Gen. Medicine

2. ABNORMAL FINDINGS IN
PULSE
Abnormality can be in the:
 Rate
 Rhythm
 Volume
 Character
 Condition of vessel wall
 Radiofemoral delay

3. ABNORMAL FINDINGS IN
PULSE RATE
1.Tachycardia(Pulse Rate>100 bpm)
2.Bradycardia(Pulse Rate<60 bpm)

4. TACHYCARDIA
Sinus rhythm Arrhythmia
Exercise Atrial Fibrillation
Infants Atrial flutter
Excitement/Anxiety VentricularTachycardia
Pheochromocytoma
Fever
Hyperthyroidism
MEDICATION:
Ca channel blockers(Nifedipine)
Sympathomimetics(e.g. salbutamol)
Vasodilators

5. BRADYCARDIA
Sinus rhythm Arrhythmia
Sleep Carotid Sinus hypersensitivity
Athletic training Sick Sinus Syndrome
Hypothyroidism Second-Degree heart block
MEDICATION: Complete heart block
Beta-blockers
Digoxin
Verapamil, Diltiazem

6. ABNORMAL FINDINGS IN RHYTHM
If Irregular:
Occasionally irregular
Regularly Irregular
Irregularly Irregular

7. CAUSES OF AN IRREGULAR PULSE
Occassionally Irregular Pulse
• Extrasystole
Regularly Irregular Pulse
• Ectopic beat occuring at a regular interval
• Second degree atrioventricular block
• Sinus arrhythmia
Irregularly Irregular Pulse
• Atrial Fibrillation
• Multiple ectopics

8. PULSE APEX DEFICIT
Difference in heart rate and
pulse rate
Atrial Fibrillation (>10/min)
Multiple ectopics (<10/min)

9. ABNORMALITIES IN PULSE VOLUME
HighVolume Pulse
LowVolume Pulse
VaryingVolume

10. High Volume Pulse
Physiological causes:
Exercise
Pregnancy
Advanced Age
Increased Environmental
Temperature

11. Pathological causes
• Arteriosclerosis
• Aortic regurgitation
• PDA
• Arteriovenous fistula
• Fever
• Thyrotoxicosis
• Anaemia
• Beri-Beri
• Complete heart block
• Cirrhosis liver

12. Low Volume Pulse
Causes:
 LeftVentricular Failure
 Hypovolemia
 Peripheral arterial disease
 Shock
 Severe Aortic Stenosis
 Pericardial Effusion

13. Varying Volume
 Combination of low, normal or high
volume pulse in varying manner
 Seen in:
Atrial fibrillation
VentricularTachycardia

14. CONDITION OF VESSEL WALL
Can be:
Normal-Soft
Thickened-firm to hard and cord-like
Elderly due to artherosclerosis

15. CHARACTER OF PULSE
 Collapsing pulse
 Slow rising pulse
 Pulsus bisferiens
 Pulsus parvus et tardus
 Pulsus bigeminus
 Pulsus alternans
 Pulsus paradoxus
 Anacrotic pulse
 Dicrotic pulse

16. Collapsing pulse/Water-hammer
pulse/Corrigan’s pulse

17. Collapsing pulse
 Sharp rise
 Ill-sustained
 Sharp fall
 Wide pulse pressure(>80mmHg)
High volume collapsing pulse in:
Aortic regurgitation
PDA
Normal volume collapsing pulse in:
Mitral Regurgitation

18. Mechanism
 In aortic regurgitation, during diastole:
Left ventricle receives
normal pulmonary venous return+portion of blood
ejected into the aorta => large stroke volume-
vigorously ejected=> rapidly rising carotid pulse

19. Collapses in early diastole – backflow through
aortic valve
Exaggerated at the radial artery by liftng the
arm.

21. Slow Rising Pulse
 Gradual upstroke with a reduced peak
 Occur late in systole
 Seen in severe aortic stenosis

22. Mechanism
Fixed obstruction restricts the rate at which
blood can be ejected from the left ventricle.

23. Pulsus Bisferiens
 Increased pulse with double systolic peak
seperated by a distinct mid-systolic dip.
 Causes:
Aortic regurgitation
Concomitant aortic stenois and regurgitation

25. Pulsus Parvus et Tardus
 Weak and delayed pulse
 Seen in conditions with:
 diminished left ventricular stroke volume
Narrow pulse pressure
Increased peripheral vascular resistance
Aortic stenosis

27. Pulsus bigeminus
 Regular alteration of pulse pressure
amplitude.
 Caused by premature ventricular
contraction that follows each regular beat
 Occurs in:
AV block
Sinoatrial block withVentricular Escape

29. Pulsus alternans
 Beat-to-beat variation in pulse volume with a
normal rhythm.
 Rare
 Occurs in :
Advanced heart failure
Toxic myocarditis
ParoxysmalTachycardias
Following Premature beat

31. Pulsus Paradoxus
 Exaggeration of the normal variability of
pulse volume with breathing.
 Inspiratory decline in systolic pressure
greater than 10mm Hg.
 Occurs in:
Cardiac tamponade
Constrictive pericarditis
Percardial effusion

33. Anacrotic Pulse
 Slow rising
 Double beating pulse
 Both waves felt in systole
Seen in Aortic Stenosis

35. Dicrotic Pulse
 Twice beating
 First wave in systole, second wave in
diastole
 Seen when PR and DP is low
 Felt due to hypotonia of vessel wall
 Seen in:
Fever (e.g. typhoid fever)
CCF
Cardiac Tamponade

37. RADIO-FEMORAL DELAY
 Most common cause: Coarctation of aorta
 Children:
Upperlimb pulses are usually normal
Reduced volume lowerlimb pulses
 Adults:
Usually presents hypertension and heart failure
 Other causes:
• Atherosclerosis of aorta
• Thrombosis or embolism of aorta

38. OTHER PERIPHERAL
PULSATIONS
 Normal-All pulsations felt equally
Absence of peripheral pulsations:
Peripheral vascular disease
Coarctation of aorta- decreased and delayed
femoral pulsation
Takayasu’s disease: decreased upper limb
pulsation

39. CAUSES OF ABSENT RADIAL
PULSE
 Anatomical abnormality
 Severe atherosclerosis
 Takayasu arteritis (Pulseless disease)
 Embolism in radial artery
 Death

40. ABNORMAL FINDINGS IN
JUGULAR VENOUS PULSE
 Raised in :
Right sided heart failure caused by chronic
pulmonary hypertension in severe lung
disease(COPD)
Cor pulmonale
Increased intrathoracic pressure-tension
pneumothorax or severe acute asthma.
Massive pulmonary embolism- very high JVP

41. Giant ‘a’ wave:Tricuspid valve stenosis
Cannon ‘a’ wave: Complete heart block &
Ventricular tachycardia
Giant ‘v’ wave:Tricuspid Regurgitation
Prominent ‘x’ and ‘y’ descents:
Constrictive pericarditis

43. THANK YOU