Physical Examination

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The blood pressure should be measured with a cuff of the appropriate size for the patient. The width of the inflatable portion of the cuff should be about 40 percent of the circumference of the limb and the length of the inflatable portion should equal 80 percent of the limb's circumference. Using a cuff that is too short or narrow or too loose may cause falsely high readings. The blood pressure should be measured at least twice if the first value is elevated (SBP of more than 140 mmHg or DBP of more than 90 mmHg). For severe elevation, measure pressure in both arms and legs, and palpate pulses in all extremities. In adults, a differential in brachial systolic pressures of more than 20 mmHg may indicate the presence of aortic coarctation, aneurysm, or dissection.

Focus the physical examination on the detection of target-organ damage and determine the acuity. Neurologic examinations that reveal focal findings or mental status changes may indicate hypertensive encephalopathy, subarachnoid hemorrhage, or stroke. A careful funduscopic examination may reveal acute changes such as hemorrhages, cotton-wool exudates, or disk or retinal edema (grade III or IV retinopathy). Alternatively, grade II retinopathy suggests chronic uncontrolled hypertension. Hyperreflexia with peripheral edema in a pregnant woman is suggestive of preeclampsia. This physical finding may also be found in elderly patients with multiple small ischemic strokes (lacunes).

On cardiovascular examination, auscultate for carotid bruits, murmurs, third and fourth heart sounds (S 3 and S4), and a pericardial rub. An S3 occurs in association with ventricular failure (either right or left), whereas an S 4 occurs when there is left ventricular hypertrophy and a noncompliant left ventricle. A right-sided S 4 may be heard with coexisting pulmonary hypertension. Left-sided congestive heart failure is associated with unexplained tachycardia as an early finding and pulmonary rales as a late finding. Diminished extremity pulses may be found in patients with coarctation of the aorta or aortic dissection. The abdomen should be examined for a bruit and a palpable pulsatile mass that may indicate the presence of an abdominal aortic aneurysm.1

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