OnExam

Measurement early in the appointment allows for later reassessment if values are abnormal.

Blood Pressure

  • Cuff (sphygmomanometer) size
    • Width of bladder ~40% of the circumference of arm
    • Length of bladder ~80% of the circumference of arm
  • Nicotine or caffeine should not be consumed 30 minutes prior to measurement
  • Examination room quiet and comfortable
  • Patient to sit quietly for 5 minutes prior to measurement with both feet placed on the floor (uncrossed) and the arm at heart level
  • Arm must be free of clothing
  1. Palpate brachial artery to verify presence of pulse
  2. Support antecubital crease at heart level
  3. Secure lower border of cuff ~2.5 cm above antecubital crease
  4. Estimate how high to inflate cuff to avoid auscultatory gap
    • Palpate the radial pulse and inflate the cuff until it disappears
    • Add 30 mm Hg
    • Wait ~15 seconds before re-inflating cuff
  5. Place bell of the stethoscope over the brachial artery
  6. Inflate the cuff rapidly to determined value and then deflate it slowly (~2-3 mm Hg/s)
    • Avoid slow or repetitive inflations of cuff (venous congestion can cause false readings)
  7. Systolic pressure: Level when 2 consecutive Korotkoff sounds are heard
  8. Continue deflating 10 mm Hg after Korotkoff sounds disappear
  9. Diastolic pressure: Level of disappearance of Korotkoff sounds
  • Record the values to the nearest 2 mm Hg
    • Repeat the measurement after ~2 minutes
  • Average the two measurements
    • Take further measurements if >5 mmHg different
  • BP should be taken in both arms at first visit
    • Further measurements should be taken in arm with the higher reading
  • Classify the BP as per the Blood Pressure Classifications

Weak and Inaudible Karotkoff Sounds

  • Raise the patient’s arm before and during inflation of the cuff. Lower the arm for the reading of the pressures.
  • Inflate the cuff and ask the patient to make a fist several times and then continue the measurement.

Arrhythmias

  • Take several measurements as the pressure values will vary with arrhythmias but keep in mind that the measurements will only be approximations

Anxious Patient ("White Coat Hypertension")

  • Try to make patient comfortable
  • Take a measurement at the end of the office visit

Heart Rate and Rhythm

  • Radial pulse is easily accessible and therefore commonly used
  • Use the pads of your middle and index fingers over the radial artery
  • Note rate, rhythm, amplitude, and contour of pulse
  • If rate and rhythm normal, assess for 15 s and multiply value by 4 to beats per minute (bpm)
  • If tachycardic (>100 bpm) or bradycardic (<60 bpm), count for full 60 s
  • If irregular rhythm detected:
    • Auscultate heart for the most accurate heart rate measurement Differentiate between regularly irregular, irregularly irregular, or variable with respiration

Respiratory Rate and Rhythm

  • Assess while patient is not paying attention
    • Useful to observe after the heart rate unbeknownst to the patient
  • Observe rate, rhythm and effort of breathing
  • Normals:
    • Early childhood: 20 – 40 bpm
    • Late childhood: 15-25 bpm
    • Adult (>15 years of age): 12 – 20 breaths per minute (bpm)

Temperature

  • Often reserved for when there is a suspected abnormality
  • Timings noted are for analog probes; electronic probes provide readings much quicker

Oral Temperatures

  • 37°C (98.6°F) average
  • Closed lips around thermometer and under tongue for 1 min
  • Delay readings if hot or cold beverages recently consumed
  • Oral temperatures not recommended if the patient is unconscious or unable to close mouth

Rectal Temperatures

  • 0.5°C (0.9°F) higher than oral
  • Patient to lie on side facing away from you with hips flexed
  • Use lubricated, stubby tip thermometer
  • Insert thermometer 3-4 cm into the anus in the direction of the umbilicus
  • Remove after 3 minutes

Tympanic Membrane Temperatures

  • 0.8°C (1.4°F) higher than oral
  • Ensure external auditory canal clear of cerumen
  • Aim infrared beam towards the tympanic membrane in the canal and hold it for 2-3 seconds

Axillary Temperatures

  • 1.0°C (1.8°F) lower than oral
  • Not as accurate as the other measurements (not frequently used)
  • Requires holding thermometer in the axilla for 5-10 min

References

  1. Bickley LS, Szilagyi, PG. Chapter 4, Beginning the Physical Examination: General Survey and Vital Signs. In: Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007: 105-112.