Fig. 2B.6: Pulsus alternans.

Method of Eliciting Collapsing Pulse (Fig. 2B.7)

Palpate the radial artery and trace the artery proximally to a point where it is just felt

At this point, wrap your wrist around the patient’s forearm, so as to place the heads of the

metacarpals over the artery.

Simultaneously, palpate the radial and ulnar arteries by encircling the patient’s wrist with your other

hand.

Now, abruptly raise the patients hand above the shoulder (artery becomes in line with the central

aorta, allowing direct systolic ejection and diastolic backflow).

In collapsing pulse, both radial and ulnar arteries are felt distinctly and, there is an abrupt thrust/knock

and collapse under the metacarpal heads on elevation.

Thrust produced is similar to the one produced by tilting of water hammer toy.

It is due to diastolic run-off in aortic regurgitation.

Collapsing pulse is characterized by rapid upstroke (percussion wave) followed by rapid descent

(collapse) of the pulse wave without dicrotic notch, which reflects low systemic vascular

resistance.

Rapid upstroke is due to the rapid ejection of greatly increased stroke volume.

The rapid descent or collapsing character is due to:

Diastolic “run-off” (backflow) into the left ventricle

Reflex vasodilation mediated by carotid baroreceptors secondary to large stroke volume

The rapid run-off to the periphery due to decreased systemic vascular resistance.

Corrigan’s pulse/sign is largely used to describe the abrupt distension and quick collapse of

carotid pulse in aortic regurgitation, whereas the term Watson’s water hammer pulse is used for

the characteristic pulse seen in peripheral arteries like the radial artery

Note: Make sure the patient does not have shoulder pain before doing this.

Method of Eliciting Pulsus Bisferiens

Best felt in brachial and carotid arteries

Felt by applying graded pressure

With fingers press and occlude the brachial artery

On slowly releasing the pressure, the double peaking of the pulse is appreciated.

Condition of Vessel Wall

Vessel wall thickening is assessed by using Osler’s sign (described under the pseudohypertension in

chapter blood pressure in chapter 2, page no 13).

Peripheral Pulses

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Refer Figure 2B.8.

Palpation of Carotid Pulse (Figs. 2B.9 and 2B.10)

Ask the patient to relax the neck.

Palpate the right carotid artery by placing your left thumb near the upper neck between the

sternomastoid and trachea roughly at the level of cricoid cartilage.

Note the character of the pulse.

Now, repeat the procedure on other side by placing your right thumb over the patients left carotid.

Note: Make sure not to compress the carotid sinus.

It is advisable to auscultate for carotid bruit prior to palpation, to prevent possible dislodgement of the

atherosclerotic plaque (if present).

Fig. 2B.7: Demonstration of collapsing pulse.

Fig. 2B.8: Image showing site of different peripheral pulses.

Fig. 2B.9: Demonstration of palpation of right carotid pulse. Fig. 2B.11: Demonstration of palpation of brachial pulse.

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Fig. 2B.10: Demonstration of palpation of left carotid pulse. Fig. 2B.12: Site of examination of femoral pulse.

Palpation of Brachial Pulse (Fig. 2B.11)

To examine the brachial artery in the right arm, the examiner supports the patient’s forearm in his left

hand.

Patient’s upper arm abducted, the elbow slightly flexed, and the forearm externally rotated.

The examiner’s right hand is then curled over the anterior aspect of the elbow to palpate along the

course of the artery just medial to the biceps tendon and lateral to the medial epicondyle of the

humerus.

The position of the hands should be switched when examining the opposite limb.

Palpation of Abdominal Aorta

The abdominal aorta is best palpated by applying firm pressure with the flattened fingers of both

hands to indent the epigastrium toward the vertebral column.

For this examination, it is essential that the subject’s abdominal muscles be completely relaxed; such

relaxation can be encouraged by having the subject flex the hips and by providing a pillow to support

the head.

In extremely obese individuals or in those with massive abdominal musculature, it may be impossible

to detect aortic pulsation.

Palpation of Common Femoral Artery (Fig. 2B.12)

The common femoral artery emerges into the upper thigh from beneath the inguinal ligament one-third

of the distance from the pubis to the anterior superior iliac spine.

It is best palpated with the examiner standing on the ipsilateral side of the patient and the fingertips of

the examining hand pressed firmly into the groin.

Palpation of Popliteal Artery (Fig. 2B.13)

The popliteal artery passes vertically through the deep portion of the popliteal space just lateral to the

midplane.

Generally, this pulse is felt most conveniently with the patient in the supine position and the

examiner’s hands encircling and supporting the knee from each side.

The pulse is detected by pressing deeply into the popliteal space with the supporting fingertips.

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Fig. 2B.13: Demonstration of palpation of popliteal artery.

Since complete relaxation of the muscles is essential to this examination, the patient should be

instructed to let the leg “go limp” and to allow the examiner to provide all the support needed.

Palpation of Posterior Tibial Artery (Fig. 2B.14)

The posterior tibial artery lies just posterior to the medial malleolus.

It can be felt most readily by curling the fingers of the examining hand anteriorly around the ankle,

indenting the soft tissues in the space between the medial malleolus and the Achilles tendon, above

the calcaneus.

The thumb is applied to the opposite side of the ankle in a grasping fashion to provide stability.

Palpation of Dorsalis Pedis Artery (Fig. 2B.15)

The dorsalis pedis artery is examined with the patient in the recumbent position and the ankle relaxed.

The examiner stands at the foot of the examining table and places the fingertips across the dorsum of

the forefoot near the ankle.

The artery is palpated lateral to the extensor hallucis tendon, against the navicular bone.

This pulse is congenitally absent in approximately 10% of individuals.

Radio-Radial Delay

Proceed to palpate both radial pulses simultaneously to detect any inequality in timing. This is known as

radio-radial delay. Causes include:

Presubclavian coarctation

Thoracic inlet syndrome: Cervical rib

Takayasu’s disease

Aortic arch aneurysm.

Fig. 2B.14: Demonstration of palpation of posterior tibial pulse.

Fig. 2B.15: Demonstration of palpation of dorsalis pedis artery.

Radio-Femoral Delay (Fig. 2B.16)

If the femoral pulse is appreciated at the same time as the radial pulse, the patient is said to have radiofemoral delay. This is a sign of coarctation of aorta. This can rarely be seen with aortoarteritis.

Fig. 2B.16: Demonstration of radio-femoral delay.

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RESPIRATION

Respiratory Rate

Counted by placing the examiner’s palm over the patient’s abdomen, noting the rise and fall of the

abdomen. Simultaneously divert the patient’s attention by measuring the patient’s pulse with your other

hand (Fig. 2B.17).

Normal pulse rate : respiratory rate = 4:1

Normal (16–20)

Tachypnea Bradypnea

>20 <10

Physiological:

Anxiety

Exertion

Pathological:

Emphysema

Pneumothorax

Acute respiratory distress from infections

Pleurisy

Pulmonary embolism

Metabolic acidosis

Cardiac insufficiency

Anemia

Hyperthyroidism Weakness of respiratory muscles

Obesity

Restrictive chest wall disease

CNS-depressant drugs (e.g. opiates, benzodiazepines, barbiturates, alcohol)

Uremia

Increased intracranial pressure

Hypothermia

Hypothyroidism

Muscles of Respiration

Inspiration Expiration

Main:

External intercostal muscle

Diaphragm

Predominantly passive process

Accessory muscles:

Serratus anterior

Sternocleidomastoid (SCM)

Scalenus anterior

Pectoralis

Trapezius

Accessory muscles (used in forceful expiration):

Internal intercostals

Abdominal muscles

Quadratus lumborum

Latissimus dorsi

Type of Respiration

Keep two hands flat, one on the chest and other on the abdomen and watch for movements of hand (Fig. 2B.18).

In abdominothoracic—movements of hand over the abdomen are more prominent.

In thoracoabdominal—movements of hand over the thorax are more prominent.

Abdominothoracic Thoracoabdominal

Due to well-developed abdominal muscles Well-formed internal intercostal muscles

Seen in males Seen in females

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Fig. 2B.17: Method of calculating respiratory rate.

Fig. 2B.18: Method of assessing type of respiration.

Variants

Purely thoracic Purely abdominal

Abdominal movement during respirations is

absent

Thoracic movement during respiration is absent

Peritonitis

Pregnancy

Ascites/ovarian cyst

Pleuritic chest pain

Defective chest wall

Respiratory muscle paralysis [neurogenic, neuromuscular junction (NMJ),

and muscular]

Abnormal Patterns of Breathing (Fig. 2B.19)

Regular Irregular

Cheyne–Stokes (periods of apnea

alternating with hyperapnea)

Cardiac failure (LVF)—most

common cause

Raised intracranial pressure

(ICP)

Brainstem lesions

Biot breathing (an uncommon variant of Cheyne-Stokes respiration. Periods of apnea

alternate irregularly with a series of breaths of equal depth that terminates abruptly)

Meningitis

Kussmaul’s (rapid deep breathing) Ataxic

Brainstem disorders

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Metabolic acidosis [diabetic

ketoacidosis (DKA) and renal

failure]

Apneustic

Pontine lesions

Fig. 2B.19: Different type of breathing patterns.

Pursed Lip Breathing

Seen with chronic obstructive pulmonary disease (COPD)

Mechanism of auto-positive end-expiratory pressure (PEEP)

The purpose of this breathing is to slow down the air flow during the exhalation to build up back

pressure in the airway to avoid a sudden drop in intrapulmonary pressure resulting in alveolar and

airway collapse.

Airway Obstruction

Upper airway obstruction—prolonged inspiration

Lower airway obstruction—prolonged expiration.

BLOOD PRESSURE

Definition

Arterial blood pressure (BP) can be defined as the lateral pressure exerted by the moving column of

blood on the walls of the arteries.

BP = Cardiac output × Peripheral resistance

Systolic blood pressure (SBP)

Defined as the maximum BP in the arteries attainable

during systole

Normal: 120 + 20 mm Hg

Diastolic blood pressure (DBP)

Defined as the minimum pressure that is obtained at the end of the

ventricular diastole

Normal range: 60–90 mm Hg

Pulse pressure (PP)

Denotes the difference between systolic and diastolic

pressure

PP = SBP − DBP = 40 mm Hg

Mean arterial pressure (MAP)

DBP + one-third pulse pressure

Normal = 95 mm Hg

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