Interpretation

Adds to the interpretation in the examination page. Doesn't replace it. So first learn that.

General inspection • Hands • Radial pulse • Brachial pulse • Blood pressure • Face • Eyes • Tongue • Carotid pulse • Jugular venous pressure and pulse waveform • Inspection of the precordium • Palpation of the precordium • Auscultation of the precordium • Auscultation of the neck • Dynamic manoeuvres (if appropriate) • Lung bases • Abdomen • Peripheral pulses (lower limbs) • Oedema.

General Inspection

As always, take a step back and take an objective look at the patient. • Do they look ill? If so, in which way? • Are they short of breath at rest? Is there any cyanosis (see b p. 191)? • What is their nutritional state? • Are they overweight? • Are they cachectic (underweight with muscle wasting)? • Do they have features of any genetic syndrome such as Turner, Down, or Marfan?

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• Hands

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• Radial pulse

And peripheral pulses

For each, you should attempt to detect the rate and rhythm of the pulsation. For the brachial and carotid pulsations in particular, you should also determine the volume and character (waveform) of the pulse.

Pulse rate This should be expressed in beats per minute (bpm). A rate <60 bpm is called bradycardia whereas tachycardia is a pulse >100 bpm. A normal healthy adult pulse rate should be 60–100 bpm.

Rhythm You should feel the pulse for as long as it takes to be sure of the rhythm. In general, the pulse can be either regular or irregular but variations exist. • Regular: a self-explanatory definition. Remember that the pulse rate may decrease with inspiration and increase with expiration in the normal state. • Irregularly irregular: a completely random pattern of pulsation synonymous with AF. The atria twitch and contract in an irregular fashion, sending electrical impulses to the ventricles (and, therefore, causing contraction and arterial pulsation) at random intervals. • Regularly irregular: not quite the contradiction that it seems—a nonregular pulse can occur in some other regular pattern. For example, pulsus bigeminus will cause regular ectopic beats, resulting in alternating brief gaps and long gaps between pulses. In Wenckebach’s phenomenon, you may feel increasing time between each pulse until one is “missed,” and then the cycle repeats. • Regular with ectopics: a very difficult thing to feel and be sure of without an ECG. A normal regular heart rate may be intermittently interrupted by a beat that is out of step, making the pulse feel almost irregularly irregular.

Character/waveform and volume This is best assessed at the carotid artery. Feel for the speed at which the artery expands and collapses and for the force with which it does so. This takes some practice to master, and it may be useful to imagine a graph.

Some examples follow:

• Aortic stenosis: a “slow rising” pulse, perhaps with a palpable shudder. This is sometimes called anacrotic or a plateau phase. • Aortic regurgitation: a “collapsing” pulse that feels as though it suddenly hits your fingers and falls away just as quickly. Try feeling atthe brachial artery and raising the arm above the patient’s heart. This is sometimes referred to as a waterhammer pulse. • Pulsus bisferiens: a waveform with two peaks, found where aortic stenosis and regurgitation coexist • Hypertrophic cardiomyopathy: this pulse may feel normal at first but recedes quickly. It is often described as “jerky.” • Pulsus alternans: an alternating strong and weak pulsation, synonymous with a severely impaired left ventricle in a failing heart • Pulsus paradoxus: pulse is weaker during inspiration (causes includecardiac tamponade, status asthmaticus, and constrictive pericarditis)

Radioradial delay Feel both radial pulses simultaneously. In the normal state, the pulses will occur together. Any delay in the pulsation reaching the radial artery on one side may point to pathology, such as an aneurysm at the aortic arch or subclavian artery stenosis.

Radiofemoral delay Palpate the radial and femoral pulses on the same side simultaneously. They should occur together. Any delay in the pulsation reaching the femoral artery may point to aortic pathology, such as coarctation.

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• Brachial pulse

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• Blood pressure

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• Face

Carotid Pulse

Jugular Venous Pressure

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• Eyes

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• Tongue

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• Carotid pulse

Above

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• Jugular venous pressure and pulse waveform

Above

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• Inspection of the precordium

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• Palpation of the precordium

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• Auscultation of the precordium

Murmurs

Timing. Duration. Character and pitch. Intensity. Location. Radiation. And postural changes. Use these information to diagnose!

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• Auscultation of the neck

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• Dynamic manoeuvres (if appropriate)

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• Lung bases

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• Abdomen

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• Peripheral pulses (lower limbs)

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• Oedema.

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Then start learning important presentations and short cases one by one. Put new pages for each and keep adding from all sources as you learn on. Start from a base like below, (take from 1 theory lecs + 2 short cases books + 3 all textbooks and make note for the case and study)