Useful physical exam skills for inpatient assessment
This month's expert discusses measuring vital signs, orthostatic hypotension, and the cardiac exam in the context of inpatient care.
When seeing inpatients, I like to go back to the basics of vital signs, not just what was recorded, but what I can do as a quick estimate if I'm concerned about a patient. I measure their pulse and their respiratory rate, which oftentimes is not recorded accurately. If I'm really worried about a patient and they just don't look good, I can estimate their blood pressure simply by measuring their pulse at different locations. If I can feel their pulse at the radial artery, that means they've got a systolic blood pressure of at least 80 mm Hg. If I can feel it at the femoral area, they've got a systolic pressure of at least 70. If I can feel it at the carotid, they have a systolic pressure of at least 60. So those kinds of things can give me a good estimate of how ill is my patient, and are they going to need rapid intervention or ICU care?
I have a pretty low threshold to measure orthostatic hypotension on patients, especially in the setting where they might be either volume-depleted or they may be losing blood. That's a value-added quick thing that can be done. It seems a relatively simple physical exam maneuver, but in my experience it is oftentimes not done. And so you can add a lot of information to your assessment.
If you're thinking a patient might be bleeding, orthostatic testing gives you a sense of how much blood loss they may have. They're significantly orthostatic if the pulse goes up by 30 beats per minute or more. Some patients can't tolerate standing to achieve that blood pressure evaluation, but others can. If a patient is coming in with syncope, the orthostatic test could also be helpful related to volume depletion, but also consideration of autonomic dysfunction or similar conditions.
A number of aspects of the cardiac physical examination are really helpful in making a diagnosis, for example, the jugular venous pressure (JVP) assessment. It has a really good positive likelihood ratio (over 5) to help diagnose heart failure, as does assessing the apical impulse. Some of us don't realize that and so aren't checking the apical impulse on a regular basis. If you have a patient who's coming in with shortness of breath and you don't know exactly what's going on, check the JVP, and check the apical impulse. If the JVP is greater than 8 cm or if the apical impulse is enlarged (more than 4 cm) or displaced from its typical location (5th intercostal space, mid-clavicular line), any/all of those findings are strongly predictive of heart failure as the etiology for shortness of breath. Those findings have really high likelihood ratios (5 to 10 range) to help me diagnose a patient who may have heart failure and who's sitting right in front of me, even when other data isn't necessarily consistently pointing in that direction.
