22 . SYSTEMS - CARDIOVASCULAR GENERAL EXAMINATION AND THE PULSE
Carotid GENERAL EXAMINATION ../ !1J;.'. ---..d ". n A general assessment of the cardio :'I_I " .:2J vascular system (Table 1) should take ~;~ ~ -I( into account the patient's age and sex. It is also essential to determine if the patient:
• is in pain • is experiencing shortness of breath • has a cough • is pale or cyanosed • has evidence of fluid retention • has the 'mitral' facial appearance (dilated cyanotic vessels over the cheek bones) • has chest operation scars • has tar-stained fingers Vein • has signs of hyperlipidaemia t ... Pubic tubercle (including fat deposits in the skin). Fig. 1 The routinely palpated pulses. The first part of the patient that a doctor usually comes into contact with much more information about the pulse produce a detectable peripheral impulse. is the hands, and their temperature and character. It is important to detect a pulse deficit as colour should be noted. Peripheral cyanosis When palpating the pulse, pay particular a normal peripheral pulse rate may con in the absence of central cyanosis might attention to five major characteristics: ceal an inefficient fast heart rate. A pulse suggest inadequacy of peripheral circula rate, rhythm, volume, cbaracter and state deficit may be found in atrial fibrillation, tion, as would coldness of the peripheries. of the vessel wall. 'extra' beart beats (extrasystoles) and in Clubbing, in the presence of heart dis At some stage of the examination, the heart block. In atlial fibrillation the pulse ease, suggests either cyanotic congenital rest of the peripheral pulses (Fig. I) rate is irregular and, unlike the pulse healt disease or infective endocarditis. should be felt. When the radial pulse is in atrial or ventricular ectopics (in which Splinter haemorrhages suggest infective being palpated it is useful to compare the there are predictable compensatory endocarditis. two sides. pauses after each ectopic beat), the timing and force of the following pulse is unpredictable. Table 1 Review of cardiovascular examination RATE • Assess the whole ci rcumstances surrounding the A fast pulse, about 100-150 beats per VOLUME patient"s presentation minute, may occur in exercise, heart • Assess the patient's general condition looking The term 'pulse volume' refers to move specially for signs of hyperlipldaemia such as failure, fever, thyrotoxicosis, severe xanthelasma anaemia, acute haemorrhage or ectopic ment of the palpating finger and not • Assess the patient's hands necessarily to tbe volume of blood • Assess the characteristics of the radial pulses and pacemakers(s) eitber in the atria or flowing. s~mme\rv 0\ raillal pulse ventricles. • Assess other pulses if appropriate Ectopic pacemakers occur in such A small volume pulse is found 1I1 • Take the blood pressure blood flow obstruction, the causes of • Assess the jugular venous pressure conditions as atrial fl utter, paroxysmal • Inspect the chest wall supraventricular tachycardia, ventricular which include: • Palpate the precordium tacbycardia and multiple individual • Auscultate. assessing the heart sounds. added • narrowing of tbe heart valves (stenosis) sounds. and murmurs ectopic beats (either atrial or ventricular). • a low blood volume (as in gastro • Look for signs of right or leM·sided heart failure A slow pulse, about 50 beats per minute intestinal haemorrhage or or less, may be caused by extreme fitness, dehydration) hypotbyroidism, complete beart block, • post-beart-attack (myocardial digitalis overdosage, ~-blocker therapy. infarction) state THE PULSE • any state in which the heart cannot RHYTHM contract efficiently The pulse impulse as felt in the arteries is • generalized or localized peripberal the pressure wave initiated by ventricular The pulse rbytbm may be regular or circulatory inadequacy for any reason systole and usually, but not always, in·egular. If the pulse is ilTegular, the • in shock states (p. 138). reflects blood flow and cardiac output. apex beat rate should be ascertained Traditionally, the pulse is assessed by and compared with the pulse rate at the VESSEL WALL gently compressing the radial artery wrist. A slower pulse at the wrist than at against the lower end of tbe radius, using the apex of the healt constitutes a pulse Clinical assessment of arterial wall the \1ub\ls of the \\\cl.e'io.. a\\..
PULSE CHARACTER (Fig. 2) occur with pericardial effusions, con circulating blood cannot supply heat to strictive pericarditis or in serious bron the peripheries fast enough. Normally, Deep inspiration normally increases the choconstriction. The blood pressure also blanching of the skin caused by digital pulse rate. Inspiration increases the chest falls during inspiration. pressure only lasts for a few seconds, but volume, thus the lungs can contain more in the presence of peripheral circulatory blood than otherwise. This leads to a Plateau pulse failure the blanching time is prolonged. reduced return of blood to the left side of A plateau pulse is a sustained but small The blood pressure may be low (if it can the heart, which then speeds up to com volume pulse which is found in aortic be measured) in arteries which supply the pensate for the reduced blood volume stenosis. area involved. presented to it. If marked, this will con stitute sinus arrhythmia (Fig. 2), which Pulsus alternans Acute limb ischaemia is a cyclical variation in the pulse rate, Pulsus alternans is an alternation of In acute limb ischaemia there may be a speeding up during inspiration and normal and small volume pulses, repre history suggesting a source for an occlud slowing down dUling expiration. It is a senting failure of the left ventricle to ing embolism, a predisposing hypervisco common finding in young people. provide the normal impulse with each sity state of the blood or Severe peripheral The ability to appreciate a normal contraction. When the blood pressure is vascular disease. The limb affected is pulse character can only be gained from taken, the pulse rate suddenly doubles typically painful, pale, pale on elevation, experience. as the sphygmomanometer mercury falls with dusky pink or redness on subse (see p. 25). There are in effect two quent dependency, cold and pulseless. Collapsing pulse different systolic blood pressures. Later ulceration and gangrene may A collapsing pulse is caused by a large develop (Fig. 3). difference between the systolic and Pulsus bisferiens diastolic blood pressure. A collapsing Pulsus bisferiens is a double impulse Chronic limb ischaemia pulse is thus best ascertained by taking which is found in combined aortic In chronic limb ischaemia, the history the blood pressure and finding a wide stenosis and incompetence. ranges from muscle pain on exercise, pulse pressure. However, it is tradition relieved by rest (claudication), in the calf, ally appreciated by raising the arm while thigh, or buttock to persistent pain or monitoring the pulse, and feeling a force EXAMINATION OF THE CAROTID non-healing ulcers and gangrene. Relevant ful jerk of brief duration with several pulses will be diminished or absent. fingers. Sometimes this wide pulse pres ARTERIES sure imparts a distinctive jerking move In patients with cerebrovascular symptoms ment of the neck structures because it is important to evaluate the carotid of the marked carotid artery pulsation. arteries, as neurosurgical intervention In addition, the arterial capillaries may may be possible. A murmur or a thrill exhibit visible pulsation. This is best seen not transmitted from the heart (or absent if the nails are gently compressed against pulsation) may be indicative of impaired the nailbed when the arm is elevated. The or absent blood flow. Only palpate the causes of a collapsing pulse include: carotid arteries one at a time, and if there is no pulsation in the first ensure you do • aOltic incompetence not occlude the second on palpation. • high output cardiac states such as found in thyrotoxicosis • severe anaemia PERIPHERAL PERFUSION • arteriovenous communications • high fevers If there is poor peripheral perfusion, the • complete heart block. hands and feet may be cyanosed (because of increased extraction of oxygen from Pulsus paradoxus the blood associated with the slower Fig. 3 Gangrene. Pulsus paradoxus is a diminution in pulse circulation). The temperature of extre volume during inspiration which may mities may be diminished as the slowly ..... General examination L and the pulse • If a peripheral pulse is reduced, always check for bruits. ! Pulse beats I • Blood pressure measurement often assists in the assessment of pulse abnormalities of cardiac origin. • Always palpate carotid arteries gently if the non-palpated artery is thrombosed as cerebral blood flow Normal pulse could be compromised. !Plateau pulse • Acute circulatory blockage may be reversible. !Pulsus alternansi
Fig. 2 The pulse character.