Body temperature is affected by activity, certain disease conditions (e.g., hypothyroidism/hyperthyroidism), environmental factors (e.g., hypothermia/hyperthermia), inflammation, infection, and injury. Temperature measurement is mandatory for all ED patients because deviation from normal temperature may be the only clue of a significant medical problem. Temperature measurement is most commonly performed at the oral, tympanic, temporal artery, axillary, or rectal sites. Institutional preference and the patient’s age and condition should be considered when choosing an appropriate measurement site. Some situations necessitate core temperature measurement; urinary catheter thermistors, esophageal probes, and temporal artery and tympanic thermometers correlate highly with pulmonary artery temperature, considered the “gold standard.” An abnormally high or low temperature reading should always be confirmed by an alternate route, thermometer, or observer.

Assessment of the pulse involves determination of the heart rate and rhythm (regular or irregular), as well as the quality (bounding, normal, weak and thready, or absent) and equality of central and peripheral pulses. Increased dependence on electronic technology has decreased tactile assessment of the pulse. The electronically monitored pulse rate gives no indication of quality and other characteristics of the pulse. Equally important are rhythm disturbances that may not be identified unless these changes are seen on the cardiac monitor. Premature beats may be felt on palpation as missing beats or beats with less amplitude than preceding ones. Irregular rhythms, even subtle ones, can be felt as a chaotic rhythm with varying intensity. In context with other physical findings, the pulse is an important indicator of cardiovascular function. A change in pulse rate is often the first sign that compensatory mechanisms are being used to maintain homeostasis. In early volume depletion, a healthy person with an intact autonomic nervous system can maintain normal systolic pressures with only one subtle change—a slight increase in pulse rate. Any deviation from the normal range for the patient’s age that cannot be related to psychologic or environmental factors should be considered an indication of an abnormal physiologic condition until proven otherwise.

Assess the rate, rhythm and depth of respirations, and work of breathing. To determine an accurate respiratory rate and pattern, breathing should be measured for a full minute. Generally a healthy person does not require any extra effort to breathe: airway noise is absent, nasal cartilage is quiet, and sternocleidomastoid or intercostal muscles are not required to lift the chest cage. Signs of increased respiratory effort include tracheal tugging; nasal flaring; suprasternal, intercostal, or substernal retractions; accessory muscle use (neck and abdominal muscles); an inability to speak in complete sentences; and the presence of adventitious sounds. With inspiration the chest should expand symmetrically on both sides. When pulmonary or chest wall conditions exist, the chest may rise asymmetrically during ventilation. This asymmetry can be observed with the chest exposed and can also be palpated during inspiration. Increased anteroposterior diameter can generally be seen on casual observation and indicates chronic alveolar distension. Other changes in chest contour include funnel chest, pigeon chest, kyphosis, and kyphoscoliosis. These particular anatomic changes in contour may interfere with normal lung inflation and exacerbate respiratory conditions. The patient’s tidal volume can be estimated by observing the rise and fall of the chest during ventilation. Depth of ventilations is described as shallow, normal, or deep. A normal adult moves 300 to 500 mL of air at rest and as much as 2000 mL during exercise, with a corresponding increase in rate. A fast rate is not necessarily indicative of moving more volume, nor is a slow rate necessarily indicative of moving less volume.

BP can be obtained by auscultation, palpation, noninvasive BP monitors, or through Doppler ultrasound. Proper cuff size is essential to obtaining accurate measurements—a cuff that is too small leads to falsely elevated readings, whereas a cuff that is too large results in erroneously low readings. The method used for assessment should be communicated so that other providers use the same method, allowing hemodynamic status to be trended over time. A single BP recording yields little or no information. Normal pressures measured in the ED are not necessarily an indication that all is well. A healthy person may not demonstrate a drop in systolic BP despite significant volume loss until all compensatory mechanisms (i.e., the ability to increase heart rate and vasoconstrict) have been exhausted. If the patient is undergoing antihypertensive therapy, the values obtained during the ED visit may represent a significant deviation relative to the patient’s “normally abnormal” pressure.