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|With 36 million estimated cases of uncontrolled hypertension, 14 million of whom are unaware and undiagnosed, there exists a target rich environment for the life saving diagnosis of hypertension.
Why should this be when most of these people visit clinics and doctor's offices, but remain unaware? A small number suffer the rather high threshold some doctors set for the diagnostic criteria for hypertension. The majority, however, represent a negligence in both the taking of blood pressures and the recording of the results stemming largely from cost cutting and sheer boredom.
Very few assistants know how to take a blood pressure. Rather than teaching them the right way and training them to a level of competency, accuracy and consistency, they are turned loose either with superficial knowledge or with an automated blood pressure cuff and recording instrument that may or may not be accurate and is still dependent on the assistant's ability to use the instrument correctly. If a clinician wants to treat more patients that are appreciative and save lives, the clinician would be well advised to take blood pressures his or herself.
Mechanized BP apparatuses notoriously give spurious results even the most expensive in the wrong hands. Moreover, what good is an automated cuff in the hands of a physician; he or she might rather use a mercury manometer and be certain. Today's hurried schedules with highly discounted reimbursements lead to a focus on a single problem. Ancillary abnormal findings get overlooked or discounted as probably in error. Sad but true, this happens and what more relevant condition can there be than the early diagnosis of hypertension along with the appropriate workup for underlying causes.
A proper BP reading requires an appropriate size cuff, a mercury manometer, and a stethoscope. The cuff should go first to the right arm in order not to miss Coarctation of the Aorta. The patient must fully extended the arm and raise it to chest level. The assistant must palpate a strong pulse placing the bowel of the stethoscope over the pulse while pumping the pressure to a safe level above the audible pulse, approximately 200 mm. Open the valve only a little so that the pressure drops slowly. Record the pressure for the first audible pulse, a rather distinct and abrupt point, easy to determine. Continue listening as the pressure falls. Record the first abrupt weakening change in sound and continue listening until no sound is heard recording that number as well. In some patients, there will be only one clear disappearance of sound while in others there are two changes to consider for the diastolic pressure, record them both. With only borderline BP, take another reading and do so for both arms. Record all readings such as 120/80-70 RA sitting. Include the position of the patient as well as the arm or leg. Always take multiple readings if pressure is above 120/70 and if above 140/90 take BP in one of the legs using a large cuff. Relegate BPs to only well known and trusted nurses and check even that during your physical exam. Take the patient’s pulse yourself as well; both make interesting conversation during your exam and lead to relevant system review questions.
The JAMA article below speaks of treatment protocols, but the diagnosis and workup come first. A treatment protocol may unerringly select the right treatment for the statistically average American patient but miss completely the appropriate treatment for the patient sitting before you. Many other conditions influence the choice of medications for treatment.
http://jama.jamanetwork.com/article.aspx?articleID=1778410&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst11%2F14%2F2013
|With 36 million estimated cases of uncontrolled hypertension, 14 million of whom are unaware and undiagnosed, there exists a target rich environment for the life saving diagnosis of hypertension.
Why should this be when most of these people visit clinics and doctor's offices, but remain unaware? A small number suffer the rather high threshold some doctors set for the diagnostic criteria for hypertension. The majority, however, represent a negligence in both the taking of blood pressures and the recording of the results stemming largely from cost cutting and sheer boredom.
Very few assistants know how to take a blood pressure. Rather than teaching them the right way and training them to a level of competency, accuracy and consistency, they are turned loose either with superficial knowledge or with an automated blood pressure cuff and recording instrument that may or may not be accurate and is still dependent on the assistant's ability to use the instrument correctly. If a clinician wants to treat more patients that are appreciative and save lives, the clinician would be well advised to take blood pressures his or herself.
Mechanized BP apparatuses notoriously give spurious results even the most expensive in the wrong hands. Moreover, what good is an automated cuff in the hands of a physician; he or she might rather use a mercury manometer and be certain. Today's hurried schedules with highly discounted reimbursements lead to a focus on a single problem. Ancillary abnormal findings get overlooked or discounted as probably in error. Sad but true, this happens and what more relevant condition can there be than the early diagnosis of hypertension along with the appropriate workup for underlying causes.
A proper BP reading requires an appropriate size cuff, a mercury manometer, and a stethoscope. The cuff should go first to the right arm in order not to miss Coarctation of the Aorta. The patient must fully extended the arm and raise it to chest level. The assistant must palpate a strong pulse placing the bowel of the stethoscope over the pulse while pumping the pressure to a safe level above the audible pulse, approximately 200 mm. Open the valve only a little so that the pressure drops slowly. Record the pressure for the first audible pulse, a rather distinct and abrupt point, easy to determine. Continue listening as the pressure falls. Record the first abrupt weakening change in sound and continue listening until no sound is heard recording that number as well. In some patients, there will be only one clear disappearance of sound while in others there are two changes to consider for the diastolic pressure, record them both. With only borderline BP, take another reading and do so for both arms. Record all readings such as 120/80-70 RA sitting. Include the position of the patient as well as the arm or leg. Always take multiple readings if pressure is above 120/70 and if above 140/90 take BP in one of the legs using a large cuff. Relegate BPs to only well known and trusted nurses and check even that during your physical exam. Take the patient’s pulse yourself as well; both make interesting conversation during your exam and lead to relevant system review questions.
The JAMA article below speaks of treatment protocols, but the diagnosis and workup come first. A treatment protocol may unerringly select the right treatment for the statistically average American patient but miss completely the appropriate treatment for the patient sitting before you. Many other conditions influence the choice of medications for treatment.
http://jama.jamanetwork.com/article.aspx?articleID=1778410&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst11%2F14%2F2013
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