2. Objectives
By the end of this session, participants should be
able to:
1. Correctly measure and interpret blood pressure
2. Take full history and do physical examination relevant to
hypertension
3. Request and interpret relevant investigations and
interpret results
2
3. I . BP apparatus
Mercury sphygmomanometer
• Automatic BP Machine
3
Manual blood pressure
5. Blood pressure measurement (Digital)
5
Measurement of Blood Pressure
Patient should sit quietly for 5 minutes before measurement
Use correct size cuff and bladder
Measure BP while patient is sitting on a chair with back support
and with arm supported at level of heart. Patient’s arm must be
relaxed.
Take 2 measurements at least 1-2 minutes apart
BP in both arms should be measured at first visit and the arm
with the highest BP should be used for future measurements
Elderly patients, diabetics and other patients complaining of
symptoms suggestive of postural hypotension (e.g. dizziness,
unsteadiness or fainting when changing posture) should also
have their BP measured while standing, so that BP can be
compared to sitting BP.
6. BP cuff sizes
The bladder inside sphygmomanometer cuff should be correct size for
the patient.
- A standard bladder is 12 cm in width and 35 cm long
- Obese patients (arm circumference >32 cm) will require a larger bladder
and thin patients will require a smaller bladder.
Bladder width should be 40% of circumference of arm (12cm for a
normal arm, or 15cm for arm with mid upper circumference >33cm)
Bladder length should be long enough to wrap 80-100% around arm
6
7. Quality control in BP measurement
BP measuring device must be known to be accurate.
A manual device (sphygmomanometer) requires regular
maintenance and calibration at least once a year.
Digital machines must be validated.
No smoking or consumption of any caffeine-containing beverage
(e.g., coffee, tea, soft drinks) in the 30 minutes before BP
measurement.
Very high and very low BP readings taken from a digital machine
should be confirmed using a manual machine
7
9. Practical session (Time : 45min)
Divide the participants into 4-5 groups
Every participant must practice measuring
oBlood pressure
oHeight
oWeight
oCalculate BMI and classify
oWaist Circumference
oPulse rate
Record and compare measurements done on the same
individual by different observers.
Comment on the techniques of measurement.
Use checklist to measure blood pressure among themselves
9
10.
11. Increased waist circumference (central obesity) is
strongly associated with the development of insulin
resistance
Standardizing waist circumference measurement
• Place a tape around the bare abdomen, just above the hip bone, make
sure the tape is snug, but does not compress the skin.
• The tape should be parallel to the floor, midway between the top of the
iliac crest and the lower rib margin on each side.
• The patient should relax and exhale while measurement is made.
6/4/2023 11
12. Blood pressure measurement (Manual)
12
Action
Introduce your self
Ask for Consent and Explain what you are going to do
Wash your hands
Allow patient to rest for 5 minutes
Ensure upper arm is supported at heart level with palm facing upward
Ensure that tight or restrictive clothing is removed from the arm.
Check that the cuff is the correct size
Wrap cuff snugly around the arm with the center of the bladder covering the brachial artery.
Inflate cuff until radial pulse can no longer be felt to provide estimation of systolic pressure.
Deflate cuff completely and wait 15-30 seconds before continuing.
Inflate cuff to a pressure 30mmHg higher than the estimated systolic pressure
Place diaphragm of stethoscope over brachial artery (Do not tuck stethoscope under cuff)
Deflate cuff at 2-3mmHg per second or per heartbeat
Note when the first Korotkof sound is heard. This is the systolic pressure.
Continue to deflate the cuff slowly until the sounds disappear. This is diastolic pressure.
Fully deflate cuff, remove and clean after use
13. I. Diagnosis of hypertension
Reading 1 Reading 2 Reading 2 Reading 3
Stage 1 (no multiple risk
factors, no symptomatic
end organ damage)*
Visit 1
(Community)
Visit 2 second
day
(Community)
Visit 3(facility)
(Immediate after
Reading 2)
Visit 4
(within a month
after visit 3 .Send
labs)
Visit 1
(Facility)
Visit 2
(within 1 month
+ Send labs)
Visit 3
(Next day after
visit 2)
Stage 2 (no multiple risk
factors, no end organ
damage)*
Visit 1
(Community)
Visit 2(Facility)
(Immediate, at
send labs)
Visit 3
(immediate/Nex
t day after visit
1)
Visit 1(facility)
(send labs)
Visit 2
(immediate/Nex
t day after visit
1)
Stage 1 or Stage 2 with
multiple risk factors
and/or symptomatic
organ damage
Visit 1
Severe hypertension Visit 1
HTN urgency/emergency Visit 1
o All cases with SBP >180 and/or DBP of >110 should be referred to a health facility immediately.
o At a facility level two readings should be taken at least 30 minutes apart if there are conditions
15. Diagnosis of hypertension
If a clinic blood pressure SBP is >140 and/or DBP > 90 mmHg:
Take a second reading in the consultation
If very different from the first, take a third
Discard the first reading and take the average of the latter two.
Make a diagnosis of hypertension at the first visit if:
The individual is taking antihypertensive medication or
Patient is demonstrating features of a hypertensive urgency or emergency
SBP is >180mmHg and/or DBP is >110 mmHg or
SBP is >140 mmHg and/or DBP is >90 mmHg together with evidence of
target organ damage (like raised creatinine) or diabetes mellitus. Then refer
to the next level
16. Diagnosis of hypertension
At visit 2
• If no target organ damage, or diabetes mellitus
• Diagnose hypertension if SBP is >180mmHg and/or DBP is
>110 mmHg.
• If BP <180/110, perform further evaluation using manual
BP measurements.
• Make diagnosis of hypertension if SBP averages >140
mmHg or DBP averages >90 mmHg across 3 different
readings (refer to protocol)
18. III. History relevant to hypertension
Aim of history & physical examination is to look for possible
causes, complications & associated risk factors
Note any presenting complaint
In History of Presenting Illness explore for the following:
• Headache/ confusion
• Blurred vision
• Epistaxis
• Focal weakness
• Chest pain/cough/palpitation/ dyspnoea/orthopnoea/PND
• Oedema
• Weight gain
18
19. History relevant to hypertension
cont …
Social history of cigarette smoking and alcohol use
Family history of cardiovascular disease
Past medical history (elevated cholesterol, diabetes
and current medication)
19
20. IV. Physical examination
Should include the following examinations
• General
• Cardiovascular
• Thyroid
• Respiratory
• Abdominal
• Look for peripheral edema
• Neurologic
20
21. Physical examination relevant to hypertension
21
Measurements When to
measure
Interpretation
Blood pressure Every visit
Body weight
Height
Body mass index
(BMI) =
Body weight (kg /ht
(m2)
Every visit
BMI >18.5-25 kg/m2=optimal
BMI >25 kg/m2=overweight
BMI >30 kg/m2=obese
Overweight and obesity are associated with
increased cardiovascular risk. Patients should
receive lifestyle advice about maintenance of a
healthy body weight.
Waist circumference Every visit Cut-off values for normal:
Men < 94cm: Women:< 80 cm
Increased waist circumference is associated
with increased cardiovascular risk. Patients
should receive lifestyle advice on maintenance
of a healthy body weight.
Anthropometric measurements: body weight(kg), height (m), BMI, waist
circumference (cm)
22. Requirements for investigation for secondary
hypertension and thus referral to next level
• Young patients (age below 30 years) with
hypertension
• Patients presenting with hypertensive emergencies
• Patients not controlled on 3 drugs at maximum
dosage (resistant hypertension)
• Patients with hypertension that was always
controlled and is suddenly uncontrolled
23. V. Basic Investigations at time of
diagnosis for hypertensives
At Health Center level:
- Urine dipstick (glucose, protein and blood)
- Hemoglobin/Hematocrit
- Fasting/Random blood glucose
At Hospital Level the following additional tests
should be done (for HCs through referral within
three months of diagnosis):
• Urea/ creatinine
Random/Fasting total cholesterol. LDL,HDL
Serum Potassium and
ECG
23
24. Case Study 3
Mr. Chala is a 45 year old person presents to your clinic with
history of raised blood pressure. He says his BP was 165/90
mmHg. His BP at your clinic is 170/95 mmHg and the repeat one
is 160/90 mmHg.
Questions:
1. What additional history would you want to get from Mr. Chala?
2. How would you stage his blood pressure?
On further enquiry and examination, you discover that he has
been smoking for the last 10 years. His height is 160cm and
weight 85kg, and his waist circumference is 120cm.
25. Case Study 3…
Questions:
3. Classify Mr. Chala’s BMI
4. Comment on Mr. Chala’s waist circumference
5. What cardiovascular risk factors does Mr. Chala have?
You send Mr. Chala for a urine dipstick which turns out to be
normal.
Questions:
6. What advice would you give Mr. Chala? (Role play)
7. How do you manage Mr. Chala?
26. Answers to Case Study 3
1. What additional history would you want to get from Mr. Chala?
•Time of first diagnosis of hypertension if previously known
•Past use of antihypertensive medications
•Known history of diabetes, kidney disease, high cholesterol levels
•Symptoms suggestive of heart failure, coronary heart disease, previous
stroke or transient ischemic attack, or peripheral artery disease.
•Personal habits like alcohol drinking, smoking and khat use
•History of hypertension in previous pregnancies
•Use of medications like NSAIDs (like diclofenac, ibuprofen,
indomethacin) and herbal medications
•Family history of hypertension, diabetes, stroke or heart attack
2. How would you stage his blood pressure?
•Stage 2 hypertension
27. Answers to Case Study 3 …
3. Classify Mr. Chala’s BMI
Answer: BMI = Wt/Ht (m)2 = 33.2 kg/m2 .This is in the Obese Range
4. Comment on Mr. Chala’s waist circumference .
• The waist circumference is very high suggesting central obesity.
5. What cardiovascular risk factors does Mr. Chala have?
• Hypertension, smoking, obesity
You send Mr. Chala for a urine dipstick which turns out to be normal.
Questions:
6. What advice would you give Mr. Chala.?
You would advise Mr Chala that healthy diet and regular exercise can decrease
blood pressure and weight. You also need to advise him to keep his dietary
sodium intake low as this can reduce blood pressure. In addition, you need to
advise him to stop smoking and lose weight.
7. How do you manage Mr. Chala?
As this person has more than one risk factor, he needs referral to the next
higher level of care (He needs treatment with antihypertensive and life style
modifications).
Editor's Notes
These definitions apply to adults on no antihypertensive medications and who are not acutely ill. If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension. The systolic pressure is the greater predictor of risk in patients over the age of 50 to 60.
Patients who have been diagnosed as having hypertension need detailed clinical assessment.
• Clinical assessment has three functions:
Identification of the severity of cardiovascular risk due to the blood pressure, plasma lipid profile and where relevant, cigarette smoking and concomitant diabetes mellitus.
Identify evidence of existing ‘end-organ’ cardiac, cerebral or renal damage.
Identify underlying renal or endocrine causes of hypertension
v Time of first diagnosis of hypertension
v Past antihypertensive medications use
v Symptoms suggestive of coronary heart disease(See CHD section in this chapter for detail)
v Symptoms of heart failure(see respective section for details)
v Symptoms of previous stroke (see stroke section in this chapter)
v Previous history of transient ischemic attack( see stroke section for TIA)
v Previous history of peripheral artery disease(Claudication: Pain in the legs/calves when walking, relived with rest)
v History of known kidney disease, diabetes, high cholesterol levels,
v Alcohol drinking habits, smoking and khat use
v History of possible pregnancy and history of hypertension in previous pregnancies
v Use of medications like contraceptives, NSAIDs , and herbal medications
v Family history of hypertension, diabetes, stroke or heart attack
Check:
Signs of heart failure: distended jugular veins, rales on chest examination, gallop rhythm, murmurs, enlarged liver, ascites and peripheral oedema;
Arterial pulses: diminished/ absent peripheral pulses, carotid and renal artery bruit;
Eyes: check optic fundi for hypertensive or diabetic changes and xanthomas around the eyes;
Neurologic examination- may reveal neurologic deficits of previous stroke.
• All hypertensive patients should undergo:
——Dipstick urine test for proteinuria
—— Serum urea and creatinine to assess renal involvement
—— Serum sodium and potassium to identify adrenal disease
—— Random blood glucose
—— Random serum total and HDL cholesterol
—— 12 lead ECG
• Patients where initial clinical assessment suggests renal or
endocrine disease should be referred to specialist centres for
further more detailed investigation.
• About 5% of hypertensive patients will be found to have
underlying renal or endocrine causes for their raised blood
pressure. These include:
——Concomitant type 1 or type 2 diabetes mellitus
——Underlying renal damage either as a cause or a consequence
of hypertension
▪▪ Glomerulonephritis
▪▪ Pyelonephritis
—— Evidence of aldosterone excess including Conn’s syndrome
——Other endocrine diseases associated with hypertension
▪▪ Thyroid disease
▪▪ Cushing’s disease or syndrome
▪▪ Acromegaly
——Other conditions to be excluded are aortic coarctation and
phaeochromocytoma
Case Study 3
Mr. Chala is a 45 year old person presents to your clinic with history of raised blood pressure. He says his BP was 165/90 mmHg. His BP at your clinic is 170/95 mmHg and the repeat one is 160/90 mmHg.
Questions:
1. What additional history would you want to get from Mr. Chala?
Time of first diagnosis of hypertension if previously known
Past use of antihypertensive medications
Known history of diabetes, kidney disease, high cholesterol levels
Symptoms suggestive of heart failure, coronary heart disease, previous stroke or transient ischemic attack, or peripheral artery disease.
Personal habits like alcohol drinking, smoking and khat use
History of hypertension in previous pregnancies
Use of medications like NSAIDs (like diclofenac, ibuprofen, indomethacin) and herbal medications
Family history of hypertension, diabetes, stroke or heart attack
2. How would you stage his blood pressure?
Stage 2 hypertension
On further enquiry and examination, you discover that he has been smoking for the last 10 years. His height is 160cm and weight 85kg, and his waist circumference is 120cm.
Questions:
3. Classify Mr. Chala’s BMI
Answer: BMI = Wt/Ht (m)2 = 33.2 kg/m2 .This is in the Obese Range
4. Comment on Mr. Chala’s waist circumference .
The waist circumference is very high suggesting central obesity.
5. What cardiovascular risk factors does Mr. Chala have?
Hypertension, smoking, obesity
You send Mr. Chala for a urine dipstick which turns out to be normal.
Questions:
6. What advice would you give Mr. Chala.?
You would advise Mr Chala that healthy diet and regular exercise can decrease blood pressure and weight. You also need to advise him to keep his dietary sodium intake low as this can reduce blood pressure. In addition, you need to advise him to stop smoking and lose weight.
(Role play)
Select two participants to do role play.
One will be Mr Chala and the other will be the clinician.
Do the necessary communication as the patient enters the exam room and go through the standard flow of care (History, physical exam and lab and management)
7. How do you manage Mr. Chala?
As this person has more than one risk factor, he needs referral to the next higher level of care (He needs treatment with antihypertensive and life style modifications).
