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🩺 Blood Pressure Consultation – Full Script & Teaching Notes

This page takes you from “door handle” to documented plan for a raised BP consultation, and includes a detailed section on how to measure blood pressure properly, with clinical pearls and exam tips.

1️⃣ Before You See the Patient

• 📄 Check the record: Previous BP readings, existing diagnosis of HTN, meds, CKD, diabetes, lipid profile, QRISK if available.
• ⚠️ Look for red flags: Recent chest pain, SOB, neuro symptoms, end-organ damage, very high BP (e.g. ≥180/120).
• 🧠 Frame your aim: “Is this true hypertension? Is there target organ damage? What’s this person’s global CV risk and what can we realistically change?”

2️⃣ Opening the Consultation

• Introduce & identify: “Hello, I’m Dr X, one of the doctors. Could I confirm your full name and date of birth?”
• Reason for visit: “I see you’ve come about your blood pressure today. Can you tell me what’s been happening?”
• Agenda setting: “So today I’d like to: understand your story, check your BP properly, look at risk factors, and agree a plan together. Does that sound OK?”

3️⃣ Focused History for Raised Blood Pressure

• Presenting issue:
  • “How was high blood pressure picked up?” (GP check, workplace, home monitor, pharmacy).
  • “Have you had more than one reading? Do you remember the numbers?”
  • “Any symptoms?” – headaches, visual changes, chest pain, dyspnoea, palpitations, neuro symptoms, polyuria/nocturia.
• Cardiovascular & renal symptoms:
  • Exertional chest pain or tightness, breathlessness, orthopnoea, PND, ankle swelling.
  • Neurological: TIAs, strokes, focal weakness, speech disturbance, confusion.
  • Renal: frothy urine, haematuria, nocturia, loin pain.
• Past medical history:
  • Known HTN, CKD, diabetes, hyperlipidaemia, AF, IHD, HF, stroke/TIA, peripheral vascular disease.
  • Endocrine causes (e.g. phaeochromocytoma, thyroid disease, Cushing’s) if BP is severe/resistant.
• Drug history:
  • Current antihypertensives, adherence, side effects (ankle oedema, cough, dizziness, polyuria).
  • Other meds: NSAIDs, COCP/HRT, decongestants, steroids, stimulants, herbal remedies.
  • Allergies, previous intolerance (e.g. ACEi cough, CCB ankle swelling).
• Family history:
  • Premature MI or stroke (<55 men, <65 women), known familial hypercholesterolaemia, polycystic kidneys, endocrine disease.
• Lifestyle & risk factors:
  • Smoking, vaping, alcohol intake (units/week), recreational drugs (cocaine, amphetamines).
  • Diet (salt intake, processed foods), caffeine, weight changes.
  • Physical activity, sleep (snoring, witnessed apnoeas, non-restorative sleep), stress levels.
• ICE (Ideas, Concerns, Expectations):
  • “What do you think might be causing your high BP?”
  • “Is there anything in particular you’re worried about?” (e.g. stroke, kidneys).
  • “What were you hoping we could do today?”

4️⃣ Examination – Measuring Blood Pressure Properly

This is where you integrate good technique with bedside teaching.

🩺 How to Measure Blood Pressure Properly

• 🧘 Preparing the Patient: Seat the patient quietly for 5 minutes, feet flat on the floor, legs uncrossed, arm supported at heart level. No talking, no phone.
• 🩹 Proper Cuff Placement:
  • Correct size cuff is essential: too small → falsely high; too large → falsely low.
  • The bladder should encircle ≥80% of the arm, centred over the brachial artery.
• ✋ Estimate Systolic Pressure:
  • Palpate brachial or radial artery; inflate cuff until the pulse disappears → this is the estimated systolic pressure.
  • Deflate fully and wait at least 30 seconds before auscultating.
• 🎧 Measuring BP (Auscultatory):
  • Place the stethoscope over the brachial artery (not under the cuff).
  • Inflate cuff to 20–30 mmHg above the estimated systolic.
  • Deflate slowly at ≈2 mmHg/sec listening for Korotkoff sounds.
• 📈 Identify Pressures:
  • Systolic (Korotkoff I): First appearance of clear tapping sounds.
  • Diastolic (Korotkoff V): Disappearance of sounds. If sounds persist to zero (e.g. pregnancy, hyperdynamic states) use muffling (Korotkoff IV) as diastolic.
• 📝 Recording:
  • Record systolic/diastolic, arm used, cuff size, patient position and device type (manual/automated).
  • Take at least 2 readings ≥30 seconds apart and average. If readings differ by >10 mmHg, take additional readings and average the last two.
  • Measure both arms at least once; if difference >15–20 mmHg persists, investigate (e.g. subclavian stenosis).

🔍 General Examination

• Vitals: BP both arms, HR and rhythm, RR, O₂ sats, temperature.
• Cardiovascular: Pulse character (slow-rising in AS, bounding in AR), radio-femoral delay (coarctation), JVP, peripheral oedema, displaced apex, murmurs.
• Fundoscopy (if able): AV nipping, cotton wool spots, haemorrhages, papilloedema.
• Abdominal: Aortic aneurysm, renal bruits.
• Peripheral vasculature: Peripheral pulses, bruits, ankle–brachial pressure index if PVD suspected.

5️⃣ Understanding Blood Pressure & Clinical Findings

📊 Blood Pressure in Humans

• Arterial Pulse Waveform: Generated by LV ejection. The dicrotic notch 🕳️ represents aortic valve closure.
• Korotkoff Sounds:
  • Phase I: First tapping (systolic BP).
  • Phase V: Disappearance (diastolic BP).

🧪 Key Clinical Findings

• Hypertension (clinic): Consistently >140/90 mmHg in clinic (confirm with ABPM/HBPM).
  ⬆️ risk of stroke, myocardial infarction, heart failure, CKD, AF.
• Pulse Pressure: (Systolic − Diastolic).
  • Narrow pulse pressure: Aortic stenosis, cardiogenic shock.
  • Wide pulse pressure: Aortic regurgitation, PDA, severe thyrotoxicosis, high-output states.
• Aortic Stenosis: Low pulse pressure, slow-rising carotid (parvus et tardus).
• Aortic Regurgitation: Wide pulse pressure, collapsing (Corrigan’s) pulse.
• BP Difference Between Arms:
  • 👉 Right > Left (>20 mmHg): consider left subclavian stenosis/dissection.
  • 👉 Left > Right: consider right subclavian stenosis.
  • 👉 Arm vs ankle: consider PVD or coarctation if ankle pressures are much lower.
• Normal Variation: Small 5–10 mmHg asymmetry between arms is common and usually benign.

7️⃣ Investigations After the Consultation

• ABPM or HBPM:
  • Offer 24-hour ambulatory BP monitoring to confirm hypertension where possible.
  • Alternatively, validated home BP monitoring (twice daily, 7 days, discard day 1, average the rest).
• Baseline bloods: U&Es, eGFR, electrolytes, lipids, HbA1c, FBC, LFTs, TFTs as indicated.
• Urine: Dipstick (protein/haematuria), ACR for CKD screening.
• ECG: LVH, prior MI, AF, conduction disease.
• Others if indicated: Echocardiogram, renal ultrasound, renin/aldosterone ratio, endocrine tests in resistant or young-onset HTN.

8️⃣ Explaining the Diagnosis & Risk to the Patient

Keep it simple, link numbers to risk, and emphasise modifiability.

• “Your blood pressure today is …/…. We like it to be roughly less than 140/90 in clinic for most adults.”
• “One high reading doesn’t always mean you definitely have high blood pressure, so we confirm it with readings at home/over 24 hours.”
• “Untreated raised blood pressure can, over years, increase your chance of stroke, heart attack and kidney problems. The good news is we can do a lot to reduce that risk.”

9️⃣ Management Plan – Lifestyle & Medication (High-Level)

🍏 Lifestyle

• Weight loss if overweight; even 5–10% helps.
• Reduce salt (avoid adding salt; cut processed food), moderate alcohol, stop smoking.
• Regular aerobic activity (e.g. 30 minutes brisk walking most days if able).
• Address sleep (snoring, suspected OSA) and stress (relaxation techniques, CBT, workload).

💊 Medication (principles only)

• Choice of first-line drug depends on age, ethnicity, comorbidities (e.g. ACEi/ARB vs CCB).
• Start low, go slow; check U&Es after ACEi/ARB or diuretics; warn about side effects (cough, ankle swelling, dizziness, frequent urination).
• Agree realistic targets and titration schedule; link to QRISK or similar to show absolute risk reduction.

🔟 Safety-Netting & Follow-Up

• Arrange follow-up (e.g. with ABPM/HBPM result, blood tests) in 4–12 weeks depending on severity.
• Advise to seek urgent review if:
  • Chest pain, SOB, new neuro deficit, visual loss, severe headache, or very high home BP readings (e.g. ≥180/120 with symptoms).
• Provide written information or website/app links for BP monitoring and lifestyle change.

📌 Exam Tips – OSCE & Viva

• Always mention: correct cuff size, resting 5 minutes, no talking, both arms, and averaging readings.
• In AF, say you’d take multiple readings due to beat-to-beat variability.
• Remember pulse pressure findings (AS, AR), and arm–arm differences and what they suggest.
• Close the station with a clear plan and safety-net: “We’ll confirm with home/ambulatory readings, check bloods and ECG, and then decide together on lifestyle and medication.”