Investigation and evaluation of arterial pulses,
blood pressure, and jugular venous pressure
Dr. András Tislér
October 2013.
Objectives
To understand the principles of…
• Assessing vital signs
• Examination of the peripheral arterial system
– Pulse
– Blood pressure
• Examination of jugular veins
Evaluation and management of the medical patient
• Reason for admission
• History of present illness/current complaints/ review of the systems
• Past medical / social / family history
• Mediactions/allergies
• Physical examination
• Laboratory tests
• Other investigations
• Differential diagnosis
• Confirmatory tests
• Therapy
• Follow up
DIAGNOSIS
Vital signs
• Heart rate / blood pressure
• Temperature
• Respiratory rate / 02 saturation
• Level of consciousness
Evaluating the peripheral pulse
• Palpable? (equal?)
• Heart rate?
• Regular? (rythm)
• Amplitude? contour? compressible?
• Variability?
– Beat-to-beat
– With respiration
Assessment of heart rate
• Rate
• Regularity / rhythm
• Amplitude / contour
• Variation
– Beat-to-beat
– With respiration
Arterial system
Stiff system Elastic system
Pre
ssu
re
Systole Diastole
Mean
pressure
Pre
ssu
re
Systole Diastole
Mean
pressure
Brachial and aorta pressure cirve in a young heathy
(compliant arteries) and an elderly individual (with
stiff arteries)
elderlyyoung
Examanation of the peripheral arterial system
• Palpable:
– Radial
– Dorsalis pedis/tibial posterior
– Popliteal
– Femoral
• Bruit
– Abdominal
– Femoral
– Carotid
Examanation of the peripheral arterial system
• Inspection
– Paleness
– Cyanosis
– Oedema
– Ulcers
– Emboli
• Palpation:
– Pulse
– Temperature
• Ausculatation
– Bruit
Acute arterial insufficiency in the limb:
Embolus, thrombosis
• „ 5 P-s”
– Pain
– Pallor (pale)
– Pulselessness
– Poikilothermia (coldness)
– Paresthesia
Chronic arterial insufficiency of the lower limb:
• Complain
– Intermittent claudication
• Physical examination
– Limb pale/cyanotic, colder
– Non palpable TP/DP arteries
– Muscle - skin atrophy
– Dependent rubor
– Ulcers
– Gangrene
Blood pressure measurement
• Factors influencing blood pressure
BP= volume x peripheral resistance
– Stroke volume
– Heart rate
– Distensibility of the large arteries
– Peripheral vascular resistance
– Viscosity of the blood
Arterial blood pressure
• Systolic pressure
– Increases from the heart towards the periphery (amplification)
• Diastolic pressure
– Remains unchanged toward the periphery
• Pulse pressure
– Difference between the systolic and diastolic pressure
– Increases towards the periphery
• Mean arterial pressure
– Area under the pressure curve
– ~ diastolic + 1/3 pulse pressure
Blood pressure measurement: devices
• Mercury sphygmomanometer
• Aneroid sphygmomanometer
• Automated (oscillometric) devices
Blood pressure measurement: cuff size
• „Undercuffing”: too small bladder leads to
overestimation of true BP
80%
Blood pressure measurement: methods
• Quiet room
• After 5 minutes of rest
• More than 30 minutes after
meal/coffe/smoking
• Back supported, legs
uncrossed
• Arm supported at heart level
• Deflation rate: 2 mmHg/heart
beat
• Repeat measuremnts x2 or x3
Objectives
To understand the principles of…
• Assessing vital signs
• Examination of the peripheral arterial system
– Pulse
– Blood pressure
• Examination of jugular veins
Examination of the internal (external) jugular vein
• Used mostly to assess extracellular (intravascular) fluid
volume and heart failure
• Jugular vein distension is seen in
– Fluid overload
– tricuspid valve insufficiency
– heart failure (right venticule)
– SVC compression/thrombosis, e.g. mediastinal masses
• Hepato-jugular reflux to assess right ventricular function
– Pressure on the liver increases IJV (EJV) hight that
subsequently decreases
– If not may suggest fluid overload and/or right ventricular
failure
External jugular vein distention
Markedly distended right external jugular vein (EJV).
This is the result of elevated central venous pressure (CVP). In practice
the EJV is not as reliable in determining CVP as the internal jugular vein
due to the fact that it sometimes has valves and is not in a direct line with
the right atrium. Pressure on the liver, however, will have similar impact
on the appearance of the IJV as for the EJV. This is referred to as
hepatojugular reflux.