Weak or Inaudible Korotkoff Sounds.
Consider technical problems such as erroneous placement of your stethoscope, failure to make full skin contact with the bell, and venous engorgement of the patient's arm from repeated inflations of the cuff. Also consider the possibilities of vascular disease or shock. When you cannot hear Korotkoff sounds at all, alternative methods using a Doppler probe or direct arterial pressure tracings may be necessary.
White Coat Hypertension.
Encourage the patient to relax and remeasure the blood pressure later in the encounter. Consider automated office readings or ambulatory recordings.
The Obese or Very Thin Patient.
For the obese arm, use a cuff 16 cm in width. If the upper arm is short despite a large circumference, use a thigh cuff or a very long cuff. If the arm circumference is >50 cm and not amenable to use of a thigh cuff, wrap an appropriately sized cuff around the forearm, hold the forearm at heart level, and feel for the radial pulse. Other options include using a Doppler probe at the radial artery or an oscillometric device. For the very thin arm, consider using a pediatric cuff.
Arrhythmias.
Irregular rhythms produce variations in pressure and therefore unreliable measurements. Ignore the effects of an occasional premature contraction. With frequent premature contractions or atrial fibrillation, determine the average of several observations and note that your measurements are approximate. Ambulatory monitoring for 2 to 24 hours is recommended.
The Hypertensive Patient with Systolic Blood Pressure Higher in the Arms than in the Legs.
Compare blood pressure in the arms and the legs and assess "femoral delay" at least once in every hypertensive patient.
■ Coarctation of the aorta arises from narrowing of the thoracic aorta, usually distal to origin of the left subclavian artery, and classically presents with systolic hypertension greater in the arms than the legs. In normal patients, the systolic blood pressure should be 5 to 10 mm Hg higher in the lower extremities than in the arms.
■ To determine blood pressure in the leg, use a wide, long thigh cuff that has a bladder size of 18 × 42 cm, and apply it to the midthigh. Center the bladder over the posterior surface, wrap it securely, and listen over the popliteal artery. If possible, the patient should be prone. Alternatively, ask the supine patient to flex one leg slightly, with the heel resting on the bed.
■ Palpate the radial or brachial and the femoral pulses at the same time, and compare their volume and timing. Normally, volume is equal and the pulses occur simultaneously.
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