Blood Pressure and Pulse Measurement Basics

General Examination

• Pulse - Edema - Resp: Patient should be alert, conscious, with intact memory, normal intelligence & oriented to time, place & people.

Vital Signs

• Rhythm: Regular
• Rate: Count for 30 seconds, multiply by 2.
• Volume: Assess arterial wall (rolling)
• Equality: on both sides
• Peripheral Pulsations: Assess Dorsalis pedis and Posterior tibial arteries, check them both, not just one, as sometimes one may be missing or different. Use both sides (both medial malleolus and heel)
• Arteries: Use proper technique and anatomical landmarks for assessment, lateral to tendon and big toe for flexion.

Pulse Rhythm

• Regular Rhythm: Pulse rhythm should be consistent. Problems are identified by irregularity
• Extrasystole: Irregular rhythm, extra heartbeats
• Regular Irregularity: Regular beats but with an irregular interval between them
• Irregular Irregularity: Irregular beats and irregular intervals
• Volume: High volume (special character), water-hammer pulse (no special character)
• Arterial Wall: Should not feel special characters, equal on both sides, average volume, and intact peripheral pulsations.
• Pulses: Check for normal rate, volume, and arterial wall on both sides.

Blood Pressure

• Palpatory Method: Close cuff, pump until pulse goes away (20-30 mmHg), release until you feel the pulse, this is the systolic
• Auscultatory Method: Release pressure slowly above systolic (by 30-40 mmHg), hear the first pulse sound (systolic), and final pulse sound as diastolic.
• Technique: Support arm at heart level, cuff 3cm below the biceps tendon.

Respiratory Rate

• RR: Count normal breaths by counting Inspiratory + Expiratory = 1 Cycle.

Temperature

• Normal Range: 36.5 – 37.3 C
• Axillary: Slightly higher than rectal (by 0.5 C).

Head and Neck Examination

• Head: Examine for jaundice, central cyanosis, and anemia (pallor)
• Carotid: Palpate
• Trachea: Palpate midline at thyroid cartilage
• Thyroid Gland: Check for abnormalities
• Lymph Nodes: Lymph nodes should be examined (submental, submandibular, ant and post cervical, supraclavicular, pre-auricular, post-auricular, and occipital).

Neck Veins

• Inspection: Visual assessment for pulsations and congested veins.

Upper Limb Examination

• Window test: Check for tremors and swelling with proper exposure.
• Fine Tremors: Check for tremors by having the patient stretch their arm forward and clench their fist. Observe the wrist.
• Flapping Tremors: Observe for tremors.
• Palmar Erythema: Check for redness or swelling in palm.
• Swelling and Scars: Observe for any visible swelling or scars.

Edema

• Pitting: Assess for pitting edema.
• Bilateral vs. Unilateral: Note if edema present on one or both sides.
• Medial Malleolus: Assess on the most dependent area.
• Uni vs. Bilateral: Note for uni and bilateral.

Neurological Examination

• Abnormal Gait: Examine posture for abnormalities (inspection of muscle bulk - important to note proper exposure and muscle bulk).
• Tone (Upper Limb): Assess for muscle tone, resistance (shaking wrist, elbow flexion and extension).
• Tone (Lower Limb): Assess tone for muscle (shaking ankles, knee flexion & extension).
• Power: Assess movement and strength of muscles (note proper exposure).
• Reflexes (Deep): Check reflexes using the hammer at proper exposure. Assess Biceps, Triceps, Brachioradialis.

Neurological Examination (continued)

• Neurological Examination (2 LL - Knee-Ankle): Support the legs and palpate tendons.
• Coronal Reflex: Examination for abnormalities.
• Cranial Nerves: Check for facial nerve function (frontalis, buccinator, orbicularis occuli, orbicularis oris, and retractor anguli).
• Hypoglossal Nerve: Have the patient stick their tongue out and check for deviation.

Cardiac Examination

• Inspection & Palpation: Examine cardiac shape, skin, and any movements around epigastrium.
• Apex: Note location, extent, character, and palpable sounds.
• Normal Site: Locate the apex appropriately (5th Lt intercostal space in midclavicular line).
• Extent: Record as either localized or normal.
• Character: Note the character (force and tapping) as either gentle or forcible.
• Palpable Sound: Record any audible sounds during palpation.
• Palpable Thrill: Note thrill (gentle tapping, vibration, etc.).
• Epigastric Pulsations: Describe whether pulsations are present there, and whether they’re coming from the Liver or Rt. ventricle enlargement. Also note their character.
• Left Parasternal Pulsations: Check for pulsing and thrill in the left 2nd intercostal space
• Aortic area: Check for any pulsating or thrill abnormalities. Use proper technique

Cardiac Examination (continued)

• Auscultation: Use proper technique with normal heart sounds, S1, S2, and murmurs.

Thoracic Examination

• Inspection: Assess shape, symmetry, and skin.
• Movement: Observe respiratory rate and type (thoraco-abdominal or thoracic).
• Expansion: Observe for equal chest expansion.
• Pulsations: Palpate for pulsations in apical, epigastric, and pulmonary areas.
• Back: Observe shape, skin, movement, and palpated areas of the posterior thoracic regions.

Abdominal Examination

• Inspection: Assess shape, skin, and movement.
• Subcostal Angle: Check for abnormalities and correlation with upper abdominal swelling,
• Epigastric Pulsations: Check for pulsations under the sternum.
• Umbilicus: Note location, shape, and any abnormal findings (discharges, etc.)
• Percussion: Note tidal percussion technique, resonance (or dullness) in various areas, using technique specifics.
• Palpation: Note any tenderness, noting the exact places.
• Areas: Look and listen for abnormalities in infra-clavicular, anterior-mammary, infra-mammary, axillary, superior, inferior areas