General ExaminationA GENERAL APPEARANCE1. Built1. Height: - average - dwarf - giant2. Weight: - average - over - under -cachectic♥ We can generally comment & say :- The patient is generally over-built or under-built or average-built for his age.♥ Importance of over-built:- Obesity is a predisposing factor for hypertension, DM, & CAD.- Obesity is more accurately described in terms of body mass index ( BMI ):BMI =body mass index = W / H²( W = weight in Kg, & H = height in meters ).- Obesity is classified according to BMI into 3 grades:Grade I: mild BMI = 25 - 30Grade II: moderate BMI = 30 – 40Grade III: severe BMI = above40- Obesity is classified according to the cause into 2 types:a) Simple obesity:- Not all of the persons with simple obesity eat more than theaverage person, BUT: all of the persons with simple obesity eatmore than they need.b) Secondary obesity:- In this case, obesity is just an associated feature of thedisease:Causes of secondary obesity1. Hypothalamic disorders2. Hypothyroidism ( myxoedema )3. Cushing’s syndrome
4. Corticosteroids intake♥ Importance of under-built: “ loss of weight ”- Congenital heart diseases with chronic infections &chronic hypoxia.- Cardiac cachexia in severe chronic heart failure.- Diabetes mellitus.- Thyrotoxicosis- Malignancy- Malabsorption & malnutrition2. Decubitus “ position in bed ”1. Semi sitting: is encountered in left-sided heart failure( orthopnea ).2. Sitting and leaning forward: is encountered in pericardialeffusion ( prayer’s position ).3. Squatting is encountered in the Tetralogy of Fallot.3. Consciousness & mentalitydisturbed ( drowsy, confused, or disoriented )in:▪ COPD & respiratory failure: CO2 narcosis.▪ Liver cell failure: Hepatic encephalopathy.▪ Renal failure: Uremic encephalopathy.B FACE EXAMINATION1. Pallor- We search for pallor in:- face , conjunctiva , lips, tongue , hands, palmer creases- In cardiac disease, pallor may be due to:1. Anemia2. Rheumatic activity3. Infective endocarditis
4. Low cardiac output5. ShockTypes of anemia on the clinical back ground:i. IRON DEFICIENCY ANEMIAii. HAEMOLYTIC ANEMIAiii. MEGALOBLASTIC ANEMIAIRON DEFICIENCY ANEMIA:This is the commonest type of anemia.There is usually a clue for blood lose in the history.You have to look for the evidence of chronicity which are :Angular stomatitis ”soreness at mouth angles”Atrophic glossitis:” smooth tongue”Kilonychia ”spoon shaped nails”HAEMOLYTIC ANEMIA:This will result from the reduction of life span of red blood cellsto 100 days as this will present with pallor and jaundice .Causes of haemolysis:A. Congenital1.Abnomality of the shape-spheroctosisi, elliptocytosis2.Abnormality of haemoglobin – thalasemia alpha andbeta3.Abnormality of RBC enzymes – glucose 6 phosphatedehydrogenase DEF.B. Acquired1. Atypical pneumonia – mycoplasma2. Virus – HIV , HAV3. parasite –malaria4. Connective tissues diseases= SLE5. Lymphoma and leukemia6. prosthetic valve7. drug induced –methyl dopa8. Autoimmune heamolysis
MEGLOBLASTIC ANEMIA:It is due to vitamin b12 or folic acid deficiency.It is commonly due to vit.b12 deficiency which is commonlycaused by pernicious anemia “autoimmune”In pernicious anemia ,The patient is asthenic , anemic , albinism with atrophicgastritis , amnesia.The presence of GIT symptoms , CNS symptoms ,LOWER LIMBweakness gives a clue toward the diagnosis.
2. Cyanosis♥ Definition:- Bluish discoloration of skin & mucous membranes due to thepresence of excessive blue blood ( unoxygenated ) in the circulation( more than 5 gm % reduced Hb ) or decrease blood flow peripherally.It could be Central cyanosis, or Peripheral cyanosis.The bluish color is more readily apparent in those with highhemoglobin counts than it is with those with anemia. Also thebluer color is more difficult to detect on deeply pigmented skin.When signs of cyanosis first appear, such as on the lips or
fingers, intervention should be made within 3–5 minutesbecause a severe hypoxia or severe circulatory failure may haveinduced the cyanosis.♥ Examination: Where do we search for cyanosis??- Look at the tongue, lips & nails for the blue colour of cyanosis:▪ Central cyanosis: blue colour in all “ tongue”▪ Peripheral cyanosis: blue colour in nails only “hands and feet”.If the hands are cold ,it is likely to be peripheral cyanosis.The central cyanosis will result in warm hands with blue colour.♥ Common causes:CyanosisCentral PeripheralDefinition- Blood pumped in the aortacontains more than 5 gm %reduced Hb.- Blood pumped in the aortais quit normal (oxygenated),BUT: there is stagnation ofblood in the peripheralcirculation, leading toextraction of more oxygen& development of cyanosis.Causes - Cyanotic congenital heart disease- Lung fibrosis , bronchiectasis &Pulmonary embolism, emphysemahypoxic corpulmonale.- Venous stagnation, e.g.CHF- Venous obstruction.Effect ofwarmingNo effect ImprovesEffect ofoxygeninhalationMay improve central cyanosiswhich is due to chronic lungdisease only.No effect
♥ Why do we particularly look for central cyanosis in the tongue??- Normally the colour of a tissue depends on:1 Sympathetic supply: state of blood vessels( vasoconstriction or vasodilatation ).2 Pigment granules.3 Colour of the Hb pigment in the circulating blood.- The tongue is devoid of: 1 sympathetic supply, & is devoid of: 2pigment granules, & so the tongue colour depends only on 3 colour ofthe Hb pigment in the circulating blood, & so the tongue colour is agood index of the blood colour.Causes of peripheral cyanosis:• All common causes of central cyanosis• Arterial obstruction• Cold exposure (due to vasoconstriction)• Raynaud phenomenon (vasoconstriction)• Reduced cardiac output (e.g. heart failure, hypovolaemia)• Vasoconstriction• Venous obstruction (e.g. deep vein thrombosis)Causes of central cyanosis:1. Respiratory System:• Bronchospasm (e.g. Asthma)• brochiectasis• Pulmonary Hypertension• Pulmonary embolism• Hypoventilation• COPD (emphysema and chronic bronchitis)• Lung fibrosis2. Cardiac Disorders:• Congenital heart disease (e.g. Tetralogy of Fallot, )• Pulmonary hypertension• Heart valve disease• Myocardial infarction “shock”3.blood• Methemoglobinemia
Differential cyanosisDifferential cyanosis is the bluish coloration of the lower but not the upperextremity and the head. This is seen in patients with a patent ductusarteriosus. Patients with a large ductus develop progressive pulmonaryvascular disease, and pressure overload of the right ventricle occurs. Assoon as pulmonary pressure exceeds aortic pressure, shunt reversal(right-to-left shunt) occurs. The upper extremity remains pink because thebrachiocephalic trunk, left common carotid trunk and the left subclaviantrunk is given off proximal to the PDA.4. Abnormal pigmentation- Malar flush: erythematous (red) rash in the butterfly area of theface in:▪ Mitral stenosis▪ Systemic lupus erythematosus5. Eye examinationa) Loss of hair in the outer 1/3 of the eye brows:- Myxoedema - Leprosyb) Puffiness of lower eye lids:- Diabetic nephropathy-Hypertensive patients- Graves disease- Chronic cough - Constrictive pericarditis & pericardialeffusion- SVC obstruction - Severe hypoproteinemia & renal failure- Myxoedemac) Peticheal hemorrhage in the conjunctiva:- Malignant hypertension - Infective endocarditis- Purpura
Splinter hemorrhages(Panel A) are normally seen under thefingernails. They are usually linear and red for the firstr two to threedays and brownish thereafter.Panel B shows conjunctival petechiae.Oslers nodes (Panel C)are tender, subcutaneous nodules, often inthe pulp of the digits or the thenar eminence.Janeways lesions (Panel D) are nontender, erythematous,hemorrhagic, or pustular lesions, often on the palms or soles.D) Exophthalmos:- ThyrotoxicosisE) Pallor: “ in the conjunctiva ”F) Jaundice: “ in the sclera ”ASK THE PATIENT TO LOOK DOWN AND PULL THE UPPER EYE LIDGENTLY WITH YOUR THUMBS NEAR THE LINE OF EYE LASHES TO LOOKFOR SCLERA AND TO LOOK UPWARD TO PULL THE LOWER EYELIDDOWNWARD WITH THE THUMB YO LOOK FOR CONJUNCTIVA FORPALLOR.
You have to check the elastic tissues which has a high affinity forbilirubin. They are : the sclera and under the tongue.Three types of jaundice:1.Prehepatic jaundice2.Hepatic jaundice3.Posthepatic jaundiceIn prehepatic jaundice= pallor and jaundiceIn hepatic jaundice, the commonest cause is chronic liverdiseases “cirrhosis”The stigma of chronic liver disease should be detected oncethe patient has jaundice which are:• spider nevi• Palmar erythema=reddening of the palms at the thenar and hypothenar eminences• Clubbing• Ecchymosis• Kilonychia• leukonychia• Scratch marks• Gynaecomastia• Feminising hair distribution• Testicular atrophy• Wasting of small muscles of hand and muscle emaciation• Anaemia• Caput medusae (recanalisation of the umbilical vein) (Distendedabdominal veins)Signs associated with decompensation• Drowsiness (encephalopathy)• Metabolic Flap/Asterixis (encephalopathy)• Jaundice (excretory dysfunction)• Ascites (portal hypertension and hypoalbuminaemia)• Peripheral oedema (hypoalbuminaemia)• Bruising (coagulopathy)
Signs associated with the aetiology• Dupuytrens contracture, Parotidomegally (Alcohol)• Peripheral neuropathy (Alcohol and some drugs)• Cerebellar signs (alcohol and Wilsons disease)• Hepatomegaly (alcohol, NAFLD, Haemochromatosis)• Kayser-Fleisher Rings (Wilsons)• Increased pigmentation of the skin (Haemochromatosis)• Signs of Right Heart Failure• Tattoos (Hepatitis C)Spider neviA spider angioma ( spider nevus, vascular spider, and spider telangiectasia) is atype of telangiectasis found slightly beneath the skin surface, often containing acentral red spot and reddish extensions which radiate outwards like a spidersweb. They are common and may be benign, presenting in around 10-15% ofhealthy adults and young children. However, having more than five spider naevimay be a sign of liver disease.
Spider angiomas are found only in the distribution of the superiorvena cava, and are thus commonly found on the face, neck, upperpart of the trunk and arms. They may also be present on the backsof the hands and fingers in young children.Spider angiomas are due to failure of the sphincteric muscle surrounding acutaneous arteriole. The central red dot is the dilated arteriole and the red "spiderlegs" are small veins carrying away the freely-flowing blood. If momentarypressure is applied, it is possible to see the emptied veins refilling from the centre.No other angiomas show this phenomenon.
The hepatic jaundice can be caused by any pathological process thatinvolves the liver like hepatitis , hepatic carcinoma , congested liver ,liver cirrhosis etc.Those patients commonly present with bleeding tendency withecchymosis , Leg edema and jaundice.In posthepatic jaundice, there is obstruction in the common bile ductwhich shift the bilirubin to be excreted in the urine “increasedurobilinogen, stercobilirubin” .This will result in change the colour ofurine and stool.There will be 3 signs :1.White colored stool –steatorrhea =clay colored stool2.Tea colored urine –dark brown =haematuria3.Olive green eyes as the jaundice is progressiveIt is a surgical jaundice that need surgical intervention.Causes of obstructive jaundice:1. obstruction of common bile duct byStone, tumor , stricture , blood clot , porta hepatis2. carcinoma head of pancrease3. carcinoma of ampulla of vater
SUMMARY;1. look for the patient and comment on the conscious level, position onbed , general looking , colour of skin.2. Exam the hair for alopecia , upper eye lids , ask the patient tolook down and pull the upper eye lids of the patient with yourthumbs to look for jaundice.3. Ask the patient to look up and pull the lower eye lids forconjunctiva for pallor , bleeding.4. Exam the mouth- tongue and mucous membrane for cyanosis ,pigmentation , pallor , atrophy , lose of papilla.5.Ask the patient to set to look for the neck and exam for swellings ifpresent and ask him to swallow for thyroid swelling.5. Sit behind the patient while he is sitting and exame for lymph nodes.6. Ask the patient to lie on the bed elevated 45 for neck veins.7. Exam hands for pallor& cyanosis ,nails for clubbing , pulse.8. Exam lower limbs for calf swelling, pedal edema, ischemic signs.C NECK EXAMINATION1. Neck veins2. Carotid arteries3. Thyroid gland4. Trachea5. Lymph nodes1. Neck Veins Jugular Venous Pulse ( JVP )a) Identification:▪ There are 2 jugular veins on each side of the neck:External Internal- Easy to see, but gives falseimpression of raised pressure.- More difficult to see, but is accuratefor measurement of pressure &pulsations.- Runs from the midpoint of theclavicle upwards to cross thesternomastoid muscle obliquely.Runs deeply from the sternoclavicularjoint upwards & laterally to the angleof the jaw.▪ Both can be identified by asking the patient to perform aValsalva manoeuvre.
b) Comment: Neck veins should be examined for:I Pressure: ( congested or not?? )♥ Positioning the patient:- No special position to measure the JV pressure.-Just make the patient relaxed & comfortable with his headslightly elevated on a pillow & his sternomastoid musclesrelaxed.-Adjust the head of the bed so as to maximize the JV pulsations& make them visible in the lower half of the neck ( above theclavicle, but below the jaw.(-Usually, the head of the bed needs slight elevation (45º-However, when the patient’s venous pressure is increased, the headof the bed may need more elevation up to 60º or even 90º.
- In all these positions , the sternal angle remains about 5cm above the right atrium.♥ Measuring the pressure:- Identify the external jugular vein.- .Identify the pulsations of the internal jugular vein Because,this vein lies deep to the sternomastoid you may not see the. ,vein itself Instead watch for the pulsations transmitted throughthe surrounding soft tissues.- Identify the highest point of pulsation in the internal jugular vein:▫ With a centimeter ruler measure the vertical distance between this point &the sternal angle, as in the Fig. below.▫ Venous pressure greater than 3 cm above the sternalangle is considered elevated ( with the patient in any position ).II Pulsations:( pulsating ornot?? )♥ JV pulsationsreflect pressurechanges in the right atrium.
♥ Normally, the JV pulsations are wavy & consist of: a-wave : right atrial contraction. x-descent : right atrial relaxation. c-wave : - transmitted from adjacent carotids.- upward bulge of tricuspid valve into right atrium. v-wave : right atrial filling during ventricular systole. y-descent: right atrial empty & opening of tricuspid v.♥ Normal systolic collapse:▪ Normally, the x-descent coincides with the arterialpulsations.Important points in comment on the neck veins* Unilateral distension of the ext. jug. vein is usually due to local kinking or obstruction.* Empty neck veins when the patient is horizontal may indicate hypovolemia.* Full neck veins up to the angle of the jaw when the patient is upright may indicatesevere CHF.* Hepato jugular reflux:- In CHF, exert firm & sustained pressure with your hand over the patient’s righthypochondrium for 1 minute.- Watch for an increase in the JV pressure. A rise of more than 1 cm is abnormal &confirms the presence of CHF ( positive hepato jugular reflux ).c) Clinical significance of neck veins:1) Abnormal pressure: Congested neck veinsCongested pulsating:- Right sided HF- Pericardial effusion & constrictive pericarditis- HypervolemiaCongested non-pulsating:- SVC obstruction- Mediastinal syndrome2) Abnormal Pulsations: Abnormal waves a- wave :- GAINT: complete heart block,pulmonary hypertension, PS, TS- Absent : AF
x-descent:- Obliterated ( systolic expansion of neck veins ):* TR* AF* Cannon waves:. regular : nodal rhythm. occasional : A-V dissociation- Prominent :* Constrictive pericarditis* Pericardial effusion y-descent :- Prominent :* Constrictive pericarditis2. Carotid Arteriesa) Prominent pulsations: volume load e.g. Aortic regurgetation.b) Systolic thrill:1- Propagated from the base of the heart:- Aortic stenosis: there will be thrill over the base of theheart.2- Initiated in the vessel itself:- In cases with big pulse volume, e.g. Aortic regurge: therewill be no thrill over the base of the heart.Jugular venous pulsations Carotid artery pulsationsImpulse Wavy impulse One impulsePalpation Rarely palpable ( betterseen )PalpableLocation Lateral to thesternomastoidMedial to thesternomastoidUpper level Has an upper level No upper levelCongestion- Increases with gentlepressure- Increases with hepatojugular reflux- No effect- No effect- No effect- No effect
- Decreases with inspiration- Varies with positionHead/Neck Lymph NodesThe greatest supply of lymph nodes are located in the head and neck. Sourcestend to differ on the name of these lymph nodes. These particular names of thelymph nodes used correspond to adjacent structures.• Preauricular, in front of the ear• Posterior auricular (mastoid), superficial to the mastoid process• Occipital, at the base of the skull• Submental, midline, behind the tip of the mandible• Submandibular, halfway between the angle and the tip of the mandible• Jugulodigastric, under the angle of the mandible• Superficial cervical, overlying the sternomastoid muscle• Deep cervical, deep under the sternomastoid muscle• Posterior cervical, in the posterior triangle , the edge of the trapeziusmuscle• Supraclavicular, just above & behind the clavicle.Head & neck lymph nodes1. SUBMENTAL2. SUBMANDIBULAR
3. PAROTID4. PREAURICULAR5. POSTAURICULAR6. OCCIPITAL7. ANTERIOR CERVICAL8. SUPRACLAVICULAR9. POSTERIOR CERVICALWhen examining for lymph nodes you want to note:• Site: localised to one region or generalised?• Size: Large nodes are usually abnormal (greater than 1 cm)• Consistency: Hard nodes suggest carcinoma, soft may benormal and rubbery nodes may be due to lymphoma• Tenderness: Usually implies acute inflammation or infection• Fixation: Nodes that are fixed to underlying structures aremore likely to be due to carcinoma• When examining one area, always compare to the other side• When examining for lymph nodes, usually an abdominalexamination should take place. Particularly examining forsplenomegaly, hepatomegaly, para-aortic nodes and anypotential masses.HOW TO EXAM THE LYMPH NODES?Using a gentle circular motion with your finger pads palpate each lymphnode in the order previously stated. It is a good idea to palpate both sidesat the same time, comparing the two sides symmetrically. Normal cervicalnodes should be less than one centimeter, movable, discrete, soft, andnontender.AXILLARY LYMPH NODESPatient position:Usually the patient is seated or reclined on a couch for this examination.The examiner tends to raise the patient’s arm, and using the left hand forthe patients right axilla, (and vice versa) the examiner passes theirextended fingers high into the patients axilla.
The patients arm is now brought to rest on the examiners forearm.Now the examiner should palpate for the following groups of nodes:1) CENTRAL/APEX2) LATERAL3) PECTORAL (medial)4)INFRACLAVICULAR5) SUBSCAPULAR .Every effort should be made to feel for nodes in each of these areas.Axillary or armpit lymph nodes drain lymph from the arms,breast, chest wall and upper abdomenINGUINAL LYMPH NODESFor clinical purposes, an oblique set of nodes along the inguinal ligamentarea and a longitudinal set overlying the femoral vessels are usuallypalpated for.Have the patient reclined on the couch for this assessment. You will needto expose the groin area.Note that small nodes can be commonly detected in otherwise normalpatients.Causes of L.N. enlargement:1. INFECTION2. LEUKEMIA
3. LYMPHOMA4. HIV5. METASTASES6. CONNECTIVE TISSUE DISEASESD UPPER LIMBS1. Clubbing.2. Spooning: iron deficiency anemia.3. Splinter hemorrhages: infective endocarditis.4. Subcutaneous nodules: rheumatic fever.5. Pallor or peripheral cyanosis.Clubbing▪ Definition:- Tissue proliferation of the nail bed due to chronic toxemia orhypoxia.Clubbing develops in five steps:1. Fluctuation and softening of the nail bed (increased ballotability)2. Loss of the normal <165° angle (Lovibond angle) between thenailbed and the fold (cuticula)3. Increased convexity of the nail fold4. Thickening of the whole distal (end part of the) finger (resembling adrumstick)5. Shiny aspect and striation of the nail and skinSchamroths test or Schamroths window test (originally demonstrated bySouth African cardiologist Leo Schamroth on himself)is a popular testfor clubbing. When the distal phalanges (bones nearest the fingertips) ofcorresponding fingers of opposite hands are directly opposed (place
fingernails of same finger on opposite hands against each other, nail tonail), a small diamond-shaped "window" is normally apparent between thenailbeds. If this window is obliterated, the test is positive and clubbing ispresent.▪ Degrees:1- First:- Obliteration of the angle of the nail bed.- Increased nail curvature in longitudinal &lateral axes.- When palpating the nail base, it gives a spongy or floatingsensation.2. Second: Parrot beak appearance.3. Third: Drum stick appearance.▪ Causes of clubbing:NO ACUTE CAUSE , IF PRESENT IT IS A CHRONICCAUSE.A) Cardiac:Cyanotic congenital heart disease (cyanoticclubbing )- Infective endocarditis ( pale clubbing ).- Atrial myxoma (benign tumor)B) Chest:
• Fibrosing alveolitis.• Lung cancer, mainly non-small-cell (54% of all cases), notseen frequently in small-cell lung cancer (< 5% of cases)• Interstitial lung disease• Complicated tuberculosis• Suppurative lung disease:• lung abscess, empyema, bronchiectasis, cystic fibrosis• Mesothelioma of the pleura• Arteriovenous fistula or malformation`C) Hepatic & GIT:- Liver cirrhosis, especially biliary.- Ulcerative colitis & Crohn’s disease.- Bilharzial polyposis coli.D) CongenitalOthers:• Hyperthyroidism (thyroid acropachy)• Familial and racial clubbing and "pseudoclubbing" (people ofAfrican descent often have what appears to be clubbing)• Vascular anomalies of the affected arm such as an axillary arteryaneurysm (in unilateral clubbing)A special form of clubbing is hypertrophic pulmonaryosteoarthropathy, known in continental Europe as Pierre Marie-Bamberger syndrome. This is the combination of clubbing andthickening of periosteum (connective tissue lining of the bones)and synovium (lining of joints), and is often initially diagnosedas arthritis. It is commonly associated with lung cancer.E LOWER LIMBS
1. Oedema.2. Dorsalis pedis pulsations.3. Clubbing & peripheral cyanosis.4. Chronic leg ulcers.Oedema1. Examination:-Press firmly with your thumb for at least 10 seconds behind eachmedial malleolus, over the dorsum of each foot & over the shins- Look for pitting: a depression in the skin caused by pressure.- Check for sacral oedema in bed ridden patients.- Palpate the calf muscles for signs of DVT: calf muscles arefirm, tense & tender.- Look for signs of inflammation: redness, hotness ordiscoloration.2. Characteristics of cardiac oedema:1. Occurs in the dependant parts of the body:Ankle oedema : in ambulant patients.Sacral oedema : in bed ridden patients.2. Bilateral, but one side may be affected more due to:Deep venous thrombosis.Postural, in patients sleeping on one side.3. Always pitting4. Oedema of lower limbs always precedes appearance of ascites,except in two conditions in which ascites occurs first “Ascites precox”:a) Percardial effusion & constrictive pericardit- Kinking of hepatic veins causes early liver congestion & ascites.- Obstruction of lymphatics passing through the central tendon of thediaphragm causes accumulation of lymph in the peritoneum.b) Tricuspid incompetence:- Regurgitation of blood causes liver congestion & ascites.4. Differential diagnosis of cardiac oedema:
1. Renal Oedema:This occurs in nephritis or nephritic syndromes. Oedema occursfirst in the eye lids and is associated with features of renal disease.Nephrotic syndrome:1.protenuria2.hypoalbuminemia3.generalized anasarca4.hyperlipidemiaNephritic syndrome:1.Haematuria2.Hypertension3.Urine casts2. Hepatic Oedema:Oedema of lower limbs occurs after ascites and is associatedwith features of liver disease.3. Nutritional Oedema:This occurs with severe nutritional deficiency.4. Angioneurotic Oedema:-This allergic oedema occurs with constant relation to certainfactors, as eating certain food or inhaling certain substances.- Oedema occurs acutely especially in the lips, eye lids & larynx,but may be generalized . There is usually positive family history ofoedema or other allergies, and the patient himself may have otherforms of allergy.- Rapid response of oedema to antiallergic measures ischaracteristic.5. Local Oedema
G VITAL SIGNS1. Temperature, BP & respiratory rate2. Pulseones pulse represents the tactile arterial palpation ofthe heartbeat by trained fingertips. The pulse may bepalpated in any place that allows an artery to becompressed against a bone, such as at the neck (carotidartery), at the wrist (radial artery), behind the knee(popliteal artery), on the inside of the elbow (brachialartery), and near the ankle joint (posterior tibial artery).► Rate:• Normally: 60-100 beat / min.• Abnormally: bradycardia, or tachycardia.• Can be counted in half a min. & multiplied by two.► Rhythm:• Regular or irregular.• If irregular: you should:
1. Count the rate in one whole min.2. Count the apical heart rate.• Irregularity is either:1. Occasional: extrasystoles.2. Marked: AF• Pulsus deficit (difference between apical rate & radialpulse rate):1. In extrasystoles: Pulsus deficit is lessthan 10.2. In AF: Pulsus deficit ismore than 10.► Volume:• Average.• Big: - AR & hyperdynamic circulation.• Small: - Decreased filling: Pericardial effusion &constrictive pericarditis.- Decreased pumping: HF & myocardial disease.- Obstruction: MS, AS & pulmonaryhypertension.► Special character:Water hammer: AR & hyperdynamic circulation.Pulsus alternans: Alternating strong & weakregular beats in LVF.Pulsus paradoxus: Diminished pulse volume oninspiration in:Pericardial effusion, constrictive pericarditis &COPD.Pulsus bigeminus: Alternating normal beats& extrasystoles in:- Digitalis toxicity - Very frequent extrasystoles.Pulsus bisferiens: A double systolic peakin double aortic & IHSS.Plateau pulse: Delayed upstroke, in AS.► Arterial wall:
&Thickened felt in.atherosclerosis► Equality of pulse volume on both sides:Normally, pulse volume is equalon both sides.Abnormally, there is unequalpulse volume on both sides, in:1. Pressure from outside:- Cervical rib, or pancoast tumour.2.Disease of the arterial wall:- Aneurysm of aortic arch, or subclavian artery.- Arteritis.3. Occlusion of the lumen:- Thrombosis or embolism.