Proper blood pressure taking technique and what is an auscultatory gap??


In my second quarter of year two med school we are covering the cardiac system (2nd time since last year, but in more depth). We learned how to take a blood pressure last year and did some extensive practicing fall quarter this year, but we’re back at it again for the cardiac system. One step of the blood pressure taking technique we are taught is after applying the cuff we are to take the patient’s wrist and check for their pulse. We are to continue checking the pulse as we inflate the cuff so we know when the cuff is at the point where it is blocking the flow of blood. Inflate the cuff another 20 mmHg of pressure then listen with the stethoscope on the brachial artery as the cuff slowly deflates. We are listening for the blood as it begins to flow again as the cuff is deflating.3712792250_472cd5fa9c_z









What was surprising to me was that most clinicians that have taken my BP have not checked the pulse while inflating the cuff. Talking with my peers and instructors we found we’ve shared this experience. I’ve watched a clinician taking my BP pick a random number on the BP dial and inflate to that number. Here’s where the problem can come in: if there’s an auscultatory gap. An auscultatory gap is the temporary disappearance of the blood flow sounds while the cuff is deflating.


It is most often seen in older patients and it is strongly associated with hardening of the arteries. The problem with not checking the pulse while inflating the cuff is that the patient’s blood pressure could be grossly underestimated if the reading is unintentionally begun in the gap. Checking the pulse ensures that the top, and true, systolic pressure is reached before beginning the reading.









Frech, T. M., Penrod, J., Battistone, M. J., Sawitzke, A. D., & Stults, B. M. (2012). The prevalence and clinical correlates of an auscultatory gap in systemic sclerosis patients. International Journal of Rheumatology, 2012, 590845. doi:10.1155/2012/590845

Cavallini, M. C., Roman, M. J., Blank, S. G., Pini, R., Pickering, T. G., & Devereux, R. B. (1996). Association of the auscultatory gap with vascular disease in hypertensive patients. Annals of Internal Medicine, 124(10), 877–883.

Elderberry syrup

Something that is well known for this time of year is the flu, the upper respiratory flu, not the stomach flu. I’ve decided to write a post about this for several reasons: 1) it’s usually on everyone’s minds during pre-winter and winter season, 2) it’s going around in the Seattle area right now based on this article, 3) I happened to learn a few things about it in Botanical Medicine lab fall quarter. We had a final project requirement of preparing two herbal preparations (one internal, and one external) to target a specific health condition. I chose to target influenza A because I had read some research in the past about Elderberry extract having a significant impact on the duration and severity of symptoms of influenza. I became slightly obsessed this summer with wild harvesting my own elderberries on one of our trips to Eastern Washington and making my own elderberry syrup. So it was natural that I decided to make one of my preparations for this project elderberry syrup.

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I’ll share with you part of my write up for my project.

“Influenza is caused by an orthomyxovirus, an RNA virus that infects the upper respiratory tract. Most influenza is caused by influenza virus type A, and although some illnesses are caused by type B, type A is more severe and is more commonly seen. Influenza is typically characterized by fever, myalgia, headache, sore throat and cough. Although the illness is typically self-limiting in 5-7 days, it is nevertheless important to address due to its ease of communicability(it’s easy to catch), short incubation period (doesn’t take long from the time you’re exposed to getting symptoms), related loss of productivity(can’t get to work, school, etc), and risk of morbidity in certain at-risk patients.

The elderberry syrup I made consisted of Sambucus nigra ssp. cerulea, also known as Blue Elderberry. This was the main herb for my target condition because I have known for some time the research showing Sambucus nigra extract having powerful antiviral effects, and the ability to shorten the duration of influenza. I also knew it was possible to wild harvest it in Eastern Washington during the late summer. Since it was my main herb I chose for addressing influenza I will share some extra information about it.  Sambucus nigra, black elder, has been used for centuries in folk medicine as treatment for colds, influenza and sinusitis. The berries of elder contain high levels of flavonoids that have been shown to have antiviral activity against several different viruses, including influenza virus. The main flavonoids in elderberries are the anthocyanins cyanidin 3-glucoside and cyanidin 3-sambubioside, and it has recently been demonstrated that these substances are detectable in blood plasma after oral ingestion of elderberry extract. Raw honey is used to increase shelf life, flavor, and for its antiviral properties. Clove and fresh ginger are added to enhance the flavor profile.

I chose a syrup because it is tasty, easy to take, and quick and easy to prepare. The syrup can be made in a fairly large quantity if you are able to wild harvest many quarts of fresh elderberries. The syrup can be made up and it will last for about 3 months with refrigeration, and can also be frozen. Also, the berries can be frozen and the syrup made up as needed.”

I’ll include my recipe write up from my project, which is also available in the below references from Rosemary Gladstar’s book. I used honey since that’s what she recommended but I’ve noticed syrups on the market use vegetable glycerin, and since I have that I’ll try that next time. Please never give honey to infants under the age of 2.

Rather than making syrup in the past I have purchased encapsulated elderberry extract. That might be something to look into if making your own doesn’t work for you. Check with your health care provider before making any decisions about your health and check my disclaimer here.

Elderberry Syrup  


  • Large pot
  • Fine mesh metal strainer
  • Sterile canning jars or container of choice
  • Tongue depressor or chopstick


  • 2 quarts fresh ripe elderberries, Sambucus nigra, Caprifoliaceae family; (I wild harvested Sambucus nigra ssp. cerulea found commonly in Eastern Washington)
  • ¼ cup water
  • ¼ ounce freshly grated gingerroot, Zingiber officinalis, Zingiberaceae family
  • ½ teaspoon ground clove flower buds, Syzygium aromaticum, Myrtaceae family
  • Honey


  1. Combine elderberries with ¼ cup water in large pot and simmer over medium heat until soft.
  2. Strain out pulp, reserving liquid
  3. Return liquid to pot, composting pulp
  4. Using tongue depressor or chopstick measure amount of liquid, marking level on tongue depressor or chopstick
  5. Add ginger and cloves and simmer, uncovered, until liquid reduces to half its original volume (use marked tongue depressor to check)
  6. Pour juice into measuring cup and note volume
  7. Return to pot and add equal amount of honey, stirring to combine thoroughly
  8. Let cool, then store in sterile bottles in refrigerator
  9. Use within 12 weeks or freeze


Couch, Robert B. “Medical Microbiology.” 1996. 6 December 2014. <;.

Gladstar, Rosemary. Medicinal Herbs A Beginner’s Guide. Storey Publishing, 2012.

Kinoshita, et al. (2012). Anti-influenza virus effects of elderberry juice and its fractions. Bioscience, Biotechnology, and Biochemistry, 76(9), 1633–8. doi:10.1271/bbb.120112

Krawitz, et al. “Inhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B.” BMC Complementary and Alternative Medicine (2011): 11:16.

Zakay-Rones, Z., Thom, E., Wollan, T., & Wadstein, J. “Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment  of Influenza A and B Virus Infections.” Journal of International Medical Research (2004): 132–140.