DOCSLIB.ORG

General Examination and the Pulse

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
General Examination and the Pulse 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\\<i wi<i<i\'~ \:\\\'b~\.'>.. <i<:t,\:\,,\\. \\\\'i> '&.'C'O.\\'i> \\\'0.\ \\\)\ '0.\\ 'Je,n\-(\­ \\"oJuer\\l\'E, \pre\1\ous\y thought to reflect Palpation of the carotid pulse may give cular contractions are forceful enough to atteriosclerosis) is liable to error. GENERAL EXAMINATION AND THE PULSE 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. .
Load more

Recommended publications
  • 1. Intermittent Chest Pain: Angina: • Stable: (Caused By
    CVS: 1. Intermittent chest pain: Angina: • Stable: (caused by chronic narrowing in one or more coronary arteries), episodes of pain are precipitated by exertion and may occur more readily when walking in cold or windy weather, after a large meal or while carrying a heavy load; the pain is promptly relieved by rest and/or sublingual glyceryl nitrate (GTN) spray, and typically lasts for less than 10 minutes. • unstable angina (caused by a sudden severe narrowing in a coronary artery), there is usually an abrupt onset or worsening of chest pain episodes that may occur on minimal exertion or at rest. • Retrosternal/ Progressive onset/ increase in intensity over 1–2 minutes/ Constricting, heavy/ Sometimes arm(s), neck, epigastrium/ Associated with breathlessness/ Intermittent, with episodes lasting 2–10 minutes/ Triggered by emotion, exertion, especially if cold, windy/ Relieved by rest, nitrates Mild to moderate. • Aggravated by thyroxine or drug-induced anemia, e.g. aspirin or NSAIDs Esophageal: • Retrosternal or epigastric/ Over 1–2 minutes; can be sudden (spasm)/ C: Gripping, tight or burning/ R: Often to back, sometimes to arms/ A: Heartburn, acid reflux/ T: Intermittent, often at night-time; variable duration/ Lying flat/some foods may trigger/ Not relieved by rest; nitrates sometimes relieve/ Usually mild but esophageal spasm can mimic myocardial infarction. 2. Acute chest pain: MI: • SOCRATES: Retrosternal/ Rapid over a few minutes/ Constricting, heavy/ Often to arm(s), neck, jaw, sometimes epigastrium/ Sweating, nausea, vomiting, breathlessness, feeling of impending death (angor animi)/ Acute presentation; prolonged duration/ ’Stress’ and exercise rare triggers, usually spontaneous/ Not relieved by rest or nitrates/ Usually severe.
    [Show full text]
  • CARDIOLOGY Section Editors: Dr
    2 CARDIOLOGY Section Editors: Dr. Mustafa Toma and Dr. Jason Andrade Aortic Dissection DIFFERENTIAL DIAGNOSIS PATHOPHYSIOLOGY (CONT’D) CARDIAC DEBAKEY—I ¼ ascending and at least aortic arch, MYOCARDIAL—myocardial infarction, angina II ¼ ascending only, III ¼ originates in descending VALVULAR—aortic stenosis, aortic regurgitation and extends proximally or distally PERICARDIAL—pericarditis RISK FACTORS VASCULAR—aortic dissection COMMON—hypertension, age, male RESPIRATORY VASCULITIS—Takayasu arteritis, giant cell arteritis, PARENCHYMAL—pneumonia, cancer rheumatoid arthritis, syphilitic aortitis PLEURAL—pneumothorax, pneumomediasti- COLLAGEN DISORDERS—Marfan syndrome, Ehlers– num, pleural effusion, pleuritis Danlos syndrome, cystic medial necrosis VASCULAR—pulmonary embolism, pulmonary VALVULAR—bicuspid aortic valve, aortic coarcta- hypertension tion, Turner syndrome, aortic valve replacement GI—esophagitis, esophageal cancer, GERD, peptic OTHERS—cocaine, trauma ulcer disease, Boerhaave’s, cholecystitis, pancreatitis CLINICAL FEATURES OTHERS—musculoskeletal, shingles, anxiety RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE AN ACUTE THORACIC PATHOPHYSIOLOGY AORTIC DISSECTION? ANATOMY—layers of aorta include intima, media, LR+ LRÀ and adventitia. Majority of tears found in ascending History aorta right lateral wall where the greatest shear force Hypertension 1.6 0.5 upon the artery wall is produced Sudden chest pain 1.6 0.3 AORTIC TEAR AND EXTENSION—aortic tear may Tearing or ripping pain 1.2–10.8 0.4–0.99 produce
    [Show full text]
  • A Case of Dyspnoea and Visible Neck Pulsations
    Online image challenge A case of dyspnoea and visible orthopnoea and palpitations. The symptom aggravation was Heart: first published as 10.1136/heartjnl-2015-308831 on 13 January 2016. Downloaded from abrupt with simultaneous occurrence of both dyspnoea and neck pulsations palpitations. After medical stabilisation, the neck pulsations were as shown in online supplementary video 1. QUESTION What is the most likely cardiac condition? CLINICAL INTRODUCTION A. Aortic regurgitation A 48-year-old male patient with a history of New York Heart B. Congestive cardiac failure Association (NYHA) Class II dyspnoea for the last 2 years C. Tricuspid regurgitation presented with acute onset breathlessness associated with D. Ventricular tachycardia http://heart.bmj.com/ on September 30, 2021 by guest. Protected copyright. Benny PJ, et al. Heart March 2016 Vol 102 No 6 e1 Online image challenge ANSWER: A visible at the root of the neck and no periodicity of pairs as Heart: first published as 10.1136/heartjnl-2015-308831 on 13 January 2016. Downloaded from The major clue here is to find out whether it is an arterial noted in this video. pulsation or a venous pulsation. Typically, an elevated jugular venous pulse ( JVP) will be equally or more prominent at the Panakkal Jose Benny, Gopalan Nair Rajesh, Chakkanalil Govindan Sajeev root of the neck and will show an upper level. The descents Department of Cardiology, Government Medical College, Kozhikode, Kerala, India will be more prominent than the outward pulsations.1 On Correspondence to Dr Panakkal Jose Benny, Senior Resident, Department of the contrary, arterial neck pulsations will be most prominent Cardiology, Government Medical College, Kozhikode 673008, Kerala, India; at the mid-neck level with little or no appreciable pulsation [email protected] at the root of the neck.
    [Show full text]
  • Quick Guide to Cardiopulmonary Care
    Edwards Clinical Education Quick Guide to Cardiopulmonary Care 4th Edition This reference guide is presented as an aide to guide medical personnel by Edwards Lifesciences. The information in this reference guide has been compiled from available literature. Although every effort has been made to report faithfully the information, the editors and publisher cannot be held responsible for the correctness. This guide is not intended to be, and should not be construed as, medical advice. For any use, the product information guides, inserts and operation manuals of the various drugs and devices should be consulted. Edwards Lifesciences and the editors disclaim any liability arising directly or indirectly from the use of drugs, devices, techniques or procedures described in this reference guide. Note: Algorithms and protocols included in this book are for educational reference only. Edwards does not endorse or support any one specific algorithm or protocol. It is up to each individual clinician and institution to select the treatment that is most appropriate. ISBN 978-0-615-96605-2 Quick Guide to Cardiopulmonary Care 4th Edition Editors William T. McGee, MD, MHA, FCCP, FCCM Critical Care Medicine Associate Professor of Medicine and Surgery University of Massachusetts Medical School Caulette Young, BSN, RN, CCRN, CHSE Clinical Nurse Consultant John A. Frazier, BS, RN, RRT Sr. Manager Edwards Lifesciences Previous edition editor Peter R. Lichtenthal, M.D. Previous editions contributors and reviewers Diane K. Brown, RN, MSN, CCRN Barbara “Bobbi” Leeper, MN, RN, CCRN Quick Guide to Cardiopulmonary Care Pertinent clinical information dedicated to the critical care clinician The intent of the Quick Guide is to provide a ready reference for hemodynamic monitoring and oxygenation assessment of the critically ill.
    [Show full text]
  • Pulse 1 Pulse
    Pulse 1 Pulse In medicine, a person's pulse is the arterial palpation of a heartbeat.[1] It can be felt in any place that allows for an artery to be compressed against a bone, such as at the neck (carotid artery), at the wrist (radial artery), behind the knee (popliteal artery), on the inside of the elbow (brachial artery), and near the ankle joint (posterior tibial artery). The pulse rate can also be measured by measuring the heart beat directly (auscultation), usually using a stethoscope. Physiology The pulse is a decidedly low tech/high yield and antiquated term still useful at the bedside in an age of computational analysis of cardiac performance. Claudius Galen (129AD?) was perhaps the first physiologist to describe the pulse. The pulse is an expedient tactile method of determination of systolic blood pressure to a trained observer. Diastolic blood pressure is non-palpable and unobservable, occurring between heartbeats. Pressure waves generated by cardiac systole move the artery walls, which are pliable and compliant. These properties form enough to create a palpable pressure wave. The heart rate can be (much) higher than the pulse rate depending upon the cause or etiology. In this case, the heart rate is determined by auscultation of the heart apex, in which case it is not the pulse. The pulse deficit (difference between heart beats and pulsations at the periphery) is determined by simultaneous palpation at the radial artery and auscultation at the heart apex. Pulse velocity, pulse deficits and much more physiologic data is readily and simplistically visualized by the use of one or more arterial catheters connected to a transducer and oscilloscope.
    [Show full text]
  • Represented, but the Latter, Instead Or Being Rounded Muscles ; Both Rise and Fall Are Rapid and the Line of the and Sustained, Forms a Sharp Angle
    1529 begun aouve at the tlllH1 1-10, and transvetsely Excended from ON THE PULSUS BISFERIENS OF AORTIC the right border of the sternum to a point nearly one inch to REGURGITATION.1 the left beyond the posirjon of the maximum Impulse. A long, soft diastolic murmur in the aortic area entirely replaced the MICHELL M.D. BY J. CLARKE, M A, CAMB., aortic second sound, aLd was conducted upwards but more M.R.C.P. LOND., distinctly downwards along the left border of the sternum, PHYSICIAN TO THE GENERAL HOSPITAL, AND LECTURER ON PRACTICAL and was audible at the apex. the first sound at the PHYSIOLOGY, UNIVERSITY BRISTOL. COLLEGE, apex was indistinct, and sometimes during his stay in hospital a systol’c murmur appealed there. No systolic SHORTLY after reading the very instructive and interest- murmur was heard at the base. The pulmonary second ing papers of Dr. Graham Steell on this subject,2 and sound was feeble. There was a little dulness at the base of the left and the liver and were both to which I here express my indebtedness, a well-marked lung, fpleen There was no and the urine did not contain of the somewhat rare of this described enlarged. dropsy .example type pulse albumen. A cardiographic tracing at this time, taken him came under own observation. This of by my variety over the seat of the maximum ventricular impulse, showed pulse is generally described as a form produced by aortic delay in the pulse wave (only an indication and not a good stenosis, but occurring much more rarely than the more tracing of the brachial pulse was obtained) ; in the ventri- cisual modification of the pulse found in this lesion-namely, cular curve the rise due to the auricle was well marked, and a the anacrotic pulse.
    [Show full text]
  • Hysteresis Compensation in a Tactile Device for Arterial Pulse Reproduction
    sensors Article Hysteresis Compensation in a Tactile Device for Arterial Pulse Reproduction Fernando Carneiro *,†, Paulo Abreu ID and Maria Teresa Restivo ID LAETA—INEGI, Associated Laboratory for Energy, Transports and Aeronautics—Institute of Science and Innovation in Mechanical and Industrial Engineering, University of Porto, 4200-465 Porto, Portugal; [email protected] (P.A.); [email protected] (M.T.R.) * Correspondence: [email protected] † Current Address: Rua Dr. Roberto Frias, 400 Porto, Portugal. Received: 6 April 2018; Accepted: 15 May 2018; Published: 19 May 2018 Abstract: This paper describes a system for training healthcare practitioners in the identification of different arterial pulses. The driving system uses a linear solenoid in an open loop force control. Due to the large hysteresis it exhibited, a form of compensation was implemented, based on the classic Preisach model of hysteresis. Implementation of said model resulted in a significant reduction of force tracking error, demonstrating the feasibility of the chosen approach for the intended application. Keywords: hysteresis compensation; preisach model; feedforward controller; palpation simulation; tactile interface 1. Introduction Palpation of the pulse is a medical technique that allows a physician to rapidly assess the status of a given person’s cardiovascular system. It can be a good source of information, as it enables the physician to perform a rough measurement of heart rate, rhythm, strength of contraction and artery elasticity [1]. This allows estimation of the pulse waveform, which can be an indicator of the development of different cardiovascular diseases [2–5]. Examples include the pulsus bisferiens, pulsus paradoxus and pulsus alternans, that are associated with conditions such as aortic stenosis and regurgitation, hypertrophic cardiomyopathy, pericardial tamponade, restrictive pericardis and dilated cardiomyopathy [3].
    [Show full text]
  • Paper 1 Questions
    CUM1 2/15/05 4:33 PM Page 3 QUESTIONS 1 Paper 1 Questions MCQs [1] Concerning cardiac failure . (c) Dressler’s syndrome (a) valvular disease is the most common cause in the UK (d) electromechanical disociation (b) raised levels of atrial natriuretic peptide (ANP) are (e) left ventricular aneurysm thought to be beneficial in heart failure (c) a third heart sound is a common finding on [5] The following cardiac events are matched correctly ausculation to the corresponding ECG changes . .. (d) the heart looks small on plain postero-anterior (a) inferior infarct Æ ST-segment depression in leads chest radiograph II,III and aVF (e) all diuretics used in treatment of cardiac failure (b) pericarditis Æ downward-sloping ST-segment potentially cause hypokalaemia depression in all anterior chest leads (c) atrial fibrillation Æ irregularly irregular P-waves [2] Concerning hypertension . (d) first degree heart block Æ broad QRS complexes (a) approximately 50% of all cases of hypertension are (e) ventricular aneurysm Æ persistent ST-segment caused by renal dysfunction elevation in chest leads (b) patients with Conn’s syndrome usually have a raised [6] In peripheral arterial occlusive disease... serum potassium level (a) the relationship between radius of artery and flow (c) hypothyroidism does not cause hypertension within it is described by the Fick principle (d) the ‘Cushing reflex’is an increase in systolic blood (b) claudication means ‘cramping’in Latin pressure that occurs secondary to Cushing’s (c) Leriche syndrome is arterial occlusive disease below syndrome the popliteal trifurcation (e) malignant hypertension can be diagnosed on (d) ‘rest pain’commonly occurs in the feet and fundoscopy alone metatarsal heads (e) arterial ulcers are usually painless [3] Acute myocardial infarction .
    [Show full text]
  • Cardiovascular Examination
    Muhammed Akunjee and Nazmul Akunjee GP Principals, London, UK Zeshaan Maan, Surgical Trainee, London, UK and Mina Ally Foundation Doctor, Dartford, UK © Scion Publishing Ltd, 2012 ISBN 978 1 904842 78 1 First published in 2012 All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission. A CIP catalogue record for this book is available from the British Library. Scion Publishing Limited The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury, Oxfordshire OX16 9UX www.scionpublishing.com Important Note from the Publisher The information contained within this book was obtained by Scion Publishing Limited from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention. Readers should remember that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. You should always follow the guidelines laid down by the manufacturers of
    [Show full text]
  • Download Demo
    ExamsBoost Boost up Your Certification Score AACN CMC Cardiac Medicine Certification For More Information – Visit link below: https://www.examsboost.com/ Product Version Up to Date products, reliable and verified. Questions and Answers in PDF Format. Visit us athttps://www.examsboost.com/test/cmc/ Question: 1 Which of the following findings is suggestive of pulsus paradoxus? A. Inspiratory drop in SBP > 10 mmHg B. Expiratory drop in SBP > 10 mmHg C. Inspiratory rise in SBP > 10 mmHg D. Expiratory drop in SBP > 10 mmHg Answer: A Explanation: The finding suggestive of pulsus paradoxus is inspiratory drop in SBP > 10 mmHg. Pulsus paradoxus can be found in cardiac tamponade, constrictive pericarditis, airway obstruction, superior vena cava (SVC) obstruction, COPD, and asthma. Question: 2 The nurse is preparing to record the blood pressure of a patient. What should be the correct position of the patient and arm? A. Patient sitting on chair taken in left arm B. Patient supine and upright taken in both arms C. Patient in any position taken in any of the arms D. Patient lying down on bed taken in right arm Answer: B Explanation: The correct position of the patient and arm is that blood pressure should be taken in both arms with the patient supine and upright with the arm at the level of heart. Dependency of the arm below heart level leads to an overestimation of systolic and diastolic pressures of about 10 mm Hg and raising the arm above heart level leads to underestimation of blood pressures. Question: 3 Which of the following correctly defines pulse pressure? A.
    [Show full text]
  • Systolic Ejection Murmur Presenting with Dyspnea on Exertion
    CARDIOVASCULAR BOARD REVIEW C. RIMMERMAN, B.P. GRIFFIN, EDITORS A SELF-TEST ON A TOBIAS PEIKERT, MD CRAIG R. ASHER, MD BRIAN P. GRIFFIN CLINICAL Department of Internal Medicine, Department of Cardiovascular Department of Cardiovascular Cleveland Clinic Medicine, Cleveland Clinic Medicine, Cleveland Clinic CASE Systolic ejection murmur presenting with dyspnea on exertion 43-YEAR-OLD WOMAN was referred to ■ DIFFERENTIAL DIAGNOSIS A the cardiology outpatient clinic for OF SYSTOLIC EJECTION MURMUR evaluation of a systolic ejection murmur. Her symptoms at presentation consisted of dysp- Which of the following conditions should nea on exertion, decreased exercise tolerance, 1 not be included in the differential diagno- generalized fatigue, and intermittent palpita- sis of a systolic ejection murmur? tions. Her functional impairment was consis- tent with New York Heart Association ❑ Aortic valve stenosis (NYHA) class 2 to class 3. She had a known ❑ Mitral valve regurgitation cardiac murmur since childhood. In the past ❑ Aortic valve sclerosis she experienced presyncopal episodes and, on ❑ Hypertrophic cardiomyopathy one occasion, syncope. ❑ Subaortic membrane She admits to the social use of cigarettes and alcohol. Her father had coronary artery Mitral valve regurgitation is the only one of disease and diabetes mellitus, and an uncle the above conditions that does not present had died suddenly of an unknown cause. with a systolic ejection murmur. Keep an open Systolic murmurs are characterized as mind when Physical examination “ejection” (TABLE 1) or “regurgitant”. Systolic Her vital signs were within normal limits. She ejection murmurs are audible only during part evaluating had no carotid bruits or jugular venous disten- of systole, that is, they begin after S1 and end patients with tion.
    [Show full text]
  • Examination of CVS PART 1 DR UMMAR PULSE
    Examination of CVS PART 1 DR UMMAR PULSE • A pulse wave is a waveform that is felt by the finger, produced by cardiac systole which traverses the arterial tree in a peripheral direction at a rate much faster than that of the blood column. EXAMINATION • Rate, • Rhythm • Volume • Character • A-P deficit • Condition of vessel wall • R-F delay • Whether felt in all peripheral locations & symmetry. • Radial pulse – Rate & rhythm • Carotid pulse – Vol & character • Brachial pulse – BP. RADIAL PULSE • Feeling for the waveform is not useful here as it is too far from the heart. • Use your 1st and 2nd fingers to feel just lateral to the tendon of the flexor carpi radialis and medial to the radial styloid process at the wrist. BRACHIAL ARTERY • Brachial artery :Feel at the medial side of the antecubital fossa, just medial to the tendenous insertion of the biceps. CAROTID ARTERY • This is the best place to assess the pulse volume and waveform. • Find the larynx, move a couple of centimetres laterally and press backwards medial tothe sternomastoidmuscle. • Be sure not to compress both carotids at once for fear of stemming blood flow to the brain particularly in the frail and elderly. FEMORAL ARTERY • This is another useful place for assessing the waveform unless there is disease or abnormality in the abdominal aorta. • The patient is usually stripped to their underwear by this point in the examination and should be lying on a bed or couch with their legs outstretched. The femoral pulsation can be felt midway between the pubic tubercle and the anterior superior iliac spine.
    [Show full text]