Patient Intake and Vital Signs
9.3% of the exam
14 of the 150 scored items (about 9.3%). This domain rewards exactness: identifiers and intake sequence, normal ranges by route and by age, AHA blood pressure technique and staging, orthostatics, pulse oximetry, BMI and pain tools — plus the error sources that move a number and the line between reporting an abnormal value and interpreting it. Work every "check yourself" prompt from memory before opening the answer; that retrieval is what makes the numbers stick.
1. The 14 Items: Identify First, Then Intake
Patient Intake and Vitals is 14 of the 150 scored items — about 9.3% — and almost all of it is procedure you can memorize exactly. The order does not change: 1. Two patient identifiers before anything else (The Joint Commission, NPSG.01.01.01): name, date of birth, medical record number, or another person-specific identifier such as the last four digits of the Social Security number. The patient's room number or physical location is never an acceptable identifier — locations change, people do not. 2. Chief complaint: the reason for the visit in the patient's own words, quoted. 3. Medication reconciliation: every prescription, OTC drug, vitamin and herbal — name, dose, route, frequency, last dose taken. 4. Allergies: the substance AND the reaction. 5. Vital signs. You collect and document. You do not diagnose, adjust a dose, or explain what a value means. That boundary is tested directly.
2. Temperature: The Route Changes the Number
The traditional average adult oral temperature is 98.6 °F (37.0 °C); normal varies between people and across the day, so treat any single "normal range" as approximate and compare against the patient's own baseline. The site shifts the value: - Rectal and tympanic run about 0.5–1 °F ABOVE oral - Axillary runs about 0.5–1 °F BELOW oral - Temporal artery varies by device; follow the manufacturer CDC defines fever as a measured temperature of 100.4 °F (38.0 °C) or greater. Always document the route — the same patient produces different numbers by site. Error sources: hot or cold drinks, smoking or gum before an oral reading; cerumen or wrong pinna pull for tympanic (adult and child over 3, pull the pinna UP and back; child under 3, DOWN and back); a sweaty or unsealed axilla. AAP pediatric rule: rectal gives the most accurate reading under 3 years, tympanic is not used under 6 months (the ear canal is too narrow), and oral is not recommended until about age 4.
3. Pulse, Respirations and Pulse Oximetry
Adult resting pulse is 60–100 bpm: under 60 is bradycardia, over 100 is tachycardia. Document rate, rhythm (regular or irregular) and volume (strong, weak, thready). Count a FULL 60 seconds when the rhythm is irregular, when the patient is an infant or young child, or when taking an apical pulse — stethoscope at the fifth intercostal space, left midclavicular line. A radial rate lower than the apical rate is a pulse deficit; report it. Adult respirations are 12–20 per minute at rest: under 12 bradypnea, over 20 tachypnea. Count them without announcing it, because awareness changes the rate; keep your fingers on the radial pulse and watch chest rises. Name the patterns: apnea, dyspnea, orthopnea, hyperventilation, Cheyne-Stokes. Pulse oximetry is typically 95–100% in adults. Nail polish, artificial nails, cold or poorly perfused fingers, motion and hypotension all corrupt it. The FDA warns that pulse oximeters can read HIGHER than true arterial oxygen saturation, and that this OVERESTIMATION is more likely in patients with darker skin pigmentation, which risks missed hypoxemia. A reassuring number never overrides a patient who looks short of breath — report what you observe.
4. Blood Pressure: Technique Is Worth More Than the Number
Preparation (AHA/CDC): no caffeine, exercise or smoking for 30 minutes; empty bladder; five minutes of quiet seated rest; no talking during or between readings. Position: back supported, feet flat on the floor, legs uncrossed, arm bare and supported at heart level. Cuff (AHA): bladder width at least 40% of arm circumference and bladder length about 80% of arm circumference; lower edge 2–3 cm above the antecubital fossa, leaving room for the stethoscope. Measure the arm — a cuff too small for the arm reads falsely HIGH, and a cuff too large reads falsely LOW. Inflate to AT LEAST 30 mm Hg above the PALPATED systolic — the point at which the radial pulse disappears. Deflate at about 2 mm Hg per second (or per heartbeat when the heart rate is slow). Systolic is the first Korotkoff sound (phase I); diastolic is their disappearance (phase V). If you must repeat, wait a full minute and re-inflate from zero — never re-pump a partly deflated cuff.
5. Staging the Reading, and Orthostatics
AHA staging uses the average of two or more properly taken readings: - Normal: below 120 AND below 80 - Elevated: 120–129 AND below 80 - Stage 1: 130–139 OR 80–89 - Stage 2: 140 or higher OR 90 or higher When systolic and diastolic fall in different bands, stage by the HIGHER category. AHA hypertensive crisis is a reading HIGHER than 180 systolic and/or HIGHER than 120 diastolic. Wait five minutes and recheck; if it holds and the patient has NO symptoms, notify the provider immediately. If the patient also has chest pain, shortness of breath, back pain, numbness or weakness, vision change or difficulty speaking, that is a hypertensive EMERGENCY — activate emergency services per your protocol rather than writing a rooming note. Orthostatics: BP and pulse supine after five minutes, then repeated at 1 minute and 3 minutes standing. Orthostatic hypotension is defined by the consensus statement of the American Autonomic Society and the American Academy of Neurology as a sustained fall of at least 20 mm Hg systolic OR at least 10 mm Hg diastolic within three minutes of standing. A sustained pulse rise of 30 bpm or more within ten minutes of standing WITHOUT a blood pressure drop is the criterion for postural tachycardia syndrome (POTS) — a different finding. Document both; do not label either one. Stay with the patient — they may faint.
6. Size, Pain, and How Life Stage Moves Every Range
Anthropometrics: BMI = kg ÷ m², or lb ÷ in² × 703. CDC adult bands: underweight below 18.5, healthy weight 18.5 to below 25, overweight 25 to below 30, obesity 30 or higher. CDC waist risk: greater than 40 inches in men, greater than 35 inches in non-pregnant women. Pain: 0–10 numeric scale for adults; Wong-Baker FACES self-report, validated from age 3 and usable in adults; FLACC observational, validated for 2 months to 7 years, for a child who cannot self-report. An adult who cannot self-report — advanced dementia, intubation, severe cognitive impairment — needs an observational behavioral tool chosen by your facility's protocol, not a self-report scale; document the behaviors you actually see. Life stage: children run faster pulse and respirations that slow with age (PALS). Growth charts are the WHO standards from birth to 2 years and the CDC charts from 2 years up (CDC/AAP). Older adults show isolated systolic hypertension, fall orthostatic more easily, and have a BLUNTED fever response with a lower baseline temperature. In pregnancy resting pulse rises; per ACOG, a systolic of 140 or higher or a diastolic of 90 or higher after 20 weeks is reported promptly, and 160/110 or higher is severe range.
Where people lose points
✗ "Inflate 20–30 mm Hg above the expected systolic" vs "inflate at least 30 mm Hg above the PALPATED systolic"
✓ AHA technique is: palpate the radial pulse, note where it disappears, then inflate at least 30 mm Hg above THAT point. Guessing from an expected value can land you inside an auscultatory gap and give a falsely low systolic. Palpate first, every time.
✗ Cuff too SMALL vs cuff too LARGE
✓ Too small reads falsely HIGH; too large reads falsely LOW. The AHA sizing rule is bladder width at least 40% of arm circumference and bladder length about 80% of it. Measure the arm rather than reaching for whatever cuff is on the wall.
✗ Cuff edge "1 inch" vs the AHA figure of 2–3 cm above the antecubital fossa
✓ The AHA figure is 2–3 cm above the antecubital fossa — enough room to seat the stethoscope over the brachial artery without the cuff edge touching it. Older material rounds this to "one inch"; learn the AHA number and the reason for it, which is stethoscope clearance.
✗ Arm BELOW heart level vs arm ABOVE heart level
✓ Below heart level falsely RAISES the reading; above heart level falsely LOWERS it. An unsupported arm the patient holds up also raises it — about 10 mm Hg per AMA/AHA Target:BP — because isometric muscle work adds pressure. Support the arm on a surface at heart level; do not let the patient hold it.
✗ "Hypertensive crisis is 180/120 or higher" vs "hypertensive crisis is HIGHER THAN 180 and/or HIGHER THAN 120" — and "stage 2 starts at 160/100" vs "stage 2 starts at 140/90"
✓ AHA: crisis is a reading higher than 180 systolic and/or higher than 120 diastolic, and stage 2 begins at 140 systolic OR 90 diastolic. The 160/100 figure is an older threshold that still circulates in outdated study material. Memorize the current four bands and the crisis line as separate facts.
✗ Hypertensive crisis WITHOUT symptoms vs hypertensive EMERGENCY with symptoms
✓ AHA splits these. Higher than 180 and/or higher than 120 with no symptoms: wait five minutes, recheck, and notify the provider immediately. The same reading WITH chest pain, shortness of breath, back pain, numbness or weakness, vision change or difficulty speaking is a hypertensive emergency — activate emergency services per protocol; do not send the patient back to the waiting room.
✗ Orthostatic HYPOTENSION vs a pulse rise on standing (POTS criterion)
✓ Orthostatic hypotension is defined by BLOOD PRESSURE: a sustained fall of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of standing. A sustained heart-rate rise of 30 bpm or more within ten minutes of standing, WITHOUT that pressure fall, is the postural tachycardia syndrome criterion — a separate entity. Many clinic protocols ask you to flag either finding, but they are not the same thing, and naming the syndrome is the provider's job.
✗ "Rectal is one degree higher, axillary is one degree lower" vs the actual offsets
✓ The offset is a range, not a flat one degree: rectal and tympanic run about 0.5–1 °F ABOVE oral, axillary about 0.5–1 °F BELOW. What the exam cares about is the DIRECTION plus the fact that you must document the route. Never convert between routes in the chart — record what you measured and where.
✗ Tympanic pinna pull: UP and back vs DOWN and back
✓ Adults and children over 3: pull the pinna UP and back. Children under 3: pull it DOWN and back. The goal is the same either way — straighten the ear canal so the sensor aims at the tympanic membrane. Wrong direction, wrong number. And per AAP, tympanic is not used at all under 6 months.
✗ Radial pulse vs APICAL pulse
✓ Radial is at the wrist, thumb side, and may be counted for 30 seconds and doubled ONLY if the rhythm is regular. Apical requires a stethoscope at the fifth intercostal space, left midclavicular line, for a full 60 seconds — and it is the correct choice for infants, irregular rhythms and patients on cardiac medications. A radial rate lower than the apical rate is a pulse deficit: report it.
✗ Chief complaint in the PATIENT'S words vs your clinical label
✓ Write "burning in my chest after eating, three days" — not "GERD" or "probable reflux." Naming a condition is diagnosing, which is outside the medical assistant's scope of practice. Quote the patient, add onset, duration and severity, and stop.
✗ A true ALLERGY vs a side effect or intolerance
✓ "Codeine makes me nauseated" describes an intolerance; "codeine gave me hives and throat tightness" describes an allergy. Both get documented, in the correct field with the reaction described — mislabeling an intolerance as an allergy can strip a patient of an effective drug for life. You record the patient's description verbatim; the provider decides which one it is.
✗ Medication reconciliation = LIST what the patient actually takes vs FIX the list
✓ Your job is to capture reality: name, dose, route, frequency, last dose, including OTC, vitamins and herbals, plus doses the patient skipped. If the patient reports taking double the prescribed dose, you document that and flag it for the provider. Telling the patient to stop or change a dose is prescribing, and it is outside your scope of practice.
✗ REPORTING an abnormal value vs INTERPRETING it for the patient
✓ You may say "your blood pressure is 184 over 122; I'm going to have the provider look at this right now." You may not say "you have hypertension" or "that means you need medication." Report the value, the recheck, the time and the patient's symptoms to the provider — then let the provider interpret.
✗ Wong-Baker FACES vs FLACC
✓ Wong-Baker FACES is SELF-report, validated from age 3 and usable in adults — the patient chooses the face. FLACC is OBSERVATIONAL (face, legs, activity, cry, consolability), scored by you, validated for children 2 months to 7 years who cannot self-report. Choosing an observational scale for a child who can talk throws away better data; choosing a self-report scale for a child who cannot produces a meaningless number.
Numbers to memorize
| Domain weight | 14 of 150 scored items (about 9.3%) |
| Adult oral temperature | Traditional average 98.6 °F / 37.0 °C; normal varies by person and time of day — compare to the patient's own baseline |
| Fever (CDC) | Measured temperature of 100.4 °F (38.0 °C) or greater |
| Rectal / tympanic vs oral | About 0.5–1 °F HIGHER than oral |
| Axillary vs oral | About 0.5–1 °F LOWER than oral |
| Pediatric temperature route (AAP) | Rectal is most accurate under 3 years; tympanic not used under 6 months; oral not recommended until about age 4 |
| Tympanic pinna pull | Adults and children over 3: UP and back. Children under 3: DOWN and back |
| Adult resting pulse | 60–100 bpm; under 60 bradycardia, over 100 tachycardia |
| Apical pulse site | Fifth intercostal space, left midclavicular line, full 60 seconds |
| Adult respirations | 12–20 breaths/min at rest; under 12 bradypnea, over 20 tachypnea |
| Adult pulse oximetry | Typically 95–100%; FDA warns readings can overestimate true saturation, more so with darker skin pigmentation |
| BP — normal (AHA) | Below 120 AND below 80 |
| BP — elevated (AHA) | 120–129 AND below 80 |
| BP — stage 1 (AHA) | 130–139 OR 80–89 |
| BP — stage 2 (AHA) | 140 or higher OR 90 or higher |
| BP — hypertensive crisis (AHA) | HIGHER than 180 systolic and/or HIGHER than 120 diastolic — wait 5 min and recheck, notify the provider immediately; with chest pain, shortness of breath, back pain, numbness or weakness, vision change or difficulty speaking it is a hypertensive emergency, activate emergency services |
| Staging rule when numbers disagree | Stage by the HIGHER category; stage from the average of 2 or more properly taken readings |
| Cuff bladder width (AHA) | At least 40% of arm circumference |
| Cuff bladder length (AHA) | About 80% of arm circumference |
| Cuff placement (AHA) | Lower edge 2–3 cm above the antecubital fossa, on a bare arm, midline of the bladder over the brachial artery |
| Inflation level (AHA) | At least 30 mm Hg above the PALPATED systolic (the point the radial pulse disappears) |
| Deflation rate (AHA) | About 2 mm Hg per second, or per heartbeat when the heart rate is slow |
| Korotkoff sounds | Phase I (first sound) = systolic; phase V (disappearance) = diastolic |
| BP preparation (AHA/CDC) | No caffeine, exercise or smoking 30 min; empty bladder; 5 min quiet seated rest; no talking during or between readings |
| BP positioning (AHA/CDC) | Back supported, feet flat on the floor, legs uncrossed, bare arm supported at heart level |
| BP errors that RAISE the reading (AMA/AHA Target:BP) | Cuff over clothing 5–50 mm Hg; full bladder 10–15; talking about 10; unsupported arm about 10; crossed legs 2–8; unsupported back and feet about 6 |
| Orthostatic procedure | BP and pulse supine after 5 min, then repeated at 1 min and 3 min standing |
| Orthostatic hypotension (American Autonomic Society / AAN consensus) | Sustained fall of at least 20 mm Hg systolic OR at least 10 mm Hg diastolic within 3 minutes of standing |
| Pulse rise on standing — NOT orthostatic hypotension | A sustained heart-rate rise of 30 bpm or more within 10 minutes of standing WITHOUT a BP fall is the postural tachycardia syndrome (POTS) criterion; document and report it, but do not call it a positive orthostatic drop |
| BMI formula | kg ÷ m², or lb ÷ in² × 703 |
| CDC adult BMI bands | Underweight below 18.5; healthy weight 18.5 to below 25; overweight 25 to below 30; obesity 30 or higher |
| Waist circumference risk (CDC) | Greater than 40 inches in men; greater than 35 inches in non-pregnant women |
| Conversions | 1 kg = 2.2 lb; 1 in = 2.54 cm; °C = (°F − 32) × 5/9; °F = (°C × 9/5) + 32 |
| Pain tools | 0–10 numeric (adults); Wong-Baker FACES self-report validated from age 3 and usable in adults; FLACC observational validated 2 months–7 years; an adult who cannot self-report needs an observational behavioral tool per facility protocol |
| Patient identifiers (The Joint Commission, NPSG.01.01.01) | At least two person-specific identifiers, e.g. name, date of birth, medical record number, last 4 of SSN; NEVER the room number or physical location |
| Growth charts (CDC/AAP) | WHO growth standards birth to 2 years (recumbent length, head circumference); CDC growth charts 2 years and older (standing height, BMI) |
| PALS infant, 1 month–1 year | Awake HR 100–180 bpm; RR 30–53 breaths/min |
| PALS toddler, 1–2 years | Awake HR 98–140 bpm; RR 22–37 breaths/min |
| PALS preschool, 3–5 years | Awake HR 80–120 bpm; RR 20–28 breaths/min |
| PALS school age, 6–11 years | Awake HR 75–118 bpm; RR 18–25 breaths/min |
| PALS adolescent, 12–15 years | Awake HR 60–100 bpm; RR 12–20 breaths/min |
| Pregnancy (ACOG) | Resting pulse rises; systolic 140 or higher OR diastolic 90 or higher after 20 weeks is reported promptly (ACOG confirms gestational hypertension on 2 occasions at least 4 hours apart); 160/110 or higher is severe range |
| Older adults | Isolated systolic hypertension is common; febrile response is blunted and baseline temperature lower, so infection can present below 100.4 °F; orthostatic drops are more frequent |
| Notify the provider immediately (EXAMPLE standing orders — site protocols vary, follow yours) | BP higher than 180/120 on recheck; SpO2 below 90%; adult pulse below 50 or above 120; a respiratory rate outside 12–20 that is sustained or paired with visible distress; temperature 100.4 °F (38.0 °C) or higher; and ANY new chest pain, severe shortness of breath, syncope, new confusion or acute severe pain regardless of the numbers |
Test yourself
No answers here on purpose — retrieving them is the practice. Drill this domain if any of these stall you.
- List the intake sequence in order, from the moment you call the patient back to the moment you record the last vital sign.
- State the four AHA adult blood pressure categories with their exact numbers, then state the hypertensive crisis threshold, whether it is inclusive, and what changes when the patient has symptoms.
- Give the full preparation and positioning checklist before a blood pressure reading — six items minimum.
- How far above the palpated systolic do you inflate, at what rate do you deflate, how far above the antecubital fossa does the cuff's lower edge sit, and what is the auscultatory gap?
- Which direction does each of these bias the blood pressure reading: cuff too small, cuff too large, arm below heart level, cuff over clothing, patient talking? Give the mm Hg figure for the last two.
- Describe the full orthostatic vital sign procedure with its timing, state the two blood pressure findings that define orthostatic hypotension, and state what a sustained 30 bpm pulse rise WITHOUT a blood pressure fall is the criterion for.
- Give the adult normal ranges for pulse, respirations and oxygen saturation, the CDC fever threshold, and name the term for each abnormal direction of pulse and respirations.
- A tympanic reading is 100.1 °F. Roughly what oral value does that suggest, and does the tympanic value itself meet the CDC fever definition?
- Convert: a patient weighs 176 lb and is 5 ft 6 in tall. Give the weight in kilograms, the height in centimeters, and the BMI with its CDC category.
- Which pain tool for each: a 4-month-old, a 4-year-old who is verbal, a 30-year-old, and a nonverbal adult with advanced dementia?
- Name three ways an older adult's vital signs differ from a young adult's, and two things that change about how you handle a pregnant patient's pulse and blood pressure.
- State the awake pulse and respiratory rate ranges for a PALS infant, toddler, preschooler, school-age child and adolescent, with the age band for each.
- A patient's second reading is 186/124 and she reports a headache and blurred vision. State exactly what you do, what you say to the patient, and what you must not say.
- During medication reconciliation a patient says he takes "two of the blue water pill instead of one, because my ankles swell." What do you document, and what is outside your scope of practice here?
- List every value from this guide that would trigger immediate provider notification under the example standing orders, and explain why that list is protocol-dependent rather than universal.