Chronic hypertension physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-In-Chief: Yazan Daaboul, Serge Korjian

Overview

A thorough physical examination should be performed in the hypertensive patient to identify signs of end organ damage (retina) as well findings that might suggest that the hypertension is secondary to another disorder (secondary hypertension) such as renal artery stenosis.

Physical Examination

The physical examination should include:

Vital Signs

• Measurement of vital signs (temperature, pulse, respiratory rate, blood pressure). Blood pressure should be measured according to appropriate technique.
• Measurement of height, weight, waist and abdominal circumferences. Calculation of BMI is required.

Head

• Moon facies suggests Cushing's syndrome

Eyes

• Examination of optic fundi to identify evidence of end organ damage such as papilledema

Neck

• Auscultation of the suprasternal notch to ascertain if a bruit suggestive of coarctation is present
• Palpation of thyroid gland to assess for hyperthyroidism

Cardiac

• Assess for end organ damage such as left ventricular hypertrophy and heart failure

Abdomen

• Auscultate for presence of an abdominal bruit they may suggest renal artery stenosis
• Abdominal examination for enlarged kidneys, masses, distended urinary bladder, and abnormal aortic pulsations that suggest an abdominal aortic aneurysm

Pulses

The presence of coarctation is suggested by a radial femoral delay, a difference in the strength of the pulse in the upper extremities (right stonger than left) and the following detailed findings:

• Left subclavian proximal to coarctation: hypertension and normal pulses in both arms and hypotension and diminished pulses in lower extremities (differential hypertension). Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm. This may be appreciated best by simultaneous arm and leg pulse palpation.
• Left subclavian distal to coarctation: hypotension and diminished pulses in left arm and lower extremities. Asynchronous radial pulses will be detected in the right and left arms. A brachial-femoral delay between the right arm and the femoral artery may be apparent, while no such delay may be observed with left arm brachial-femoral palpation.
• Both right and left subclavian artery originate below coarctation: blood pressure and pulses decreased in all four extremities.
• In mild cases though the pulses are palpable in all for extremities a brachial-femoral delay can be appreciated.
  • Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.

Neurological assessment

• Focal neurologic deficits suggestive of end organ damage should be noted

2013 ESH/ESC Guidelines For The Management of Arterial Hypertension (DO NOT EDIT)

Summary of Recommendations on Physical Examination (DO NOT EDIT)

Class I

"1. It is recommended that all hypertensive patients undergo palpation of the pulse at rest to determine heart rate and to search for arrhythmias, especially atrial fibrillation. (Level of Evidence: B)"