michigan hypertension core curriculum - State of Michigan

E Circulation
G Neurologic
General appearance
Inspection begins when the patient first enters the clinic. Observe the patient’s behavior
and gait for signs of neurologic deficits. Observe respiratory pattern for signs of dyspnea on
exertion. Determine the patient body habitus. Central weight gain (apple shape) correlates with
metabolic risk factors for cardiovascular disease.
Waist measurement
Patient should be wearing gown and non-restrictive briefs or underwear. The
measurement should not be made over clothing. The patient should stand erect with
the abdomen relaxed, the arms at the sides and feet together. The measurer faces the
subject and places an inelastic tape around the subject in a horizontal plane at the level
of the natural waist. The measurement should be taken at the end of a normal expiration
without the tape compressing the skin. Record to the nearest 0.1cm.
Respiration
Respiration affects the level of BP, with SBP falling during inspiration. The basis for
this effect is twofold. First, during inspiration, intrathoracic pressure falls, the lungs expand,
and pulmonary venous capacitance increases. This results in increased venous return to the
right ventricle and diminished blood flow to the left ventricle. The decreased left ventricular
preload contributes to the lowered SBP. Second, changes in intrathoracic pressure are directly
transmitted to the intrathoracic aorta. The degree of fall in systemic BP is proportional to the
fall in intrathoracic pressure. During the normal respiratory cycle SBP falls between 5 to 10 mm/
Hg from the end of expiration to the end of inspiration. In asthma, however, this drop is larger
and may exceed 10mm/Hg. The excessive drop in systolic BP during the respiratory cycle
is known as the pulsus paradoxus. Pulsus paradoxus has also been observed in pericardial
tamponade.
Pulse
Manual determination of pulse rate is integral to BP evaluation. Pulse rate, rhythm
and pulse contour are evaluated. Tachycardia or bradycardia may reflect intrinsic cardiac
disease, medical illness or reaction to medication. Similarly, rhythm reflects cardiac arrythmias.
The brachial pulse should be compared to the apical impulse (palpated or auscultated). Not
all cardiac contractions are transmitted to the periphery – this is particularly true in special
situations such as atrial fibrillation. Premature ventricular contractions (PVC) result in
uncoordinated ventricular contraction and diminished stroke volume. Thus, only assessing the
presence of peripheral pulses may underestimate the true heart rate.
Similarly, patients with pulsus alternans, alternating weak and strong ventricular
contractions result in only half of the cardiac contractions being effective. This discrepancy
of peripheral and apical rate is known as pulse deficit. Pulsus bisferiens, a double peak in the
pulse, is difficult to palpate, but may manifest as a “split” Korotkoff sound.
Palpate pulses in both arms and one leg. Coarctation of the aorta usually presents with
equal radial but diminished femoral pulses. Rarely (