal defect.
The last abnormal heart sound that we'll discuss is a result of pericarditis, which refers to
inflamed pericardium. The sound is known as the "friction rub", which occurs due to the
rubbing of the inner and outer pericardium layers against each other
Now that we have reviewed the normal and abnormal heart sounds, let's discuss the
auscultation steps essential to distinguish them from one another. Remember, each murmur is
usually heart loudest at the anatomical area that corresponds to the valvular pathology
When auscultating to specifically diagnose a murmur, ask the patient to breathe in and out
deeply, as the murmur timing in the respiratory cycle can provide a vital diagnostic clue. Start
by placing the diaphragm in the aortic area to detect murmur due to aortic stenosis. If present,
auscultate the carotid area as this murmur classically radiates to this neck region. Always listen
for at least 5 seconds to ensure that you're not missing any subtle sounds. To detect murmur
due to aortic regurgitation, request the patient to lean forward. Remind the patient to breath in
and out constantly. Now, using the diaphragm, auscultate at the lower left sternal border, close
to the tricuspid area. This is done to accentuate the murmur of aortic regurgitation. In the same
position, if pericarditis is present, you might encounter sounds due to the friction rub.
Next, request the patient to lie back and using the diaphragm, listen to the sound in the mitral
area to identify mitral regurgitation. If present, move the stethoscope laterally to confirm
radiation to the axilla. In addition, using the bell of the stethoscope, auscultate the mitral area
to check for the presence of mitral stenosis. Subsequently, using the diaphragm auscultate the

pulmonic area. Here, you can clearly distinguish the second heart sound and sometimes you
may hear the S2 split. Note at which phase of respiratory cycle the splitting occurs, as this can
help in classifying the split as physiological, paradoxical or fixed. In addition, you may
encounter the systolic murmur due to pulmonary stenosis or a diastolic one due to pulmonary
regurgitation.
Next, auscultate the tricuspid area. Here, similar to the pulmonic area, you may come across
the murmurs associated with tricuspid regurgitation and stenosis, which are systolic and
diastolic in nature, respectively. Next, instruct the patient to lie on their left side and with the
bell pressed lightly on the patient's chest, auscultate in the mitral and the tricuspid area. In this
position, you might hear the murmur of mitral stenosis, as well as the galloping S3 and S4
sounds.
Additionally, if you suspect hypertrophic cardiomyopathy, then using the diaphragm,

auscultate between the apex and left lower sternal border. If you hear a systolic, crescendo-
decrescendo murmur in this area then you should request the patient to sit straight and perform
the Valsalva maneuver. One of the ways to this is by asking the patient to blow out with mouth
closed. This maneuver is known to accentuate the hypertrophic cardiomyopathy-associated
murmur. Furthermore, if the rare patent ductus arteriosus or PDA is suspected, then auscultate
the upper left chest region to listen for the characteristic continuous machine-like murmur.
You've just watched JoVE's video on cardiac auscultation highlighting the abnormal heart
sounds. In this video, we reviewed the phonocardiograms of commonly encountered abnormal
heart sounds and the pathology behind their occurrence. We also highlighted the important
steps that every physician should perform during cardiac auscultation so that the presence of
abnormal sounds does not go undetected. As always, thanks for watching!

PERIPHERAL VASCULAR EXAM
Overview
Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New
Haven, CT
The prevalence of peripheral vascular disease (PVD) increases with age and is a significant
cause of morbidity in older patients, and peripheral artery disease (PAD) is associated with
cardiovascular and cerebrovascular complications. Diabetes, hyperlipidemia, hypertension,
and tobacco use are important disease risk factors. When patients become symptomatic, they
frequently complain of limb claudication, defined as a cramp-like muscle pain that worsens
with activity and improves with rest. Patients with chronic venous insufficiency (CVI) often
present with lower extremity swelling, pain, skin changes, and ulceration.
While the benefits of screening asymptomatic patients for PVD are unclear, physicians should
know the proper exam technique when the diagnosis of PVD is being considered. This video
reviews the vascular examination of the upper and lower extremities and abdomen. As always,
the examiner should use a systematic method of examination, though in practice, the extent of
the exam a physician performs depends on their suspicion of underlying PVD. In a patient who
has or is suspected to have risk factors for vascular disease, the vascular exam should be
thorough, beginning with inspection, followed by palpation, and then auscultation, and it
should include special maneuvers, such as determining the ankle brachial index. Maneuvers
that make use of a handheld Doppler are demonstrated in a companion video.

Figure 1. The major arm and leg arteries.
Procedure
1. Preparation
1. Wash your hands prior to examining the patient.

2. Have the patient put on a gown. This examination should never occur through clothing.
3. Check the blood pressure in both arms.
2. The Upper Extremities
1. Have the patient lie supine on the exam table, with the head raised to a comfortable
position.
2. Begin with inspection by exposing the entirety of both arms. Note symmetry, color,
hair pattern, size, skin changes, nail changes, varicosities, muscle wasting, and trauma
(Table 1).
3. Palpate by using the back of the fingers to assess skin temperature. Examine from distal
to proximal, comparing one side to the other.

4. Assess capillary refill by applying firm pressure over the distal 1st or 2nd digit for 5
sec. Release pressure and count how many seconds it takes for the normal skin color to
return. A normal capillary refill time (CRT) is less than 2 sec, and values greater than
5 sec increase the likelihood of vascular disease. Additionally, CRT may be prolonged
in hypovolemia and cooler ambient temperatures.
5. Palpate for edema over the dorsum of the hands using firm pressure for at least 2 sec.
If present, palpate proximally, noting the extent and distribution of the edema, and
whether or not it is pitting. Grade the edema as trace, mild, moderate, or severe.
6. Palpate the major arteries and note the symmetry, the intensity, and the regularity of
the pulse. Useful terminology to describe the pulse intensity includes absent,
diminished, normal, or bounding. If unsure, compare the patient's pulse to your own
pulse. Use anatomical landmarks to find the pulse. If no pulse is felt, vary the pressure,
then adjust your position, as there is variability in the path of each artery.
1. Palpate the radial arteries, which lie lateral to the flexor carpi radialis tendon.
2. Palpate the ulnar arteries, which are just lateral to the flexor carpi ulnaris tendon.
3. Palpate the brachial arteries in the antecubital fossa, medial to the biceps tendon.
The artery can be followed proximally in the medial groove between the biceps
and triceps muscles.
3. The Abdomen
1. Lower the head of the table so the patient is lying flat.

2. Inspect the abdomen for dilated veins. Dilated veins around the umbilicus may be due
to portal hypertension or obstruction of the inferior vena cava (IVC).
1. For dilated superficial veins, determine the direction of filling by using a finger
to compress the vein proximally.
2. Use a second finger to strip the blood distally from the vein and then leave the
finger in place, thus compressing two points along the flattened vein.
3. Remove the proximal finger and note the speed at which the vein refills.
4. Repeat the process; however, remove the distal finger and compare the filling
speed. Note the direction of the fast filling, which is away from the source of
venous hypertension.

3. Palpate for the abdominal aorta, just above the umbilicus and slightly left of the midline.
Use 3 to 4 finger pads of both hands to apply slow and steady downward pressure. The
hands should point cephalad and slightly toward each other.
4. Once the pulse is encountered, gradually bring the fingertips closer together until the
lateral walls of the aorta are felt. Measure the distance between the fingers.
5. Next,auscultatefor bruits using the diaphragm of the stethoscope, applying moderate
pressure. A bruit with a systolic and diastolic component is more likely to be pathologic
than a systolic bruit alone.
1. Auscultate the renal arteries above the umbilicus and 1" to 2" lateral to the
midline.
2. Auscultate the abdominal aorta above the umbilicus and to the left of the
midline.
3. Auscultate the iliac arteries below the umbilicus and 1" to 2" lateral to the
midline.
4. The Lower Extremities.
1. Begin with inspection by exposing the entirety of both legs, but leave the genitalia
covered. Look for changes as described in Step 2.2 and Table 1.
2. Palpate for temperature, CRT, edema, and arteries, as described in Step 2.3.
3. Palpate the dorsalis pedis (DP) arteries, just lateral to the extensor hallucis longus
tendon. One or both DP arteries may be congenitally absent in a small percentage of
patients.
4. Palpate the posterior tibialis (PT) arteries at the posterior-inferior aspect of the medial
malleolus.
5. Palpate the popliteal arteries, beginning with the leg slightly flexed at the knee. Place
both thumbs on the patellar ligament and wrap your fingers around the knee, such that
the fingertips land in the middle of the popliteal fossa. If there is difficulty identifying
the pulse, gradually flex the knee in 15° intervals while continuing to palpate. If unable
to encounter the pulse in this position, have the patient turn to the prone position, flex
the knee, and support the lower extremity. Place your hands on either side of the knee
and use the thumbs to palpate the popliteal artery.
6. Palpate the femoral arteries, just inferior to the inguinal ligament, approximately
midway between the anterior superior iliac spine and the symphysis pubis.

7. Auscultate the femoral arteries using the bell or diaphragm of the stethoscope, using
light pressure, so as not to artificially induce a bruit.
Finding Peripheral Arterial Disease Chronic Venous Insufficiency
Edema Absent or mild Present, unilateral, or bilateral
Well demarcated, often distal leg, Irregular margins, often over anterior
Ulcers
dorsum of foot, toes (trauma sites) shin and medial malleolus
Hair
Decreased No change
Distribution
Pallor (acute), dependent hyperemia

Color Brown-red hyperpigmentation
(chronic), distal gangrene (severe)
Nails Decreased growth, thickened Thickened, darkened, onychomycosis
Varicose Veins Absent Present
Muscle Difficult to detect due to significant

May be present
Atrophy edema
Skin
Thin, shiny, atrophic Thickened, scaly
Appearance
Temperature Cool No change
Table 1. Skin changes associated with peripheral vascular disease.

5. Special Maneuvers
1. Use the Allen test prior to cannulating the radial artery to ensure adequate collateral
flow through the palmar arch from the ulnar artery.
1. Begin by palpating the ulnar and radial arteries on the side.
2. Ask the patient to make a tight fist.
3. Apply sufficient pressure over the ulnar and radial arteries to occlude them.
4. Ask the patient to open the fist, and note the pallor of the palm.
5. Release the ulnar artery. If sufficient collateral flow is present, the palm should
become pink again within 3 to 5 sec.
2. Use Buerger's test to assess for PAD of the lower extremities, and it may also be useful
for predicting the severity of the disease. With the patient supine, elevate the legs to
60° for 2 min or until the pallor of the distal extremity is noted.
1. Lower the legs and allow them to dangle below the table's edge. Observe for 2
min or until a hyperemia is observed over the dorsum of the foot, indicating
arterial insufficiency.
3. Perform the following maneuvers in patients with varicose veins to localize the site of
incompetent valves.
1. Perform the Brodie-Trendelenburg test with the patient in the supine position.
1. Elevate the leg of interest and strip the blood proximally out of the great
saphenous vein (GSV).
2. Compress the GSV just below the sapheno-femoral junction (SFJ), and
ask the patient to stand.
3. Observe the filling of the GSV, which under normal circumstances, fills
distal to proximal and takes 20 to 30 sec. Rapid filling with the GSV
occluded suggests insufficiency of the perforating veins.
4. Release the pressure over the GSV. Accelerated filling suggests venous
insufficiency at the level of the SFJ.
2. Perform the cough test to detect reflux at the SFJ. With the patient standing,
palpate over the SFJ with light pressure.
1. Instruct the patient to cough. A palpable thrill suggests retrograde flow
and venous insufficiency.
3. To perform the Perthes test, place a tourniquet around the leg, just below the
knee.

1. Instruct the patient to perform 10 heel raises. Emptying of the varicose
veins suggests incompetence above the level of the tourniquet (SFJ,
sapheno-popliteal junction, or thigh perforating veins). If the veins
remain distended, the site of insufficiency is the calf perforating veins.
Peripheral vascular disease is an important cause of morbidity, particularly in older patients.

The detection and subsequent treatment of PVD can improve quality of life and potentially
mitigate cardiovascular and cerebrovascular complications. General screening for peripheral
vascular disease of the extremities is not a current recommendation by the US Preventive
Service Task Force (USPSTF). However, the USPSTF does recommend ultrasound screening
for abdominal aortic aneurysms in males who have smoked and are aged 65 to 75. Additionally,
the American Heart Association/American College of Cardiology recommends a
comprehensive vascular exam in anyone at risk of PVD.
The most important findings that make PAD more likely in a patient include characteristic
ulcers, asymmetric temperature difference in the foot, absent pulses, and limb bruits. The most
important finding that argues against significant PAD is the presence of at least one pedal pulse
on a given leg. A positive Buerger's test increases the likelihood of more extensive disease. Of
the physical exam maneuvers to localize the site of reflux in patients with varicose veins,
Perthes and Brodie-Trendelenburg tests are the most helpful for ruling out a particular location
as the site of reflux. The overall accuracy of these venous reflux maneuvers is limited, however,
and detection of the site of reflux is improved through use of a handheld Doppler.
This video reviewed a systematic method and proper technique of vascular examination of the
extremities and abdomen, and included a review of special diagnostic maneuvers that should
be performed if PVD is suspected. Like all aspects of the physical exam, practice is critical for
improving accuracy, and an understanding of the relevant anatomy is important to a successful
examination and interpretation of the exam findings.

Transcript
The prevalence of peripheral vascular disease increases with age and it is a significant cause of
morbidity in older patients. The peripheral vascular exam plays a key role in bedside diagnosis
of this condition.
Peripheral vascular disease, or PVD, includes peripheral artery disease, abbreviated as PAD,
and chronic venous insufficiency, or CVI. PAD refers to the narrowing of the peripheral arterial
blood vessels primarily caused by the accumulation of fatty plaques, or atherosclerosis. When
patients with PAD become symptomatic, they frequently complain of limb claudication defined
as a cramp-like muscle pain that worsens with activity and improves with rest. On the other
hand, CVI is a condition in which peripheral vein walls become less flexible and dilated, and
the one-way valves do not work effectively to prevent the reverse flow. Thus, leading to
pooling of blood in the extremities. Patients with CVI often present with lower extremity
swelling, pain, skin changes, and ulceration.
When the diagnosis of PVD is being considered, every examiner should follow the proper
peripheral vascular exam technique, though the extent of the exam depends on the suspicion of
the underlying PVD. This video reviews the general steps for the vascular examination of the
upper extremities, the abdomen, and the lower extremities.
Let's go over the steps involved in a comprehensive peripheral vascular physical examination.
Prior to the examination, have the patient put on a gown. This investigation should never occur
through clothing. Wash your hands thoroughly before meeting the patient.
Upon entering the room, first introduce yourself and briefly explain the procedure you're going
to conduct. Check the patient's blood pressure is in both arms. After recording the blood
pressure, start with the vascular exam of the upper extremities. Request the patient to lie supine
on the exam table with the head raised to a comfortable position. Expose the entirety of both
arms and begin with visual inspection. Note symmetry, color, hair pattern, size, skin changes,
nail changes, varicosities, muscle wasting, and trauma.
Next, palpate by using the back of the fingers to assess skin temperature. Examine from distal
to proximal, comparing one side to the other. Then, assess capillary refill by applying firm

pressure over the distal first or second digit for five seconds. Release pressure and count how
many seconds it takes for the normal skin color to return. Normal capillary refill time is less
than 2 seconds. Following that, palpate for edema over the dorsum of the hands using firm
pressure for at least two seconds. If present, palpate proximally, noting the extent and
distribution of the edema, and whether or not it is pitting. Grade the edema as trace or mild,
which is 1+; moderate or 2+; or severe that is 3+.
Next, palpate the major arteries of the upper extremities. Always use the surface anatomical
landmarks to find the pulse. Start by locating the flexor carpi radialis tendon and lateral to that
palpate the radial artery. While palpating, note the intensity, rhythm, and symmetry as
compared to the other side. Intensity can be described as absent, diminished, normal, or
bounding. If unsure, compare the patient's pulse to your own pulse. Subsequently, locate the
flexor carpi ulnaris tendon and slightly lateral to it palpate the ulnar artery. Next, medial to the
biceps tendon in the antecubital fossa, palpate the brachial artery. This artery can be followed
proximally in the medial groove between the biceps and triceps muscles. For any artery, if no
pulse is felt, vary the pressure, and then adjust your position, as there is variability in the path
of each artery.
Lastly, if you planning to cannulate the radial artery, perform the Allen's test. Ask the patient
to make a fist and apply sufficient pressure over the ulnar and radial arteries to occlude them.
Then instruct the patient to open the fist and note the pallor of the palm. Release the ulnar
artery; if sufficient collateral flow is present, the palm should become pink again within 3 to 5
sec. Here we see a sluggish collateral flow, while on the other hand of the collateral flow was
good. This concludes the vascular exam of the upper extremities.
Now let's move to the abdomen. Start by lowering the head of the table so that the patient is
lying flat. Adjust the gown to allow sufficient exposure of the abdominal area. First, inspect
for dilated veins. If present, follow the procedure described in the text below. Next, locate the
abdominal aorta, which is just above the umbilicus and slightly left of the midline. Then,
palpate using three to four finger pads of both hands to apply slow and steady downward
pressure. The hands should point cephalad and slightly toward each other. Once the pulse is
encountered, gradually bring the fingertips closer together until the lateral walls of the aorta
are felt. Approximate the distance between the fingers, which is normally less than 3 cm.
Following palpation, use the diaphragm of the stethoscope to auscultate the aorta for bruits,

while applying moderate pressure. Also, auscultate the renal arteries above the umbilicus and
one to two inches lateral to the midline, followed by the iliac arteries below the umbilicus and
one to two inches lateral to the midline.
The last part of the vascular exam involves the lower extremities. Begin with inspection, by
exposing the entirety of both legs, leaving the genitalia covered. Similar to upper extremities,
look for changes in symmetry, color, hair pattern, size, skin changes, nail changes, varicosities,
muscle wasting, and trauma. Also, palpate for temperature, perform the capillary refill test, and
palpate for the presence of edema. This patient had a non-pitting edema of left leg.
Thereafter, begin with the palpation of the major leg arteries. First, locate the extensor hallucis
longus tendon, and palpate the dorsalis pedis artery, which lies just lateral to the tendon. Next,
pinpoint the medial malleolus, and posterior and inferior to the malleolus you'll find the
posterior tibialis artery. After that, palpate the popliteal arteries. Place both thumbs on the
patellar tendon, slightly flex the patient's knee and wrap your fingers such that the fingertips
land in the middle of the popliteal fossa. If there is difficulty identifying the pulse, gradually
flex the knee in 15° intervals while continuing to palpate. If unable to encounter the pulse in
this position, have the patient turn to the prone position, flex the knee, and support the lower
extremity. Now place your hands on either side of the knee and use the thumbs to palpate the
popliteal artery. Next, palpate the femoral arteries, just inferior to the inguinal ligament,
approximately midway between the anterior superior iliac spine and the symphysis pubis.
Lastly, auscultate the femoral arteries using the bell or diaphragm, while applying light
pressure, so as not to artificially induce a bruit.
"This concludes the general peripheral vascular exam. There are other maneuvers that can be
done for patients with suspected peripheral vascular disease. However, in reality, these are
rarely performed in the office, particularly when imaging is available. These maneuvers include
the Buerger's test for peripheral artery disease. And the Brodie-Trendelenburg test, cough test
and the Perthes test for patients with varicose veins. The procedures describing these
maneuvers can be found in the accompanying text."
You've just watched JoVE's video on the peripheral vascular exam. This video reviewed a
systematic method and proper technique of vascular examination of the extremities and the
abdomen. Like all aspects of the physical exam, practice is critical for improving accuracy of

vascular assessment. In addition, an understanding of relevant anatomy is important for correct
interpretation of the findings. As always, thanks for watching!

PERIPHERAL VASCULAR EXAM USING A CONTINUOUS WAVE DOPPLER
Overview
Source: Joseph Donroe, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New
Haven, CT
Peripheral vascular disease (PVD) is a common condition affecting older adults and includes
disease of the peripheral arteries and veins. While the history and physical exam offer clues to
its diagnosis, Doppler ultrasound has become a routine part of the bedside vascular
examination. The video titled "The Peripheral Vascular Exam" gave a detailed review of the
physical examination of the peripheral arterial and venous systems. This video specifically
reviews the bedside assessment of peripheral arterial disease (PAD) and chronic venous
insufficiency using a handheld continuous wave Doppler.
The handheld Doppler (HHD) is a simple instrument that utilizes continuous transmission and
reception of ultrasound (also referred to as continuous wave Doppler) to detect changes in
blood velocity as it courses through a vessel. The Doppler probe contains a transmitting
element that emits ultrasound and a receiving element that detects ultrasound waves (Figure
1). The emitted ultrasound is reflected off of moving blood and back to the probe at a frequency
directly related to the velocity of blood flow. The reflected signal is detected and transduced to
an audible sound with a frequency directly related to that of the received Doppler signal (thus,
faster blood flow produces a higher frequency sound).

Figure 1. Generation of a Doppler signal. The handheld Doppler emits an ultrasound signal,
which is then reflected back by moving blood, and finally received by the Doppler probe.
The HHD is easily used in the office or hospital setting to detect pulses, screen for PAD using
the ankle brachial pressure index (ABPI), and localize venous insufficiency. This video reviews
these procedures; however, it is not intended to be a comprehensive review of non-invasive
vascular testing.
Procedure
1. Preparation
1. Obtain a blood pressure cuff, an HHD machine, Doppler gel, and skin marker.
2. Wash hands prior to examining the patient.
3. Begin with the patient in a gown, lying comfortably supine on the exam table.

Figure 2. The major arteries of the upper and lower extremities.
2. Lower Extremity Arterial Assessment
1. For patients with weak or absent pulses by palpation, or historical risk factors for
peripheral arterial disease (PAD), use the HHD to assess blood flow. Begin by applying
gel in the expected area of the artery being investigated ( Figure 2).
2. Place the Doppler over the artery at a 45 degree angle to the skin, pointing cephalad. If
the Doppler signal is not detected, slowly move the Doppler probe medially and
laterally, as occasionally, the path of distal arteries can vary. Remember that a small
percentage of people may have a congenitally absent dorsalis pedal (DP) artery.
3. If a signal is encountered, note the character of the sound wave produced. While some
HHD have a screen or can print out the waveform to view, the shape can also be
determined by listening. A normal arterial waveform in the lower extremity is triphasic
(Figure 3). The first component of the wave occurs in systole and is generated by the
rapid flow of blood toward the probe, generating a high frequency wave. At the end of
systole and beginning of diastole, blood flow slows and reverses direction, resulting in
a second, lower frequency wave. Finally, forward returns at the end of diastole,

producing the low frequency third wave. Distal to an arterial stenosis, the amplitude of
the waveform becomes progressively dampened with loss of flow reversal, resulting in
a monophasic waveform. Immediately over a partially stenosed segment of artery, the
flow velocity is increased, producing a high frequency wave. Complete arterial
occlusion without collateral flow leads to absence of flow distally and no signal
generation.
Figure 3. The triphasic Doppler arterial waveform.
The initial large deflection is forward blood flow during systole. The second deflection is the
reversal of flow in early diastole. The third deflection is return of forward flow in late diastole.
4. If frequent reassessment is necessary, mark the location where the arterial pulse is
found.
5. If there is suspicion for peripheral arterial disease based on the history or physical exam,
calculate the ankle brachial pulse index (ABPI). Prior to performing the procedure, have

the patient lie supine and relax for 10 min, with both the upper and lower extremities at
the level of the heart.
1. Place the appropriately-sized blood pressure (BP) cuff on the upper arm. Make
sure the cuff bladder length is at least 80% and the bladder width at least 40%
of the arm circumference.
2. Apply gel to the antecubital fossa medial to the biceps tendon and find the
brachial artery with the HHD.
3. Inflate the cuff until the Doppler signal disappears.
4. Slowly deflate the cuff. The first Doppler signal heard reflects the systolic
pressure. Record this number and repeat the process in the other arm.
5. Place the appropriately sized BP cuff on the lower extremity, just proximal to
the ankle.
6. Apply gel to the dorsum of the foot lateral to the extensor hallucis longus tendon
and use the HHD to find the DP artery.
7. Inflate the cuff until the Doppler signal disappears.
8. Slowly deflate the cuff. The first Doppler signal heard reflects the systolic
pressure. Record this number and repeat the process over the posterior tibialis
(PT) artery.
9. Repeat this on the other leg.
10. Calculate the ABPI for a given leg by dividing the higher systolic pressure of
the DP or PT artery in that leg with the higher of the two brachial artery systolic
pressures. Table 1 shows the interpretation of the ABPI.
ABPI of leg A = Higher pedal pressure of leg A / Higher brachial pressure (A or B)
Value Interpretation

>1.4 Non-compressible, calcified arteries
1.0-1.4 Normal range
0.91-0.99 Borderline
0.41-0.90 Mild to moderate peripheral arterial disease
<0.4 Severe peripheral arterial disease
Table 1: Interpretation of the Ankle Brachial Pressure Index (ABPI).
6. Assess for venous insufficiency of the lower extremity in patients with edema or
varicose veins. Have the patient in the standing position with their weight shifted onto
the unexamined leg.
1. Apply a generous amount of gel and place the HHD over the femoral artery,
just below the inguinal ligament. Slowly move the probe medially, while
squeezing and releasing the ipsilateral calf muscle to generate audible flow
through the venous system. Once the HHD transmits this signal clearly, it is in
the vicinity of the saphenofemoral junction (SFJ).
2. Move just inferior and medial to the SFJ to isolate the distal segment of the
greater saphenous vein (GSV).

3. Squeeze the calf muscle and listen for normal augmentation of flow.
4. Release the calf muscle. Re-augmentation of flow lasting more than 1 sec is
abnormal and represents retrograde flow through an incompetent valve at the
SFJ.
5. Move to the medial thigh, approximately 10 cm above the knee along the
expected path of the GSV, and apply gel.
6. Place the probe on the skin, while squeezing the calf muscle. The probe is well
positioned once a clear signal is heard.
7. Squeeze the calf muscle and listen for normal augmentation of flow.
8. Release the calf muscle. Re-augmentation of flow lasting more than 1 sec may
be heard with SFJ reflux, incompetent thigh perforator veins, or incompetent
valves within the GSV proximal to the HHD probe.
9. Move behind the patient and place gel in the popliteal fossa.
10. Use the probe to find the popliteal artery, then move medially, while squeezing
the calf muscle, to find the popliteal vein.
11. Once well-positioned over the popliteal vein, squeeze the calf muscle and listen
for normal augmentation of flow.
12. Release the calf muscle. The venous anatomy around the popliteal fossa is
complex, and re-augmentation of flow lasting more than 1 sec usually cannot
be localized to one particular superficial or deep vein. Rather, it may represent
reflux at the saphenopopliteal junction (SPJ), the small saphenous vein,
tributaries of the GSV, or calf veins.
A careful history and physical exam are important for anyone suspected of peripheral vascular
disease based on symptoms or risk factors. The HHD has become part of the routine bedside
vascular examination and should be used to complement the physical exam, if PVD is
suspected. It is not a technically difficult tool to use, and the maneuvers described in the video
can be performed by general physicians. Just like for the physical exam, knowledge of the
vascular anatomy is critical to the success of the HHD exam.
Vascular assessment by HHD has some important limitations. A false positive Doppler signal
may occur over an artery distal to a total occlusion, if sufficient collateral flow has developed,

leading to the inaccurate belief that PAD is not present. Additionally, the ABI may be falsely
high in calcified vessels as they become less compressible. This is particularly relevant to
diabetic patients. Venous testing by HHD is far more accurate for localizing valvular reflux
than physical exam maneuvers, such as the Brodie-Trendelenburg test, cough test, and Perthes
test; however, it is still less accurate than color duplex scanning. Finally, while there is some
literature describing HHD testing for deep vein thrombosis, this is not considered standard of
care, and thus, it is not reviewed here. If clinical suspicion for peripheral vascular disease
persists despite reassuring physical exam and HHD testing, more formal vascular testing
should be performed by a vascular specialist.
Transcript
The use of continuous wave Doppler ultrasound has become a routine part of the bedside
vascular assessment, complementing the patient's history and physical examination.
This assessment is performed with a simple, non-invasive instrument called the handheld
Doppler device or HHD. This device consists of a probe, which is placed on the patient's skin
to detect changes in the velocity of the blood flow as it courses through a vessel. In this
presentation, we will review the principles behind the HHD device functioning, followed by a
review of how to use this device to detect pulses, measure ankle brachial pressure index, and
localize venous insufficiency.
Before discussing the steps of this exam, let's briefly review the basic principles behind the
functioning of the HHD device. This instrument works on the principle related to the frequency
of sound waves, which was proposed almost one and a half century ago in 1842 by an Austrian
physicist Christian Doppler. The principle was thus called the Doppler effect. So, what is the
Doppler effect? The example commonly used to explain this phenomenon involves an observer
and a sound-emitting object, like an ambulance, which produces sound waves at a constant
frequency denoted by ft. Initially, when the ambulance approaches, the frequency of the sound
perceived by the observer, or fr, is greater compared to ft. And, when it recedes, fr drops below
ft. This difference between the perceived sound frequency and transmitted sound frequency at
any given point in time is called the Doppler effect or the Doppler shift. Therefore, when the
ambulance is approaching the observer the shift is positive and when it recedes the shift is
negative.

The same principle applies to the continuous wave HHD device. In this case, the probe contains
a transmitting element that continuously emits ultrasound waves at a constant frequency, which
then reflect off of the blood cells and are detected by the receiving element in the probe. So
here, a blood cell is analogous to the moving ambulance and the receiving element is analogous
to the observer. Thus, the Doppler shift in the frequency experienced by the receiving element
depends on two parameters: the velocity of the blood flow and the angle of the probe to the
blood flow.
The velocity effect is evident when you think of the ambulance example. The faster the
ambulance passes by, the greater is the change in sound frequency experienced. The angle to
the blood flow is equally important, because if the probe is placed at a 45° angle to the blood
flow, then the flow is towards the receiving element and hence there is a positive Doppler shift.
If the probe were perpendicular, the flow would be neither towards nor away relative to the
probe, therefore the Doppler shift would be zero. And if it were placed at an obtuse angle, then
the flow would be actually away from the probe, which would yield in a negative Doppler
shift.
Normally, one places the probe at a 45° angle to the direction of blood flow in a peripheral
artery and this produces a Doppler waveform, which is triphasic in nature. First component of
this wave occurs in systole and reflects the rapid blood flow toward the probe, which generates
a high frequency wave. At the end of systole and beginning of diastole, blood flow slows and
reverses direction, resulting in a second, lower frequency wave on the negative side. Finally,
forward flow returns at the end of diastole, producing the low frequency third wave on the
positive side before the process is repeated for the next cardiac cycle.
Since the triphasic waveform represents normal, deviation from it provides valuable diagnostic
clues. For example, a partial arterial stenosis progressively dampens the amplitude of the
waveform distally and there is loss of flow reversal resulting in a monophasic waveform. And
a complete occlusion without collateral flow leads to no signal generation.
Some of the HHD devices are equipped with a screen or a printer that displays these
waveforms. Others come with a built in processor that convert this waveform into audible
sounds, and a triphasic wave on such a device sounds like this…

Now we will demonstrate how to use the HHD to assess the blood flow in leg arteries. You
should perform this test if your patient's symptoms and risk factors are consistent with
peripheral arterial disease or if they have weak or absent peripheral pulses by palpation.
Before starting the exam have the patient wear a gown and ask them to lie on the exam table
in supine position. Here, we will demonstrate how to use the Doppler device to evaluate the
dorsal pedal artery, but the same principle is applicable for the assessment of other leg and arm
arteries as well, including posterior tibial, popliteal, femoral, ulnar, radial and brachial arteries.
First try to find the dorsal pedal pulse by palpating just laterally to the tendon of extensor
hallucis longus. After you find the pulse, apply ultrasound gel on the skin over the area. Next,
place the probe over the gel at a 45° angle to the skin pointing cephalad.
Slowly move the probe both medially and laterally until you hear the signal. Remember that a
small percentage of people may have a congenitally absent dorsalis pedal artery. Note the
character of the sound wave. Recall-a normal arterial waveform in the lower extremity is
triphasic. If your patient needs frequent reassessment of their pulses, mark the location where
the arterial pulse is found with a skin marker.Use the same approach to assess peripheral
arteries in both lower extremities and record the findings.
Now let's discuss how to utilize the HHD device for measuring ankle brachial pressure index
or ABPI. Since the HHD is more sensitive than auscultation, it allows for more precise
measuring of blood pressure in distal arteries. And ABPI is nothing but the fraction of the
systolic blood pressure in legs to the systolic blood pressure in arms. It is a way to assess the
distal perfusion.
Prior to this test, have the patient lie supine and relax for 10 minutes with their upper and lower
extremities positioned at the level of the heart. Obtain a sphygmomanometer attached to an
appropriately sized blood pressure cuff and place the cuff on the patient's upper arm. Identify
the brachial pulse in the antecubital fossa by palpating medially to the biceps tendon. Apply
the gel on the skin over the brachial pulse and then place the probe at a 45° angle to the skin
pointing cephalad. Move the probe until you obtain the signal…

Now measure the systolic pressure in the brachial artery. Inflate the cuff until the Doppler
signal disappears, and then continue to inflate for additional 20 mmHg above that point. Then
deflate the cuff slowly, while watching the readings on the manometer. The first Doppler signal
heard signifies the systolic pressure in the brachial artery. Record this manometer reading and
repeat the procedure in the other arm.
Now use the same approach to measure the systolic pressure in dorsal pedal artery and tibialis
posterior artery in each leg. Place the appropriately sized blood pressure cuff on the lower
extremity, just proximal to the ankle. Apply gel to the dorsum of the foot, lateral to the extensor
hallucis longus tendon and use the probe to find the dorsal pedal artery as shown earlier. Once
you found the pulse, start inflating the cuff until the Doppler signal cannot be heard anymore.
Deflate the cuff slowly and record the pressure at which the Doppler signal reappears. Then,
measure the systolic pressure in the posterior tibial artery on the same side. Using the same
approach, obtain systolic pressure measurements in the dorsal pedal and posterior tibial arteries
of the other leg.
Calculate the ABPI for each leg separately by dividing the higher systolic pressure of the dorsal
pedal or posterior tibial artery in that leg by the higher of the two brachial artery systolic
pressures. The generally accepted normal range of ABPI is from 1 to 1.4. Values below 1
indicate the presence of peripheral artery disease, ranging in severity depending on the actual
value. On the other end, if the value exceeds 1.4, it suggests presence of non-compressible,
calcified arteries in that leg.
Finally, let's learn how to use the HHD device for the assessment of leg veins by performing
compression test for localizing valvular reflux.
Before starting this test, ask the patient to stand up and relax the leg to be examined with their
weight shifted onto the other leg. Apply a generous amount of gel and place the probe over the
femoral artery, just below the inguinal ligament. Then, move the probe medially, while
squeezing and releasing the ipsilateral calf muscle to generate audible flow through venous
system. Once the device transmits this signal clearly, the probe is in the vicinity of the
saphenofemoral junction. Now, move the probe slightly medial and inferior to the junction to
assess the great saphenous vein.Squeeze and release the calf muscle and listen for normal

augmentation of flow. Re-augmentation of flow lasting more than one second is abnormal and
represents retrograde flow through an incompetent valve at the saphenofemoral junction.
Repeat the same procedure for testing the great saphenous vein in the medial thigh, 10 cm
above the knee and then for testing the popliteal vein located posteriorly in the popliteal fossa.
The interpretation of the findings is described in the associated text manuscript.
You've just watched JoVE's video on the peripheral vascular exam using a continuous wave
Doppler device. This video demonstrated the principles behind the Doppler device, showed
how to perform bedside assessment of peripheral vascular system using this simple, portable
device and explained how to interpret the results obtained. As always, thanks for watching!


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What are the steps involved in performing a peripheral vascular exam using a continuous wave Doppler device?

What are the steps involved in performing a peripheral vascular exam using a continuous wave Doppler device?

What are the normal ranges for ABPI values?

What are the normal ranges for ABPI values?

JOVE SCIENCE EDUCATION DATABASE

Nabila Larasati Balqis - 1102017162 1

TABLE OF CONTENTS .......................................................................................................... 2

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1. Before patient encounter

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2. Enter the room

1. Knock on the door and ask permission to enter.

4. Consider your approach

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6. Other environmental considerations

7. Components of the exam

1. The physical examination is subdivided into the following regional/anatomic

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9. Ending the examination

Applications and Summary

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1. Certain examination locations offer opportunities to learn about a patient's social

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Applications and Summary

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Figure 2. Using the dorsum of hand to assess for warmth.

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1. Before the patient encounter

1. Keep fingernails clean, groomed, and trimmed.

2. Components of the exam

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Applications and Summary

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1. Before the patient encounter

1. Keep fingernails clean, groomed, and trimmed.

2. Components of the exam

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Intra-abdominal tumors and

Flat High Soft Short Thigh Pleural effusion

Table 1. Characteristics of different percussion notes.

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5. Other factors affecting a percussion note

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Applications and Summary

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