Practical Physiology

For medical students

Dr. Mohammed Almahdi

 Blood pressure
 Definition:
 Systolic BP : pressure exerted on the arterial wall by blood ejected from LV
contraction
 Diastolic BP : pressure exerted on the arterial wall as a result of elastic recoil of
aorta
 Values :

 Apparatuses :
1. Stethoscope : (Steth = chest, scope = to inspect)

The instrument has the following 3 parts:

a. The chest-piece:
 The chest-piece has two end pieces:
1. bell : conducts sounds without distortion but with little magnification.
2. flat diaphragm : The plastic diaphragm causes magnification of low-pitched
sounds though it distorts them a little.
 some have only the diaphragm.
b. The rubber tubing:
a single soft-rubber pressure tube (inner diameter 3 mm) leads from the chest- piece
to a metal Y-shaped connector.
c. The ear-frame:
It consists of:
 1. two curved metallic tubes.
2. a flat U-shaped spring which keeps the two
curved metallic tubes pulled together.
3. Two plastic knobs threaded over the ends of the
tubes fit snugly in the ear.
4. Two rubber tubes connect the Y-shaped
connector to the metal tubes.

2. Sphygmomanometer : (the ‘‘ BP apparatus’’)

sphygmo = pulse, manos = thin, metron = measure
1. Mercurial : the oldest and the most accurate
2. Aneroid : without fluid
3. Electronic : recent and least accurate
Mercurial Sphygmomanometer :
Parts of sphygmomanometer :
1. Spring-loaded clip 2. Lid of the apparatus
3. Graduated glass tube 4. One-way valve
5. Mercury reservoir 6. Stop cock
7. Armlet 8. Air pump (rubber bulb, with leak valve.)
 Uses of sphygmomanometer:
Diagnostic uses:
1.Measurement of arterial blood pressure.
• Hypertension.
• Hypotension.
• Pulse pressure (SBP-DBP).
• Mean arterial blood pressure (diastolic ABP+1\3pulse pressure).
• Equality of ABP.
2. Diagnosis of pulsus alternans.
3. Diagnosis of pulsus paradoxicus.
4. Trousseaus test: to diagnose latent tetany.
5. Hess test: to diagnose thrombocytopenia.
6. Walker test: to diagnose myasthenia gravis.
7. Lawnberg test: to diagnose DVT.
Therapeutic uses:
1. As a tourniquet.
2.Rotatory method (closed venesection): for ttt of acute pulmonary edema.

measuring ABP
Rules before measuring ABP:
a. The room: Quiet, Comfortably warm
b. Sphygmomanometer:
1. cuff bladder:
a. Size: should be appropriate according to the limb circumference .
 Width of bag should be 40% of limb circumference .
 Length of bag should be 80% of limb circumference .
b. Avoid placing the chest piece of the stethoscope under the wrapped cuff.
c. Avoid herniation of the bladder from its clothing.
2. The rubber tubing:
a- Avoid their obstruction (kink or twisting)
b- Avoid their leak.
c- Should be sufficiently separated from each other.
3. The Manometer
Mercury reservoir
Should be ON
Should be at the same horizontal level with the hearts
Mercury column:
Should be vertical
Should be secured from leak or obstruction
Mercury level should be at zero when the cuff is detached
c. The Examiner:
1. Sits in a comfortable position
2. Explain the procedure and reassures the patient
3. His eyes should be at the level of the mercury column
d. The patient:
1-Avoids exertion for 5-10 minutes before measurement
2-Avoids emotional stress for 5 minutes
3-Avoids smoking, caffeine or alcohol for 30 minutes- 2 hours
4-Avoids eating for 30 minutes (2 hours in elderly )
5-Avoids talking during the procedure
6-Avoids full bladder for 30 minutes
7-Position sitting or flat
8-Patients arm:
 Should be supported
 Elbow:-Slightly flexed -At the same level of the heart
 Arm selected should be free of clothing.
 There should be no arteriovenous fistulas for dialysis,
scarring from prior brachial artery cutdowns, or signs of
lymphedema (seen after axillary node dissection or radiation therapy)
Technique for measuring ABP:
1. Palpate the brachial artery and then wrap the snugly
around the patient arm with the middle of bladder over
the brachial artery pulsation ( 3-5 cm above cubital fossa ,
medial to the biceps tendon )
2. Inflate the cuff while palpating the radial pulse (to
avoid the auscultatory gap ) until it is no longer
palpable ,note the reading (palpatory method )
3. Deflate the cuff and wait 15-30 seconds before re-
inflating
4. Re-inflate steadily with the diaphragm of stethoscope
over the brachial artery to a pressure 20-30 mmHg above
the level previously determined by palpation
5. Deflate the cuff slowly (2-3 mm/sec ) listening for
korotkoff sounds as they appear (systolic) and then
disappear (diatolic) (auscultatory method)

For report, express your result as:

Right arm: Systolic/Ist diastolic/2nd diastolic; (e.g. 120/80/76).
Left arm: Systolic/Ist diastolic/2nd diastolic; (e.g. 118/76/72
Korotkoff sounds :
these are sounds produced by the pulsations of an artery under a partially
constricting blood pressure cuff (described
by the Russian physician N. S. Korotkoff in
1905).

The five phases are:

phase 1: onset of tapping sounds;
phase 2: at a pressure of about 10–15 mmHg
lower than phase 1, a murmur may
be heard after the tap
phase 3: reappearance of only the tapping
sound
phase 4: muffling
phase 5: disappearance of sounds
Q: By how much may blood pressure be wrong if the Korotkoff sounds are soft?
ANS: By as much as 60 mmHg.
Q: How can you increase the loudness of Korotkoff sounds?
ANS: a. Increase brachial flow by having the patient open and clench the
fist about 5-10 times. If popliteal or foot pressures are being taken,
flexion and extension of the ankle serves the same purpose. This
degree of mild exercise does not alter the actual blood pressure.
b. Inflate the cuff quickly.
c. Elevate the arm before inflating the cuff.

Auscultatory gap:
 a silent gap or period occurs during recording BP by auscultation although
blood passes and can be felt
 it results in underestimationof SBP & overestimation of DBP.
 Present in some hypertensive patients
 W e can avoid it by :
o Doing palpatory method at first to
know roughly systolic BP
o Rise pressure in the bag 20-30
mmHg above systolic blood
pressure known by palpation
o Do auscultatory method
 Special notes :
1. BP should be taken in right and left arms. Normally may be a difference in pressure
of 5-10 mmHg , subsequent reading should be made on arm with higher pressure.
 If difference between both arms more than 15 mmHg (same causes of unequal
pulse)
2. In general, systolic pressure increases and diastolic pressure decreases when
measured in more distal arteries.
3. Read both the systolic and the diastolic levels to the nearest 2 mm Hg. Wait 2 or
more minutes and repeat. Average your readings. If the first two readings differ by
more than 5 mm Hg, take additional readings.
4. When the systolic and diastolic levels indicate different categories, use the higher
category. For example, 170/92 mm Hg is moderate hypertension and 170/120 mm Hg
is severe hypertension.
5. Very low (even 0 mmHg) diastolic blood pressures may be recorded in patients
with chronic, severe AR or a large arteriovenous fistula because of enhanced diastolic
“run-off.” In these instances, both the phase IV and phase V Korotkoff sounds should
be recorded.
6. Systolic leg pressures are usually as much as 20 mmHg higher than systolic arm
pressures. Greater leg–arm pressure differences are seen in patients with chronic
severe AR as well as patients with extensive and calcified lower extremity peripheral
arterial disease.
7. Assessment of hypertension also includes its effects on target organs—the eyes,
the heart, the brain, and the kidneys. Look for evidence of hypertensive retinopathy,
left ventricular hypertrophy, and neurologic deficits suggesting a stroke. (Renal
assessment requires urinalysis and blood tests.)
8. A pressure of 110/70 would usually be normal, but could also indicate significant
hypotension if past pressures have been high.
9. BP in LL:
 is measured by Application of special large cuff around lower 1/3 of thigh and
auscultation of popliteal artery (in popliteal fossa) while patient lies in prone position
 normally systolic BP of LL is more than UL by 10-20 mmHg .
 indication to measure the BP from LL:
1. to diagnose LL ischemia
2. in aortic regurge
o systolic BP in LL is more than UL by 60 mmHg
3. in coarctation of aorta :
o systolic LL BP is less than UL
10. The ankle-brachial index (lower pressure in the dorsalis pedis or posterior tibial
artery divided by the higher of the two brachial artery pressures) is a powerful
predictor of long-term cardiovascular mortality
11. A rough rule of thumb for systolic pressure in infants and children is: