Workbook of Practical Human Physiology for BDS Komal Marwaha
INDEX
A
Abdominal signs 203
Abnormalities of
Q wave 60
QRS complex 60
T wave 60
Absolute bone conduction
test 147, 152
Accommodation reflex 120
Acromegaly 31
Acute
blood loss 38
hemorrhage 31
hypotension 31
MI 32
post ganglionic dysautonomia 38
Adjustable chin rest 101
Adrenal insufficiency 32, 38
Advantages of
auscultatory method of BP recording 26
oscillatory method 27
palpatory method of BP recording 26
Air pump 19
Alcoholic neuropathy 38
Ametropia 105
Amyloidal neuropathy 38
Anacrotic pulse 11
Anemia 9, 10
Aneroid sphygmomanometer 28
Aneurysms of carotid artery 122
Ankylosing spondylitis 177
Anomaloscope 93, 99
Anopia 108
Anosmia 85
Antihypertensive drugs 38
Aortic
incompetence 10
stenosis 10
Apex beat 205
Apparatus 21
Argyll robertson pupil 122
Audiometry 147
Augmented unipolar limb leads 50
Auscultatory method 18, 25
Axis deviation 63
B
Barany
caloric test 148
chair test 149
Bell spirometer 68
Benedict Roth apparatus 166
Bilateral paralysis 162
Bipolar
leads 50
limb leads 50
Blood pressure measurement 18, 21, 204
Body temperature 186
Bony developmental abnormality 202
BP sphygmomanometer 24
Brain tumors 9
Breathing patterns 202
Bronchial sounds 195
C
Calculation for predicted value of vital capacity 71
Calibration key 54
Caloric test 148
Cardiac jelly 55
Cardiovascular compensatory mechanisms on prolonge 38
Catecholamine secreting tumor of adrenal glands 31
Causes of irregular rhythm of pulse 10
Centering device/key 54
Cerebellar lesions 122
Character of breath sounds 195
Charts for distant vision 88
Chronic
aortic regurgitation 13
hypotension 32
obstructive pulmonary disease 14
Clinical examination of
cardiovascular system 200
respiratory system 190
Clinical significance of
recording vital capacity 73
spirometry 171
Coarctation of aorta 31
Color
blindness 107
vision 106, 109
Complete paralysis of trigeminal nerve 130
Computerized spirometer 68
Condition of vessel wall 4, 14
Conductive deafness 149
Cone system 106
Confrontation test 99, 100, 109
Confusion colors 93
Consensual light reflex 119
Constricted pupil 122
Constrictive pericarditis 14
Convergence of visual axes 123
Corneal reflex and conjunctival reflex 129
Corrugated rubber tube 68
Cranial nerves 82
Cushing's disease 31
Cyanosis 202
D
Decrease in vital capacity 75
Decreased blood volume 38
Demyelinating diseases 152
Deuteranopia 107
Diabetic neuropathy 38
Diarrhea 31
Diastolic blood pressure 29
Dichromats 107
Dicrotic pulse 12
Dilated
and fixed pupil 122
pupil 122
Direct
light reflex 118
method of blood pressure measurement 17
Disadvantage of
auscultatory method of BP recording 26
oscillatory method 27
palpatory method of BP recording 26
Diuresis 32
Diurnal variation 30
Double walled cylindrical chamber 68
Dynamic lung volumes and capacities 174
E
ECG
leads and connection sites 52
paper 54
E-chart 88
Edema 203
Edridge-green lantern test 93, 95, 109
Effect of
facial nerve paralysis 137
isometric exercise on blood pressure 42
isotonic exercise on blood pressure 44
lesion of vestibular nerve 152
paralysis 156, 157
posture on vital capacity 74
sympatholytic drugs 32
Electrocardiogram 49
Electrocardiograph 53
and electrodes 53
Emmetropia 105
Emotions 30
Endocrinal diseases 31
Epigastric pulsations 203
Essential hypertension 31
Examination couch 18, 67
Examination of
abdominal aorta 7
arterial pulses 3, 203
brachial pulse 6
color vision 93
cranial nerves 82
distant visual acuity 88
dorsalis pedis pulse 6
eighth cranial nerve 142
eleventh cranial nerve 160
femoral pulse 6
fifth cranial nerve 126
first cranial nerves 83
lacrimation and salivation 137
lower face 134
motor component of trigeminal nerve 129
near visual acuity 91
ninth cranial nerve 153
popliteal pulse 6
posterior tibial pulse 6
precordium 204
pterygoid 129
pulses 203
pupil 117
second cranial nerve 86
sensory component of trigeminal nerve 127
seventh cranial nerve 133
somatic fibers 114
tenth cranial nerve 156
twelfth cranial nerve 161
venous pulses 203
visual
acuity 87
field 99
Examine rhythm of respiration 193
Expiratory reserve volume 78, 172
Extreme bradycardia 13
Eyes and lids 202
F
Facial nerve 137
Factors affecting
blood pressure 30
lung volumes 174
visual acuity 105
vital capacity 73
Fever 9, 10
Filter key 54
Fluid in pleural cavity 177
Forced expiratory
flow 175, 176
volume
after three seconds 175
in one second 175
in two seconds 175
Forced vital capacity 174
Fourth nerve paralysis 123
Function of accommodation reflex 122
Functional residual capacity 78, 173
Functions of light reflex 122
G
Gas bell 68
General physical examination 183
Glomerulonephritis 31
GPE in relation to CVS examination 201
Gravity 30
Guilain Barre syndrome 38
H
Hand grip dynamometer 43
Heart
block 9
rate 62
Hemianopia 108
Hereditary syndromes 151
Heteronymous hemianopia 109
High volume pulse 10
Holmgren's wool test 93, 109
Homonymous hemianopia 108
Horner syndrome 121
Hyperaldosteronism 31
Hyperlipidemia 151
Hypermetropia 106
Hyperosmia 85
Hypertension 31
Hyperthyroidism 31
Hypertrophic cardiomyopathy 13
Hypopituitarism 32
Hyposmia 85
Hypotension 31
I
Idiopathic postural hypotension 38
Importance of cuff size 19
Indirect method of blood pressure measurement 18
Infranuclear facial palsy 138
Inspect shape of chest 192
Inspiratory
capacity 78, 173
reserve volume 77, 172
Intensity of breath sounds 196
Interpretation of pin hole test 104
Introduction to clinical examination 182
Irregularity of shape of pupil 122
Ishihara color test 109
Ishihara's
chart 96, 98
isochromatic color plates 93, 96
Isolated sixth cranial nerve paralysis 124
K
Kyphosis 177
Landolt ring chart 88
L
Large arteriovenous fistulas 13
Lead selector keys 54
Left ventricular failure 13
Length of rubber bag/cuff 19
Lesions of third cranial nerve 123
Levelling screws 69
Lithographic colored plates of Ishihara's chart 97
Loss of lung 177
Low volume pulse 10
Lower motor neuron paralysis 162
M
Malignant hypertension 31
Malnutrition 32
Map physiological blind spot 104
Mapping of
binocular field of vision 103
physiological blind spot 103
Massive pleural effusion 14
Match colors 93
Maternal rubella 151
Maximum voluntary ventilation 174
Mean arterial pressure 29
Measuring with mercury manometer 21
Mechanism of BP variation in
isometric exercise 45
isotonic exercise 46
Ménière's disease 151
Mental and emotional state 183
Mercury
manometer 18
sphygmomanometer 19, 44
Metallic
arc 101
pipe 68
Method of
clinical examination 182
connecting ECG electrodes to body 52
recording blood pressure 17
sphygmomanometry 18
Mild isotonic exercise 46
Minute ventilation 174
Mode selection key 54
Moderate isotonic exercise 46
Monochromats 106
Motor
component 133
deficits 131
fibers 154, 156
Multisystem atrophies 38
Myasthenia gravis 121
Myopia 106
Myxedema 9
N
Neck examination 185
Net air capacity of lungs 73
Neurogenic orthostatic hypotension 38
Nine connecting leads of ECG 52
Nodal point 105
Noise trauma 151
Normal
mean cardiac axis 57
values of blood pressure in adults 28
Nose clip 67
Nutritional neuropathy 38
Nystagmus 122, 152
O
Obesity 30
Observe respiration rate 192
Obstructive
cardiomyopathy 10
disease 175
lung disease 176
Oculomotor nerve lesion 121, 122
Olfactory hallucinations 85
One stage vital capacity 75
Oscillatory method 18, 27
P
Palpatory method 18, 25
Parasympathetic fibers 113
Parkinson's disease 38
Parosmia 84
Paste perimetric chart 110
Patent ductus arteriosus 10, 13
Peak expiratory flow rate 176
Pericardial effusion 10, 14
Perimetric chart 102
Perimetry 99
Peripheral pulses 4, 14, 15
Phases of Korotkoff sounds 23
Pheochromocytoma 31
Pin hole test 104
Pleural effusion 177
Pneumonectomy 177
Pneumonia 177
Position of cuff over brachial artery 20
Postural hypotension 38
Power cord and patient cable 55
P-R segment 62
Precordial position of leads 51
Pregnancy 30
Presbyopia 106
Presence of anemia 203
Primary adrenocortical insufficiency 32
Progressive cerebellar 38
Prolonged
bed rest 32
recumbency 32
use of oral contraceptives 31
Propanolol 9
Protanopia 107
Ptosis 121
Pulley and indicator needle 69
Pulmonary stenosis 10
Pulse
deficit 9
pressure 29
Pulsus
alternans 13
bisferiens 13
paradoxus 13
Pupillary reflexes 117
P-wave 59
Pylonephritis 31
Q
Q wave 59
QRS complex 60
QT interval 62
Quadrantanopia 109
R
R wave 60
Radiofemoral delay 4, 14, 15
Recording of
systemic blood pressure 17
timed vital capacity 165
vital capacity 67
Recording spirometer 68
Reflex deficits 131
Refractive errors 106
Renal diseases 31
Residual volume 78, 173
Respiratory muscle strength 74
Restrictive disease 175
Rhythm 10
Riva-Rocci cuff 18
Roman test type 92
Rotational test 149
R-R interval 63
Rubber tubes 19
S
Sarcoidosis 177
Scale and chart frame 102
Schwabach test 146
Scoliosis 177
Secondary hypertension 31
Secretomotor fibers 134
Sensitivity selection key 54
Sensorineural deafness 149
Sensory
component 133
examination 132
fibers 154, 156
Severe isotonic exercise 46
Shy-Drager syndrome 38
Significance of
hearing tests 149
PR interval 61
pulse examination 8
ST segment 62
Simple spirometer 68
Sinus arrhythmia 8
Skin color and texture 201
Sleep 30
Slow rising pulse 11
Snellen's chart 88
Somatic fibers 113
Sources of error during BP recording 26
Speed selector key 54
Sphygmomanometer 18, 21, 27
Spirogram for calculating timed vital capacity 169
Squint 122
S-T segment 62
Standard limb leads 50
Static lung volumes and capacities 170, 172
Stethoscope 22, 44
Stimulus factors 105
Student spirometer 67
Supranuclear facial palsy 138
Synchronicity 15
Systolic blood pressure 28
T
T wave 60
Temperature 30
Tentorial herniation 122
Terminology of electrocardiogram 56
Test for
motor component 139
secretomotor component 137, 142
sensory component of facial nerve 136
Test
object 101
temporal and Masseter muscle 130
Tests for
cochlear function 143
motor component of facial nerve 134
Thyrotoxicosis 9, 10
Tidal volume 77, 172
Total lung capacity 78, 173
Toxemia of pregnancy 31
Trichromats 107
Trigeminal
nerve 126
neuralgia 132
Tuberculosis 177
Tumor of juxtaglomerular cells 31
Tumors affecting eighth nerve 152
Tuning fork tests 144
Twice beating pulse 12
Two stage vital capacity 76
Types of
colour blindness 94
paralysis of facial nerve 138
U
U wave 61
Unequal pupil 122
Unilateral paralysis 162
Unipolar
chest leads 51
leads 50
Upper motor neuron paralysis 162
Uses of spirometery 172
V
Vagus nerve 156
Variations in vital capacity 75
Vascular accidents 122
Vasodilators 38
Vesicular sounds 195
Vestibular
component 152
lesions 122
Visual
acuity 87, 109
angle 105
field
defects 108
examination 109
Vital capacity 171, 173
Vocal resonance 196
Volume of blood in lungs 73
Vomiting 31
W
Watch test 144
Water hammer pulse 12
Waves of
ECG 59
pulse 11
Weber's test 146
Whisper test 143
White coat hypertension 30
Working of
bell spirometer 69
spirometer 69
×
Chapter Notes

Save Clear


Practicals

Examination of Arterial Pulse1

 
OBJECTIVES
After completion of the practical student should:
  • Know the procedure and importance of arterial pulse examination
  • Know the parameters to be examined for examination of pulse
  • Know about various waves of arterial pulse
  • Be able to describe various abnormal pulses
  • Be able to enumerate causes of tachycardia and bradycardia
  • Be able to enumerate conditions where abnormal rhythm, volume, character of pulse is present
  • Be able to enumerate peripheral sites for pulse examination.
 
INTRODUCTION
Pulse examination is one of the vital signs that must be checked with general examination. Arterial pulse is defined as the rhythmic expansion of the arterial wall due to transmission of pressure wave produced during each systole of heart along the walls of the arteries.
 
PRINCIPLE
Each ventricular contraction generates a pressure wave which is transmitted along the vessel walls, this pressure wave expands the arterial wall and the expansion is palpated as pulse.
 
METHOD OF EXAMINATION
Arterial pulse is examined by observing its following aspects/parameters of pulse:
  1. Rate
  2. Rhythm
  3. Volume (Amplitude)
  4. Synchronicity/similarity on both sides
  5. Character
  6. Condition of the vessel wall
  7. Radiofemoral delay
  8. Presence of other peripheral arterial pulses.
4
Usually radial artery is palpated for arterial pulse examination because it is easily accessible and it lies over the hard surface (lower end of head of radius bone).
 
PROCEDURE
  1. Let the subject sit comfortably and let him relax for some time.
  2. Semi-pronate his forearm and flex his wrist.
  3. Put middle three fingers (index, middle and ring finger) of your (examiner's) right hand on the subject's radial artery.
  4. Keep your examining index finger towards the subject's heart. The pressure of the index finger over the subject's radial artery is varied to judge the force and tension of the pulse and to obliterate the flow of blood into the radial artery during examination of condition of vessel wall.
  5. The middle finger is used to feel the pulse wave.
  6. The ring finger is kept towards the subjects thumb. It is used to apply pressure to prevent retrograde pulsation from the palmar arch.
  7. Compress the subject's radial artery against the head of his radius bone.
  8. Now study various aspects/parameters of arterial pulse as described below:
    1. Rate: For rate use your three fingers, count the number of pulse waves for one minute.
    2. Rhythm: Study the spacing between successive pulse waves. Note whether it is constant or not. When spacing between all the waves is constant, the pulse is said to be “regular.” When spacing is not constant, pulse is said to be irregular.
    3. Volume: Feel the uplift given to the palpating fingers during each pulse wave, i.e. the degree of expansion of the arterial walls during each pulse wave. It will tell you the volume of the pulse.
    4. Synchronicity: Simultaneously palpate radial arteries on both arms and look for the synchronicity of pulse on both the sides.
    5. Character: Study the rise, maintenance and fall of the pulse wave. If no abnormality is detected, the character of a pulse is described as normal.
    6. Condition of vessel wall: Try to palpate the vessel wall using your three fingers:
      • With the index finger obliterate the flow of blood into the radial artery
      • With the ring finger empty the vessel
      • With middle finger roll the artery against the bone to assess the thickness of the arterial wall.
      • Normally, the arterial wall is not palpable.
    7. Radiofemoral delay: Keep three fingers of your left hand over subject's radial artery and the three fingers of your other hand on the femoral artery of the subject. Compare the appearance of femoral pulse with appearance of radical pulse. The two pulses should appear together. Mark if any delay is present between them.
    8. Other peripheral pulses: Examine other peripheral pulses according to Table 1.1 and Figures 1.1 to 1.7.
5
Table 1.1   Examination of peripheral arterial pulses
Artery
Site of examination
Method of examination
Examination is important
Radial artery
Wrist
  • Subject's arm is semipronated and wrist flexed
  • Examiner's index, middle and ring fingers are pressed on the radial side of wrist against the radial bone.
  • To assess rate and rhythm
  • To examine radiofemoral delay
  • Examination is not good for studying pulse character
Brachial artery
Arm
  • Subject's upper arm is abducted, elbow is slightly flexed, and the forearm externally rotated
  • Brachial artery is palpated just medial to the biceps tendon and lateral to the medial epicondyle of the humerus
  • To assess pulse character
  • To confirm rhythm
Carotid artery
Neck
  • Examiner's fingers are pressed back to feel carotid artery against precervical muscles
  • To study pulse character and to some extent left ventricular function
  • To detect carotid stenosis
  • To palpate pulse during resuscitation (CPR)
Femoral artery
Groin
  • Subject will lie supine, examiner's fingers are placed midway between pubic tubercle and anterior superior iliac spine
  • To detect radiofemoral delay
  • To assess peripheral vascular disease
Popliteal artery
Popliteal fossa
  • With the knee slightly flexed artery is compressed deep within the popliteal fossa against the femur
  • To assess peripheral vascular disease
Tibialis posterior artery
Ankle
  • Palpated posterior to medial malleolus
  • To assess peripheral vascular disease
Dorsalis pedis artery
Dorsum of foot
  • It is palpated on the dorsum of foot, lateral to extensor hallucis longus
  • At mid point between medial and lateral malleoli, at the base of first metatarsal bone
  • To assess peripheral vascular disease
Abdominal aorta
Abdomen
  • Artery is palpated when subject's abdominal muscles are relaxed; firm pressure is applied with the flattened fingers of both hands of examiner to indent the epigastrium toward the vertebral column
  • To detect aneurysmal swelling
6
zoom view
Fig. 1.1: Examination of radial pulse
zoom view
Fig. 1.2: Examination of brachial pulse
zoom view
Fig. 1.3: Examination of popliteal pulse
zoom view
Fig. 1.4: Examination of femoral pulse
zoom view
Fig. 1.5: Examination of posterior tibial pulse
zoom view
Fig. 1.6: Examination of dorsalis pedis pulse
7
zoom view
Fig. 1.7: Examination of abdominal aorta
 
PRECAUTIONS
  1. Subject should be examined in a warm room. Cool environment may cause peripheral vasoconstriction and reduce the peripheral blood flow.
  2. Arrangements should be made so that the subject's pulses can easily be examined from both sides of the bed.
  3. Begin the pulse examination once the subject's nervousness has subsided. Slight amount of exertion or nervousness is likely to quicken the pulse so it is important to put your subject at ease and examine the pulse a little after he arrives so as to overcome these factors.
  4. Subject's forearm should be semi-pronated and wrist flexed.
  5. Palpation should be done using the fingertips (as the tips are very sensitive).
  6. Avoid palpation with the thumb. Examination with thumb carries a greater likelihood of confusion with the examiner's own pulse and generally has less discriminating sensation than the fingers.
  7. For assessing character in carotid artery and brachial artery particularly, thumb may be used because kinesthetic sensitivity is better in the thumb to detect pulse character.
  8. Pulse rate should be counted for minimum of one minute. If irregularity is detected, the pulse is counted for three minutes and the average of the three may be taken.
  9. If pulse is irregularly irregular, heartbeats must be auscultated simultaneously to detect pulse deficit if present.
  10. Pulses of both sides should be examined and compared.
 
OBSERVATIONS
Observe the rate, rhythm, volume, synchronicity, character of pulse, condition of vessel wall, radiofemoral delay and confirm the presence of all other peripheral pulses.
8
 
RESULT
It is very important to give result stating all the parameters of pulse. Students commonly make this mistake; they just express the pulse rate and leave all other parameters. One should give result of pulse examination describing rate, rhythm, volume, synchronicity, character, vessel wall condition, radiofemoral delay and the presence or absence of other peripheral pulses, e.g. if pulse has all the normal parameters the result will be ‘x’ beats/ minute, regular, good volume, synchronous on both sides, vessel wall is not palpable, there is no abnormality in character and no radiofemoral delay is present. All the peripheral pulses are palpable.
 
DISCUSSION
 
Significance of Pulse Examination
Much valuable information can be gained from examination of the peripheral pulses in addition to the status of the arterial system itself. Variations in the rate, rhythmicity, intensity, and contour of the pulse wave may yield insight into a variety of disease states. The rapid, thready pulse of hypovolemic shock is a well-known clinical sign, as is the rapid, snapping pulse characteristic of thyrotoxicosis, and the collapsing, “water-hammer” pulse of aortic insufficiency. Different aspects of pulse examination provide clue to various physiological and pathological conditions.
 
Rate
In adults a normal pulse rate after a period of rest is between 60 to 80 beats per minute.
  • Tachycardia is defined as a pulse rate more than 100 per minute.
  • Bradycardia is defined as a pulse rate less than 60 per minute.
  • Rate between 60 and 100 beats/min must be seen as normal.
 
Physiological Conditions where Higher Pulse Rate/Heart Rate is Present
  1. Infancy: In newly born infant, pulse rate is about 130/min
  2. Childhood: In children PR is higher than adults, it comes to adult level at around 20 years of age
  3. In females pulse rate is slightly higher (5/min as compared to males).
  4. After exercise
  5. After eating
  6. During emotions like anger, excitement
  7. In pregnancy
  8. In high temperature
  9. During deep inspiration
    • In healthy young individuals breathing at normal rate, the heart rate varies with the phase of respiration: it accelerates during inspiration and decelerates during expiration, especially if the depth of respiration is increased. This phenomenon of quickening of pulse during deep inspiration and slowing during deep expiration is called sinus arrhythmia. It is a normal phenomenon and is due to fluctuations in parasympathetic output to heart. 9During inspiration, impulses in the vagi from the stretch receptors n the lungs inhibit the cardioinhibitory area in the medulla oblongata. The tonic vagal discharge that keeps the heart rate low (vagal tone) decreases and heart rate increases. This can be quite marked in children and adolescents but is uncommon over the age of 30. It can persist a little longer in the physically fit.
 
 
Pathological conditions where higher pulse rate is present are:
  1. Fever: In fever PR is more because of increased sympathetic activity.
  2. Anemia: Tachycardia occurs as a compensatory mechanism to improve oxygen supply to tissues.
  3. Thyrotoxicosis: Thyroxin increases the number of β receptors in heart and also increases sensitivity of these receptors to catecholamines.
  4. Paroxysmal atrial tachycardia.
  5. Atrial flutter and fibrillation.
  6. Circulatory shock.
 
Physiological conditions where lower pulse rate/ heart rate is present:
  1. Old age
  2. During deep expiration
  3. In athletes; because of their increased vagal tone
  4. In emotions like grief
  5. During sleep and meditation.
 
Pathological conditions where lower pulse rate/heart rate is present
  1. Myxedema: Decreased PR is present because decrease in thyroxin levels will decrease the number of β receptors and their sensitivity to catecholamines.
  2. Brain tumors: Decreased PR is present because the increased intracranial pressure will lead to Cushing's reflex.
  3. Heart block: Decrease in pulse rate depends on degree of heart block. In complete heart block, rate may be 30 to 40/minute.
  4. Some drugs decrease heart rate, e.g.
    • Propanolol: It decrease heart rate by inhibiting b receptors of SA node.
    • Digitalis: It stimulates vagal nuclei in medulla; increase in vagal activity will decrease heart rate.
  5. Obstructive jaundice.
 
Pulse Deficit
In conditions of irregular rhythm, some of the heart beats may be weak and not sufficient enough to generate pressure waves in the walls of the arteries. So, radial pulse may not reflect true ventricular contraction. In such conditions, the heart rate (counted by auscultating the apex) will be more than pulse rate. Difference between pulse rate and heart rate is called pulse deficit. It is usually seen in atrial fibrillations and heart block (where deficit is more than 10).
10
 
Rhythm
It is the spacing order at which successive pulse waves are felt. When spacing between all the waves is constant, the pulse is said to be regular. When spacing is not constant, pulse is said to be irregular. The irregular pulse may have a fixed pattern of irregularity, i.e. irregular at regular interval then it is said to be regularly irregular pulse. When irregularity has no pattern then it is said to be irregularly irregular pulse.
 
Causes of Irregular Rhythm of Pulse
  1. Premature contraction or extrasystole/ectopic beat. It is due to generation of impulse from an ectopic focus present in ventricle.
  2. Atrial fibrillations. Irregularly irregular pulse is present.
  3. Atrial flutter with irregular block. Irregularity occurs due to block in conduction that occurs irregularly.
  4. Heart block with dropped beat.
 
Volume
It is the degree of expansion of the arterial wall during each pulse wave. It is felt as an uplift given to the palpating fingers. It is difficult to describe but can be appreciated by palpating the artery. Pulse volume should be compared bilaterally. It can be normal, high or low. It gives an indication of the stroke volume of the left ventricle.
 
Low Volume Pulse
It is also called pulsus parvus. It occurs when the stroke volume of heart decreases. Pulsus parvus/low volume pulse is present in:
  1. Shock
  2. Aortic stenosis
  3. Obstructive cardiomyopathy
  4. Pericardial effusion
  5. Pulmonary stenosis.
 
High Volume Pulse
It is also called pulsus magnus. It occurs due to increase in the stroke volume of heart or widening of pulse pressure. It is present in:
  1. Anemia
  2. Fever
  3. Old age
  4. Exercise
  5. Patent ductus arteriosus
  6. Thyrotoxicosis
  7. Aortic incompetence.
11
 
Character
For examination of pulse character, carotid or brachial artery is more suitable. The character is described as normal when no abnormality is detected in the rate of rise and fall of waveform of the pulse. Character of a pulse is better understood when the pulse is recorded on a paper with the help of transducer and a recorder.
 
Waves of Pulse
Normal radial pulse when recorded has following waves (Fig. 1.8).
zoom view
Fig. 1.8: Waves of radial pulse; p—percussion wave, n—dicrotic notch, d—dicrotic wave
The ‘p’ wave: It is called percussion/tidal wave occurs due to ejection of blood from ventricles during systole.
The ‘n’ notch: It is present in the descending limb of pulse tracing and represents the closure of aortic valve.
The ‘d’ wave: It is called dicrotic wave. It occurs due to rebound of blood against the closed aortic valve during diastole.
The ‘a’ wave: It is called anacrotic wave. It is sometimes seen in the upstroke of the pulse wave. It occurs due to change in velocity of ejection of blood from ventricle towards late systole.
Depending on any change in the normal wave forms; various types of abnormal pulses are described. Different types of abnormal pulses are:
 
Anacrotic pulse/slow rising pulse
It has two upstrokes. A secondary wave occurs in the upstroke of the pulse. The pulse wave is slow to rise and occurs when the ventricular ejection is prolonged (Fig. 1.9). Usually it is seen in aortic stenosis.
12
zoom view
Fig. 1.9: Anacrotic pulse
zoom view
Fig. 1.10: Dicrotic pulse
zoom view
Fig. 1.11: Collapsing pulse
 
Dicrotic Pulse/Twice beating pulse
A dicrotic pulse results from the accentuated diastolic dicrotic wave that follows the dicrotic notch. It is called ‘Twice beating pulse because the dicrotic wave is prominent and gives impression of 2 beats (Fig. 1.10). It is present in fever.
 
Water Hammer Pulse/Collapsing or Corrigan's Pulse
The Corrigan or water-hammer pulse is characterized by an abrupt, very rapid upstroke of the peripheral pulse (percussion wave), followed by rapid collapse. Dicrotic notch is usually absent. It is best appreciated by raising the arm abruptly and feeling for the characteristics in the radial pulse (Fig. 1.11). It probably results from very rapid ejection of a large left ventricular stroke volume into a low resistance arterial system.
13
It occurs most commonly in:
  1. Chronic aortic regurgitation.
  2. Patent ductus arteriosus.
  3. Large arteriovenous fistulas.
  4. Hyperkinetic states like thyrotoxicosis and anaemia.
  5. Extreme bradycardia.
 
Pulsus alternans
Pulsus alternans is a variation in pulse amplitude occurring with alternate beats due to changing systolic pressure. Pulse is regular but alternate beats are strong and weak. It is best appreciated by applying light pressure on the peripheral arterial pulse, and can be confirmed by measuring the blood pressure (Fig. 1.12). When the cuff pressure is slowly released, phase I Korotkoff sounds are initially heard only during the alternate strong beats; with further release of cuff pressure, the softer sounds of the weak beat also appear. Pulsus alternans should not be diagnosed when the cardiac rhythm is irregular. It is present in:
  1. Left ventricular failure (It is the most important cause of Pulsus alternans).
  2. Hypertrophic cardiomyopathy.
zoom view
Fig. 1.12: Pulsus alternans
 
Pulsus Bisferiens
It is a combination of the low raising pulse (anacrotic) and the collapsing pulse. This is typically seen in aortic stenosis associated with aortic incompetence (Fig. 1.13).
 
Pulsus Paradoxus
There is an accentuation of normal phenomenon of decrease in pulse volume with inspiration. There is nothing paradoxical about the pulse character unlike what the name suggests. Normally the 14decrease in amplitude of pulse with inspiration does not exceed 8 to 12 mm Hg. This much decrease in pressure can't be appreciated on palpation. When there is a more marked inspiratory decrease in arterial pressure exceeding 20 mm Hg, the pulse is termed Pulsus paradoxus (Fig. 1.14). In contrast to the normal situation; this can be easily detected on palpation. It is present in:
  • Constrictive pericarditis
  • Pericardial effusion
  • Chronic obstructive pulmonary disease
  • Massive pleural effusion.
zoom view
Fig. 1.13: Pulsus bisferiens
zoom view
Fig. 1.14: Pulsus paradoxus
 
CONDITION OF THE VESSEL WALL
Normally in young adults, arterial wall is soft, elastic and impalpable. But in old age atherosclerosis thickens the arterial wall and it may become palpable. In such conditions, the radial, brachial and temporal arteries may be quiet prominent and tortuous.
 
RADIOFEMORAL DELAY
In normal adults, the upstrokes of the radial and femoral pulses normally appear simultaneously. Normally there is no radiofemoral delay. A delay in the onset of the femoral pulse, generally associated with diminished amplitude, suggests coarctation of the aorta especially when constriction is present distal to the origin of the left subclavian artery.
 
OTHER PERIPHERAL PULSES
In absence of any pathology, all peripheral pulses are well felt and appear simultaneously on both sides. Peripheral pulses may not be felt properly in peripheral vascular disease. Reduced or absent arterial pulses are a sign of impaired blood flow. Palpation of peripheral pulses is important in diagnosis of various diseases like:
  1. Congenital abnormalities (coarctation of the aorta, anomalous peripheral arteries)
  2. Intrinsic arterial disease (atherosclerosis, thrombosis, arteritis)
  3. Vasospastic disorders (Raynaud's phenomenon)
  4. Involvement of the vessel by extrinsic compression (thoracic outlet syndrome, trauma, neoplasms).
15
WORK SPACE
Name of subject
Age
Sex
Observations
Rate:
Rhythm
Volume
Synchronicity
Character
Condition of Vessel Wall
Radio femoral delay
Presence of other peripheral Pulses
Result
ANSWER THESE QUESTIONS
Q1. Define arterial pulse.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Q2. What should be the position of subject's arm for pulse examination?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Q3. Why three fingers are used in pulse examination?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
16
Q4. Draw a labeled diagram of pulse wave.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
VIVA QUESTIONS
Q1. What are the precautions taken for pulse examination?
Q2. What is the significance of arterial pulse examination?
Q3. Why some time is given to the patient/subject before beginning pulse examination?
Q4. What is normal pulse rate?
Q5. What is pulse deficit? In which condition pulse deficit is present?
Q6. What is sinus arrhythmia?
Q7. What is tachycardia? What are the conditions in which it is seen?
Q8. What is bradycardia? What are the conditions in which it is seen?
Q9. Why pulse rate is low in athletes?
Q10. How will you examine pulse volume?
Q11. What are the conditions where pulse has low volume?
Q12. What are the conditions where pulse has high volume?
Q13. What is anacrotic pulse?
Q14. What is dicrotic?
Q15. What is water hammer pulse/collapsing pulse?
Q16. What is pulsus paradoxus?
Q17. What is pulsus alternans?
Q18. What is radiofemoral delay? How it is examined? What is its significance?
Q19. What is the significance of examining peripheral pulses?