What should be included in a comprehensive general physical examination for a patient with hypertension?

General Physical Examination in Hypertension

A thorough physical examination in hypertensive patients must systematically assess for secondary causes, hypertension-mediated organ damage (HMOD), and cardiovascular risk factors through targeted cardiovascular, renal, endocrine, and anthropometric assessments. 1

Vital Signs and Anthropometric Measurements

• Measure blood pressure in both arms at the initial visit; a difference >20 mmHg systolic or >10 mmHg diastolic (if confirmed) warrants further vascular investigation for conditions such as aortic coarctation or subclavian artery stenosis. 1
• Assess pulse rate, rhythm, and character at rest in all hypertensive patients to detect arrhythmias, particularly atrial fibrillation (including silent forms), as an irregular pulse is a key indicator. 1
• Measure height, weight, and calculate BMI (weight/height² in kg/m²) with the patient standing to identify obesity, a major cardiovascular risk factor present in approximately 40% of hypertensive patients. 1
• Measure waist circumference at the midpoint between the lower costal margin and the iliac crest to assess central obesity and metabolic syndrome risk (present in ~40% of hypertensive patients). 1
• Measure neck circumference; values >40 cm suggest obstructive sleep apnea, which contributes to 25-50% of resistant hypertension cases. 1

Cardiovascular Examination

• Palpate the apex beat to assess for lateral displacement, which indicates left ventricular hypertrophy. 1
• Auscultate for extra heart sounds (S3 or S4 gallops) and murmurs, which may indicate heart failure, valvular disease, or structural abnormalities such as aortic coarctation. 1
• Assess jugular venous pulse and pressure to detect volume overload or heart failure. 1
• Examine for peripheral edema (ankles, sacrum) as a sign of heart failure or fluid retention. 1
• Auscultate the carotid arteries for bruits, which suggest atherosclerotic disease and increased stroke risk. 1

Vascular Examination for Secondary Hypertension

• Palpate femoral pulses bilaterally and assess for radio-femoral delay; delayed or diminished femoral pulses compared to radial pulses strongly suggest aortic coarctation, particularly in patients <30 years. 1
• Compare blood pressure between arms and legs; reduced femoral BP compared to brachial BP indicates aortic coarctation or lower extremity arterial disease. 1
• Auscultate the abdomen for systolic-diastolic bruits (especially in the epigastrium and flanks), which suggest renovascular hypertension from renal artery stenosis. 1
• Assess peripheral pulses (dorsalis pedis, posterior tibial) for absence, reduction, or asymmetry, and examine extremities for cold temperature or ischemic skin lesions indicating peripheral arterial disease. 1

Renal Examination

• Palpate the abdomen for enlarged kidneys bilaterally; palpable masses suggest polycystic kidney disease, a common cause of secondary hypertension. 1

Endocrine and Metabolic Assessment

• Inspect for features of Cushing syndrome: central obesity with thin extremities, wide (>1 cm) purple striae (particularly on the abdomen), moon facies, buffalo hump, supraclavicular fat pads, easy bruising, and proximal muscle weakness. 1
• Palpate the thyroid gland for enlargement or nodules, as both hypothyroidism and hyperthyroidism can cause or exacerbate hypertension. 1
• Look for colored striae and fatty deposits in unusual locations (face, trunk), which are specific for Cushing disease/syndrome. 1

Neurological Examination

• Perform a focused neurological assessment for motor or sensory deficits, which may indicate prior stroke or transient ischemic attack from uncontrolled hypertension. 1
• Assess mental status for confusion or altered consciousness, which may suggest hypertensive encephalopathy even in the absence of severe headache. 2

Respiratory Examination

• Auscultate lung bases for crackles (rales), which indicate pulmonary edema from heart failure or flash pulmonary edema (the latter suggesting renal artery stenosis). 1

Ophthalmologic Examination

• Perform fundoscopy when BP >180/110 mmHg or when malignant hypertension is suspected to detect retinal changes (arteriovenous nicking, tortuosity), hemorrhages, exudates, or papilledema indicating hypertensive emergency. 1

Key Clinical Pitfalls to Avoid

• Do not assume a normal cardiac examination excludes left ventricular hypertrophy or early heart failure, as these conditions often have minimal or no auscultatory findings; ECG and echocardiography are required for detection. 2
• Do not skip the abdominal examination; failure to palpate for enlarged kidneys or auscultate for renal bruits will miss important secondary causes. 1
• Do not overlook bilateral arm BP measurement at the initial visit, as this simple maneuver can identify significant vascular pathology. 1
• Do not dismiss the importance of anthropometric measurements; neck circumference >40 cm is a critical clue for obstructive sleep apnea, a highly prevalent and treatable cause of resistant hypertension. 1
• Physical examination alone cannot distinguish hypertensive urgency from emergency; assessment for end-organ damage through urinalysis, creatinine, and ECG is essential because organ injury is often clinically silent. 2