Let us begin our patient’s physical examination by determining the blood pressure together. First, we shall palpate the brachial artery. Once identified, we shall inflate the blood pressure cuff until we can no longer palpate the vessel. At that point, we’ll listen together with the diaphragm of the stethoscope. We’ve just exceeded the point where the vessel was palpable, and now we shall slowly deflate the cuff listening for the Korotkoff sounds. Let’s listen together. [ Korotkoff sounds]
Our patient’s blood pressure is 170/110. It is clearly elevated.
BP determination technique
The correct technique of blood pressure measurement is as follows: seat the patient quietly for at least five minutes, with back supported and feet on the floor. When measuring blood pressure support the patient’s arm at heart level. The cuff bladder length should be at least 80% of the arm circumference. It must be applied snugly with the bladder centered over the artery. Inflate the cuff to 20 mmHg above the point at which the radial pulse disappears. Then deflate the cuff at a rate of 2-4 mmHg per second. Measure both arms. Use the arm with the higher pressure. The first Korotkoff sound marks systolic blood pressure. Disappearance of Korotkoff sounds indicates diastolic blood pressure.
Diastolic BP
In some cases, the diastolic blood pressure may be more accurately determined when the Korotkoff sounds become muffled. These include children and patients with aortic regurgitation and other high-output states such as pregnancy and anemia.
First examination
On the first examination of an hypertensive patient, the blood pressure should be taken in both arms with the patient seated. It should also be taken with the patient standing. It should be taken in the leg only if there is an indication such as a reduction in pulse amplitude as in aortic coarctation. Differences between right and left arm blood pressures of more than 10 mmHg may be abnormal, and reflect underlying disease due to vascular anomaly or occlusion, including aortic dissection. The systolic blood pressure in the legs is normally 10 to 20 mmHg higher than in the arms. If leg blood pressures are lower, coarctation should be suspected. After the first examination, subsequent blood pressure measurements should be obtained in the arm with the initially higher level.
Standing BP
The standing blood pressure should be measured as well. Normally, a minor systolic fall and a diastolic rise will occur. An orthostatic decline in blood pressure greater than 10 mmHg may be a clue to volume depletion, a secondary cause of hypertension or may reflect an autonomic neuropathy or vasodilator medication. Our patient's standing blood pressure was 168/115 mmHg. The blood pressure in the arms was the same, and in the leg was slightly higher than the arms.