Duration: 10 Minutes (2 minutes reading time, 8 minutes performance)
Learning Objectives
- Physical Examination Skills: Demonstrate correct assembly and application of a manual sphygmomanometer.
- Clinical Technique: Integration of the palpatory and auscultatory methods.
- Communication: Explain the procedure using lay language and address patient concerns regarding “white coat” hypertension.
Patient Profile
- Name: Mr. David Miller
- Age: 52 years old
- Ethnicity: Caucasian
- Occupation: High school teacher
- Social History: Smoker (10/day), sedentary lifestyle, high stress due to upcoming exams.
Presenting Complaint
Mr. Miller has presented for a routine health check. His previous pharmacy reading was 155/95 mmHg. He is anxious and believes the “machine at the chemist was broken.”
Contextual Information
- HPC: Occasional tension-type headaches; no chest pain, no shortness of breath, no visual disturbances.
- PMH: Body Mass Index (BMI) of 31 (Obese Class I). No prior diagnosis of hypertension or diabetes.
- Medications: Nil.
- Allergies: No known allergies.
- Family History: Father had a stroke at age 65.
Exam Instructions
Candidate Instructions
- Introduce yourself to the patient and establish rapport.
- Explain the importance of manual blood pressure monitoring.
- Demonstrate the correct application of the manual cuff and the technique for measurement (as per the provided guide).
- Address the patient’s anxiety regarding the procedure.
Standardised Patient (SP) Instructions
- Demeanour: You are slightly agitated and “rushed.” You don’t like needles or medical equipment.
- Opening Statement: “The machine at the pharmacy said my blood pressure was high, but I feel fine. I think those automatic machines are just unreliable.”
- Key Concern: You are worried about being put on lifelong medication.
- Prompt (if 2 mins remaining): “Why are you doing it by hand? Isn’t the digital one faster?”
Examiner Checklist Items
- [ ] Correctly identifies the cubital fossa and brachial artery.
- [ ] Positions the cuff “white patch” and artery indicator on the top/front of the arm.
- [ ] Attaches the dial hook to the cuff strap for ergonomic stability.
- [ ] Holds the pump with thumb and index finger on the screw for precise control.
- [ ] Performs the palpatory (pulse) method first to estimate systolic pressure.
- [ ] Performs the auscultatory method with gentle deflation.
Key Clinical Findings
- Vital Signs: Pulse 82 bpm (regular), RR 16 bpm.
- BP (Manual): 152/94 mmHg (confirmed hypertension in-clinic).
- Physical Exam: Lungs clear, heart sounds S1 and S2, no peripheral oedema.
Communication Triggers (Murtagh’s Approach)
- Open-ended questions: “Before we begin, what are your thoughts on your previous high reading?”
- Summarising: “So, you’re feeling stressed at work and you’re worried that the reading might be higher than it actually is because you’re nervous here today. Is that right?”
- Lay language: Avoid “sphygmomanometer”; use “blood pressure cuff.” Avoid “auscultation”; use “listening to the blood flow.”
Assessment & Marking Guide
| Domain | Minimal Competence (Pass) | Superior Performance |
| Physical Exam | Correct cuff placement above the cubital fossa. | Seamless ergonomics; dial hooked to strap; precise screw control. |
| Clinical Logic | Mentions both pulse and listening methods. | Executes both methods; explains why palpatory is needed (to avoid auscultatory gap). |
| Communication | Answers patient questions clearly. | Uses “Ask-Tell-Ask” technique; validates patient’s anxiety. |
| Professionalism | Respectful and clean hand hygiene. | Calming presence; ensures patient arm is supported at heart level. |
Sample Answers / Model Performance
Step 1: The Opening (Murtagh Style)
“Hello Mr. Miller, I’m Dr. [Name]. I understand you had a high reading at the pharmacy. Before we check it again manually, could you tell me a bit more about how you’ve been feeling lately?”
Step 2: Explaining the Manual Technique
“I’m going to use this manual cuff today. It’s the gold standard for accuracy. I’ll place this white marker right over the artery in the bend of your elbow (cubital fossa). I’ll hook the dial here so I can watch the needle closely while I feel your pulse. First, I’ll feel the pulse disappear to get an estimate, then I’ll use the stethoscope to listen for the exact numbers.”