Cardiovascular

examination

Dr Yaseen Omran
 Examination

• Check if patient is in pain and offer pain killers

• Explain what you are doing and ask for consent

• Reassure , during my examination if you feel any pain please

let me know I will stop it right away

• Wash hands
Examination
• Position the patient at 45°
• Expose the chest and look at the general
appearance of the patient
• Start from the hands  pulses  BP  face
 neck  pericardium  back  abdomen
 legs
General appearance
• Note patient’s respiratory movements
(?dyspnoea)

• ? Cachexia (severe cardiac failure)

• Marfan’s or Down’s syndromes

Hands
• Check for clubbing
• Check the nails for splinter haemorrhages
?endocarditis (majority are due to trauma)
• Check the palms for Osler’s nodes (tender,
septic emboli) and Janeway lesions (non-
tender, immunological origin)  endocarditis
• Look at the tendons of the hand for
xanthomata  hyperlipidaemia
Pulse
• Check the rate of pulse over 30 seconds (15
seconds in long cases)
• Check the rhythm
• Check radio-radial delay  subclavian artery
stenosis or dissection of thoracic aorta
• Check radiofemoral delay  coarctation of the
aorta
• Character of the pulse:
– Collapsing pulse  AR
– Pulses alternans (alternating strong and week pulse)
 advanced LV failure
Blood pressure
• Need a larger cuff for obese patients because
the normal size one will overestimate BP
• If pt had mastectomy or AV fistula on one
side use the arm on the other side
• Estimate the systolic pressure by palpating the
radial pulse and then measure it accurately
with the stethoscope
• Brachial artery should be about the level of
the heart
Blood pressure
• If the sound doesn’t disappear (korotkoff 5)
use the level at which the sound gets muffled
(korotkoff 4)
• Pulsus paradoxus:
– Not a pulse
– Fall of more than 10 mmhg during inspiration
– Think about pericardial effusion, constrictive
pericarditis and asthma
Blood pressure
• Postural hypotension is a fall of more than
15mmhg systolic or 10mmhg diastolic when
patient stands
• Causes are HANDI
– Hypovolaemia, Hypopituitarism
– Addison’s disease (adrenal failure)
– Neuropathy (autonomic neuropathy like DM)
– Drugs (TCA, antipsychotics)
– Idiopathic
Face
• Mitral facies
• Xanthelasmata (cholesterol
deposits around the eye
• Check the conjunctiva for pallor
• Check the sclera for jaundice
(hepatic congestion)

• Check inside the mouth for high

arched palate, teeth decay and
central cyanosis
Neck
• Palpate one carotid artery at a
time

• Check the right jugular vein

(45°, head turned slightly left)
– Usually decreases with
inspiration
– JVP should always be less than
8cm water (less than 3cm from
the sternal angle)
Neck
Neck
• Abdomino-jugular reflux:
– Press on abdomen for 10 sec using
your palm
– JVP should rise and then fall
– +ve reflux if JVP remains high
(>9CM) even after pressure is
released
– Not necessary to compress the liver
– Detects early stages of RHF
• Cannon waves  complete heart
block
Pericardium
• Inspection:
– check for scars, skeletal
abnormalities, pace maker…..etc
– Look for the apex beat (fifth left
intercostal space)
• Palpation:
– the first palpable intercostal
space is the second
– Palpate the apex
Pericardium
• Palpation:
– Using the heel of your hand,
palpate the left sternal edge for
parasternal impulse  RV
enlargement
– Palpate the apex and the base of
the heart with a flat hand looking
for thrills
– N.B the apex is best felt and heard
with the patient rolled to the left
(left lateral position)
– N.B the base of the heart is best
felt and heard with patient sitting,
leaning forward and in full
expiration
Pericardium
• Auscultation:
– Start with the bell at the mitral
area (best for diastolic murmurs)
– Next use the diaphragm in the
same area (systolic murmurs)
– Then the tricuspid
– Pulmonary (the best area to hear
the split in the 2nd heart sound,
more obvious with inspiration)
– Aortic
Pericardium
Pericardium
• Auscultation:
– If you hear a murmur, it’s crucial
to know if it’s systolic or diastolic
– Pericardial friction rub 
pericarditis
– Put pt in left lateral position
palpate and auscultate the apex
Pericardium
• Dynamic Auscultation:
– Auscultate the aortic area while
pt is sitting up, leaning forward
and in full expiration  best for
aortic regurgitation and
pericardial friction
– Valsalva manoeuver  best for
hypertrophic cardiomyopathy
murmur
Pericardium
Pericardium
• Auscultation:
– Ask the patient to stop breathing
and Auscultate the neck for
bruits using the bell of the
stethoscope

• NB we start and finish

auscultation with the bell
The back
• Percuss and auscultate the lung
bases for crackles
• Look and Feel for pitting
oedema at the sacrum
The abdomen
• Lie the patient flat
• Palpate the liver looking for:
– enlargement  RV failure
– Pulsatile liver  tricuspid
regurgitation

• Palpate the spleen if you

suspect endocarditis 
splenomegaly
The legs
• Look for cyanosis, atrophic
changes (PVD), oedema,
clubbing of toes or xanthomata
• Press the skin at the lower tibia
looking for pitting oedema
• Feel the dorsalis pedis and
posterior tibialis
• Compress the calves for DVT
 Case study
45 year old female comes to see you in the ED for a
sever chest pain which started 10 hours ago. The pain
radiates to the back and left shoulder. Severity is
8/10. Patient is hypertensive (well controlled on
ACEI). On further questioning her medical history is
unremarkable apart from smoking 3 cig/day and a
recent flu-like symptoms last week.
Task
1. Do appropriate physical examination
2. Give differentials
Case study
 Pericarditis
• pleuritic pain (the commonest), aggravated by
cough and deep inspiration, sometimes brought on
by swallowing; worse with lying flat, relieved by
sitting up
• pain increasing with breathing, improving when
leaning forward
 Pericarditis
• How to recognize it on ECG
– Widespread concave ST elevation and PR depression
throughout most of the limb leads (I, II, III, aVL, aVF) and
precordial leads (V2-6).
– Reciprocal ST depression and PR elevation in lead aVR (±
V1)
– Sinus tachycardia is also common in acute pericarditis
due to pain and/or pericardial effusion
 Pericarditis
• NB. ST- and PR-segment changes are relative to the
baseline formed by the T-P segment. The degree of
ST elevation is typically modest (0.5 – 1mm)
 Pericarditis
• Steps to distinguish pericarditis from STEMI:
– Is there ST depression in a lead other than AVR or V1?
This is a STEMI
– Is there convex up or horizontal ST elevation? This is a
STEMI
– Is there ST elevation greater in III than II? This is a STEMI
– Now look for PR depression in multiple leads… this
suggests pericarditis (especially if there is a friction rub!)
Auscultation with the diaphragm of the stethoscope
over the left lower sternal edge, apex or aortic area
during end expiration with the patient sitting up and
leaning forward (or on hands and knees) allows the
best detection of the rub and increases the likelihood
of observing this finding
Case study
70 year-old male comes to see you because he is
starting to feel increasingly tired over the last
three months. He feels that his heart is racing.
He can’t do his daily 30min walks anymore. He
had an MI when he was 63.
Task:
1. Appropriate PE with running commentary
2. Explain your findings to pt
3. Manage the case
 Case study

Ventricular rate varies from 130-168 beats per minute.

Rhythm is irregularly irregular. P waves are not discernible
 Atrial fibrillation
• paroxysmal: episodes come on suddenly and
generally revert spontaneously within the next
24 to 48 hours without any intervention
• Persistent: similar abrupt onset but episodes persist
for days or weeks unless active measures are taken
to revert the patient to sinus rhythm
• permanent (or chronic): where the patient has
demonstrated inability to sustain sinus rhythm for
any length of time,
 Atrial fibrillation
• The evidence suggests that patients with
paroxysmal or persistent atrial fibrillation have a
similar risk of thromboembolism to patients with
permanent atrial fibrillation.
 Atrial fibrillation
• Management:
– rate control
– rhythm control
– prophylaxis against thromboembolic complications.
• Rate versus Rhythm:
– TG: no statistically significant difference in mortality or in
quality of life between the two groups. However, some
studies suggest quality of life may be improved by being in
sinus rhythm
– UpToDate: Most patients with symptomatic new onset AF
should have at least one attempt at cardioversion
• from the above  Cardiology consult
 Atrial fibrillation
• Rate control:
– Atenolol, metoprolol, diltiazem, verapamil
– AF and HF  you can use digoxin
• Rhythm control:
– If there is doubt as to duration of the atrial fibrillation, or if it
is clear the attack has lasted more than 48 hours, do not
attempt to cardiovert until steps are taken to minimise
thromboembolic risk, except for the haemodynamically
unstable patient where there is no choice but to accept the
risk
– It is usual to aim to return the patient to sinus rhythm if
there is no clear contraindication, simply because of the
symptomatic nature of the episode.
 Atrial fibrillation
• Rhythm control:
– If a transoesophageal echocardiogram is not performed,
or is done and shows thrombus, cardioversion should
not be attempted until the patient has been fully
anticoagulated, preferably for 3 weeks
– Medically : Amiodarone or flecainide
– DC shock
 Atrial fibrillation
• Thromboembolic risk:
– Even in very recent onset atrial fibrillation, there is a risk
– All patients in whom atrial fibrillation is discovered
should be considered for long-term anticoagulation with
warfarin or dabigatran, whether discovery is because of
symptoms or as a chance finding (as is often the case in
elderly patients).
– Clinical trials have directly demonstrated an overall
relative risk reduction for stroke of about 70% with
warfarin
 Atrial fibrillation
• Oral anticoagulation:
– Patients with a previous thromboembolic event and
those with valvular disease underlying their atrial
fibrillation are at particularly high risk, and oral
anticoagulation should be started in all these patients
unless there are contraindications.
– The CHADS2 score is the most widely used means of
estimating thromboembolic risk in nonvalvular atrial
fibrillation
Atrial Fibrillation
JM6 page 1434
Case study
A 60 years old man. Diagnosed with new onset
AF. He was admitted to hospital and
cardioversion medically and electrically were
unsuccessful. A cardiology consult was organized
and the cardiologist recommended starting him
on Warfarin. Now you are back at the ward to
see the patient in your afternoon round.
Task
• Talk to the patient regarding new medication
• Answer his questions
 Warfarin
• Warfarin is an anti-clotting medicine, or
“anticoagulant”. It is used to prevent or treat
unwanted blood clots within blood vessels.
• Dose will be adjusted to find the right balance
between bleeding and clotting.
• The balance is measured using a blood test called
the “International Normalised Ratio”, or “INR”. The
ideal INR range for most people is between 2 and 3.
• INR tests are required everyday at the beginning of
the treatment. However, the frequency of these test
are reduced gradually to monthly as your INR
stabilizes.
 Warfarin
• Make sure you have your INR tests done every time
they are ordered by your doctor. Contact your
doctor or laboratory after each INR test and keep a
record of your INR results in the record section of
this booklet. Bring this booklet to your next doctor
visit.
• Other medicines can affect how well warfarin
works. Always talk to your doctor or pharmacist
before starting or stopping any prescription or
overthecounter medicines, herbal medicines,
vitamins or health supplements.
 Warfarin
• Indications
1. Prosthetic cardiac valves
2. Deep venous thrombosis
3. pulmonary thromboembolism
4. Atrial fibrillation (selected cases)
5. Transient ischaemic attacks
6. Severe peripheral vascular disease
7. Perioperatively in lower limb orthopedic surgery (low
dose)
8. Postcoronary bypass surgery (selected cases)
 Warfarin
• Contraindications
1. Active bleeding
2. Recent surgery
3. History of intracranial haemorrhage
4. Uncontrolled hypertension
5. Liver disease with impaired synthetic function—based
on (INR)
6. Pregnancy
 Warfarin
• Maintain a healthy, well-balanced diet, with a
consistent intake of green,leafy vegetables. Limit
your alcohol intake.
• The major side effect of warfarin is bleeding. Watch
yourself for signs of bleeding and if you are
concerned, contact your doctor as soon as possible.
• Think about ways you can reduce your risk of
bleeding on a day-to-day basis.
• Ensure all members of your healthcare team
(including doctors, specialists,dentists, nurses and
pharmacists) know that you are taking warfarin.
 What is INR?

• A blood test is needed to determine the effect of warfarin

for each person.
• The INR is a measure of how long it takes for blood to clot.
• The INR for a person not taking warfarin is 1. The higher the
INR, the longer it takes for blood to clot. The desired INR
for you will depend on the reason for which you are taking
warfarin.
• Your doctors will try and keep your INR within a range –
called the target INR range.
• The target INR range is different for different
conditions. For example, for people with atrial fibrillation,
the target INR range is usually 2 to 3.
 What is INR?
• Clotting is necessary to stop bleeding when you cut
yourself. When taking warfarin your clotting time is
increased so it takes longer for a clot to form.
Having your INR in the correct range reduces the
risk of potentially dangerous bleeding.
• Generally regular blood tests are essential to check
that your INR is within the correct range.
• Your dose of warfarin may be changed based on the
blood test results.
 Warfarin
• How long do I need to take warfarin?
– depends on the condition being treated and may vary
from person to person. In AF it’s lifelong
• Which time of the day Should I take Warfarin?
– Take your warfarin at approximately the same time each
day, with or without food. Take the exact warfarin dose
prescribed by your doctor. Some people might need to
take different doses every second day or on different
days of the week.
 Warfarin
• What do I do if I miss a dose?
– Try to avoid missing doses of warfarin. It is a good idea
to keep a record of the doses you take each day (this
booklet can be used). If you do miss a dose, never take a
double dose to catch up. I’ll give you written instruction
on what to do depending on when you remember.
 Warfarin
• What do I do if I miss a dose?
– If you forget to take a dose of warfarin and then
remember within 3 to 4 hours  you can still take your
tablets.
– If you forget for a longer time, do not take the tablets to
catch up but take your next dose when it is due. Keep a
record of any missed doses and tell your doctor or
pathology laboratory.
– NEVER TAKE A DOUBLE DOSE
 Warfarin and other drugs
• Increased risk of bleeding and INR may increase
– Antibiotics (e.g. ciprofloxacin, clarithromycin,
norfloxacin, roxithromycin, metronidazole,
sulfamethoxazole + trimethoprim)
– Antifungal medicines (e.g. fluconazole)
– Cholesterol lowering medicines (e.g. fenofibrate,
gemfibrozil, rosuvastatin, simvastatin)
– Medicines for abnormal heart rhythms
(e.g.amiodarone)
 Warfarin and other drugs
• Increased risk of clotting and INR may decrease
– Medicines for epilepsy (e.g. carbamazepine, phenytoin)
– Thyroid medicines (e.g. carbimazole, propylthiouracil,
thyroxine)
– Ulcer or reflux medicines (e.g. antacids, omeprazole)
 Warfarin
• What should I eat?
– 1. Maintain a healthy, well-balanced diet with low
quantities of sugar and fats, including butter, margarine
and oil. This is important for everyone, whether or not
they are taking warfarin.
– 2. Maintain a consistent or “steady” diet - avoid crash
dieting and binge eating. If your food intake and type of
food eaten remains relatively constant, your INR is more
likely to remain stable.
– It is true that warfarin is affected by the amount of
vitamin K in your diet. You do not need to avoid foods
containing vitamin K, but should aim to keep their intake
fairly constant.
 Warfarin
• Common vegetables containing high or moderate
levels of vitamin K
– Asparagus, Kale
– Broccoli (cooked), Lettuce (gourmet) e.g. Butter lettuce
(not Iceberg)
– Brussels sprouts ,Parsley
– Cabbage, Silverbeet
– Endive, Spinach
–.
 Warfarin
• Can I drink alcohol?
– Consuming large amounts of alcohol, especially binge
drinking, can affect your INR and may increase your risk
of bleeding
 Warfarin
• What should I do if I bleed?
– The major side effect of warfarin is bleeding.
– Occasional nose bleeds.
– Gum bleeding while brushing teeth.
– Easy bruising.
– Bleeding after a minor cut that stops within a few minutes.
– Menstrual bleeding that is a little heavier than normal.
– Nose bleeds, gum bleeding and bleeding from minor
cuts should all stop within few minutes. If bleeding
persists or you are at all concerned, contact your doctor
as soon as possible.
 Warfarin
• What should I do if I bleed?
– It is important for you to watch out for signs of serious
bleeding, which should be reported urgently to your
doctor. Signs of serious bleeding include:
– Severe bruising that gets worse.
– Any bleeding, including nose bleeds or bleeding gums, that takes a long
time to stop.
– Unexplained bleeding or bruising (for example, bruises on your back
and chest when you haven’t injured yourself).
– Menstrual bleeding that is much heavier than usual, or unexplained
vaginal bleeding.
 Warfarin
• INR measurement schedule
before treatment  daily for 1 week
then,
2 times a week for 2 weeks
then,
weekly for 4 weeks
then,
monthly
JM page 1440
 Case study
Your next patient in your GP clinic is a 60-year-old ♀
with a known history of AF. She presents for her
routine INR Test. You ordered INR and came back as
4.5
Task
1. History
2. PE from examiner
3. Management
 History
• Have you been taking your medications regularly?
• Did you skip or take double doses?
• Did you take any other drugs recently?
• What medications were given to you? How many
times did you take it?
• Have you changed your diet recently?
• Have you been drinking more alcohol?
• Did you have any bleeding such as in the nose,
gums, urine or bowel motions?
• Do you have any headache or abdominal pain?
 Physical Examination
• General appearance
• Vital signs including BMI
• Check the nostrils and the gum with a torch for any
bleeding
• Chest and heart: carotid bruit, rate and rhythm of
heart. ?any skin bruises
• Abdomen: hematoma or tenderness, bruises
 Management
• If the INR is higher than the therapeutic range but less
than 5:
– Omit the next dose of warfarin. Resume therapy at a lower
dose when the INR approaches the therapeutic range (back
to daily INR tests)
• If the INR is 5 to 9:
– Cease warfarin therapy; consider reasons for
elevated INR and patient-specific factors.
– Give vitamin K.
– Measure the INR within 24 hours
• The onset of the effect of vitamin K on the INR can be
expected within 6 to 12 hours.
 Management
• Any clinically significant bleeding where warfarin-
induced coagulopathy is considered a contributory
factor Cease warfarin therapy and give vit K
• SEND to hospital
<5 + signs of internal bleeding
>5
Peripheral Vascular disease
• Examination:
– Check if patient is in pain and offer pain killers

– Explain what you are doing and ask for consent

– Reassure , during my examination if you feel any pain

please let me know I will stop it right away

– Wash hands
Peripheral Vascular disease
• Examination:
– Start with a general inspection for pallor, cyanosis or any
scars on the chest wall
– hands  arms
– Neck
– Chest
– Abdomen
– Lower limb
– Cough impulse
– Burger’s test
Peripheral Vascular disease
• Hands:
– Look at the hands for
• pallor/cyanosis
• Nicotine stains
– Feel the temperature in the hands and arms and
compare (↓ in PVD)
– Capillary refill time (CRT): (should be < 2 sec)
– Feel the radial pulse and assess the pulse for rate,
rhythm and for radio-radial delay (aortic dissection)
– Palpate the brachial arteries
– Measure BP
Neck, Chest and abdomen
• Neck
– Feel the carotid pulse and assess its character and
volume (one side at a time)
– Auscultate for carotid bruits
• Chest: listen to heart sounds quickly
• Palpate the abdomen for AAA
• Auscultate the aorta (bruits): just above the
umbilicus and slightly to the left
Peripheral Vascular disease
• Lower limb:
– Inspection: ?scars, amputated toes, skin and hair
changes. Look particularly for ulcers at the heel and
between the toes.
– Look for swelling and hemosiderin deposition (varicose
veins)
– Ask the patient to wiggle the toes (unable to do so in
cases of severe ischaemia)
– Feel the temperature in the feet and legs and compare
– Assess CRT in the toes
Peripheral Vascular disease
• Lower limb:
– Palpate the femoral pulse and assess for Radio-femoral delay
(coarctation of the aorta)
– Palpate the popliteal pulse (↑ pulse  possible aneurysm)
– Palpate the posterior tibialis and dorsalis pedis
– Auscultate the femoral artery and the popliteal artery for
bruits
– Palpate any varicose veins
• Hard  thrombosis
• Tenderness  thrombophlebitis
– Assess light touch sensation in the feet only (lost in ischemia)
– Squeeze the calves ?tenderness  think DVT
Peripheral Vascular disease
• Burger’s test:
– Elevate the legs to 45° and wait 60 sec
– Check if pallor develops  poor artery supply
– Put the legs dependent at 90° on the edge of the bed
– Check for cyanosis  poor arterial supply
– Normally there might be slight change –if any- in color
Varicose veins
• Cough impulse test:
– Apply firm pressure on the long saphenous vein opening
(5 cm inferior and medial to the femoral pulse, 2.5-4 cm
inferior and lateral to the pubic tubercle)
– Ask the patient to cough
– If you feel a fluid thrill  the saphenofemoral valve is
incompetent
Varicose veins
• Trendelenburg test using your finger or a tourniquet if
available
• https://www.youtube.com/watch?v=2CKgOojQnQ8

• Normally the superficial saphenous vein will fill from

below within 30–35 seconds as blood from the capillary
beds reaches the veins; if the superficial veins fill more
rapidly with the tourniquet in place there is valvular
incompetence below the level of the tourniquet in the
"deep" or "communicating" veins. After 20 seconds, if
there has been no rapid filling, the tourniquet is
released. If there is sudden filling at this point, it
indicates that the deep and communicating veins are
competent but the superficial veins are incompetent
Case study
• A 58 year old man, presents to your surgery
because of increasing cramps in his leg. He has
suffered for about 10 years from “jumpy” legs or
‘restless leg syndrome’.
• YOUR TASK IS TO:
• 1. Obtain a relevant history
• 2. perform an examination
• 3. advise the patient
Chronic lower limb ischaemia
• Pt has high BP and on propranolol  very
important to stop BB according to JM
• Intermittent claudication is a pain or tightness in
the muscle on exercise, relieved by rest.
• Rest pain is a constant severe burning-type pain or
discomfort in the forefoot at rest, typically occurring
at night when the blood flow slows down.

• The presence of rest pain implies an immediate

threat to limb viability.
Chronic lower limb ischaemia
• Ix
– FBE: exclude polycythemia and thrombocytosis
– Colour Doppler ultrasound: measure resting ankle
systolic BP; determine ankle/brachial index; normal
value 0.9 – 1.1
– Angiography: the gold standard, reserved for proposed
intervention
Chronic lower limb ischaemia
• Tx of claudication from TG:
– a graduated walking program
– Smoking cessation.
– lipid-modifying therapy with a statin.
– an angiotensin converting enzyme inhibitor (ACEI)
– an antiplatelet drug to reduce the incidence of
cardiovascular events. Aspirin is first-line therapy
– Surgery if indicated (specialist decision)
Chronic lower limb ischaemia
• When to refer to a vascular surgeon
– ‘Unstable’ claudication of recent onset; deteriorating
– Severe claudication—unable to maintain lifestyle
– Rest pain
– ‘Tissue loss’ in feet (e.g. heel crack, ulcers on or between
toes, dry gangrenous patches, infection)
JM6 page 743
Case study
• A 45 year old mother of three, presents to your surgery
complaining about a feeling of heaviness and fatigue in
her legs, particularly by the end of the day. She has
always had “large legs” with prominent veins but
recently her legs are also quite painful during
menstruation. She seeks your opinion what can be
done to relieve the symptoms.
Task:
1. Take a brief history
2. Perform an examination
3. Advise the patient about your findings, diagnosis and
suggested management
Varicose veins
• Similar examination as PVD
• Just add cough impulse and Trendelenburg test as
mentioned before
• You are required to assess the saphenofemoral
junction. If any other vein is the problem use
doppler.
• Venous duplex ultrasound studies will accurately
localise sites of incompetence and determine the
state of the functionally important deep venous
system.
Varicose veins
• Treatment
– Keep off legs as much as possible.
– Sit with legs on a footstool.
– Use supportive stockings or tights (apply in morning before standing out
of bed).
– Avoid scratching the itchy skin over veins.
• Compression sclerotherapy
– Use a small volume of sclerosant
– Ideal for smaller, isolated veins, particularly below the knee joint.
• Surgical ligation and stripping
– This is the best treatment when a clear association exists between
symptoms and obvious varicose veins (i.e. long saphenous vein
incompetence).
– Remove obvious varicosities and ligate perforators.
• Note: Surgery for varicose veins may not relieve heavy, aching legs.
Hypertension
• Examination:
– Similar to CVS examination
– Add tests or words for other causes of hypertension
• Causes: TRACKPADS
– T- thyrotoxicosis
– R- renal artery stenosis
– A- co-arctation of aorta
– C- Cushing syndrome
– K- PCKD, Renal diseases(CRF, Glomerulonephritis, Reflux
nephropathy)
– P- phaeochromocytoma
– A- primary aldosteronism(Conn’s disease)
– D- drugs
– S- sleep apnoea (borderline high BP)
Hypertension
• Examination: keep the following in mind
– Inspection:
• Cushnoid faces, buffalo hump, central obesity  cushing
• Big jaws, bossing of forehead, thick big hands  acromegaly
• Acne, Hirsutism  PCKD
– Ask for BP chart sitting and standing and in all limbs if
available
– In the face add FUNDOSCOPY
– In the neck add thyroid palpation and auscultation for bruit
– In the abdomen add balloting of the kidney for PCKD and
auscultation of renal arteries and aorta
– The low-pitched bruits of kidney artery stenosis are best
heard by placing the diaphragm of the stethoscope firmly in
the epigastric area
Hypertension
A 45 year old ♂ came to see you for a routine
checkup. He is hypertensive, smokes 10 cig/day and
drinks 4 SD/day.
Task:
1. Perform PE
2. Manage the case
Hypertension
Starting treatment for BP:
1
ACE inhibitor or ARB
or
calcium-channel blocker (CCB)
2
If target not reached: combination
ACE1 or ARB + CCB (best evidence)
or
ACE1 or ARB + thiazide
3
If target not reached:
ACE1/ARB + CCB + thiazide

Add only one agent at a time and wait about 4 weeks between dosage
adjustments.
Hypertension
• Read the Notes from JM6 pages 970-971