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o EXAMINATION OF THE ARTERIAL PULSE

•    The character of the pulse is determined by both stroke volume and arterial compliance. and is best assessed

by palpating the carotid artenes.

•    Aortic regurgitation. anaemia and other causes of a large stroke vofume typicaliy produce a bounding pulse with a wtde amplitudę.

(Panel A)

•    Aortic stenosis impedes ventrlcular emptymg and may cause a slow rising. weak and detayed pulse.

(Panel A)

•    Normal sinus rtiythm produces a pulse that »s regular in

timo and lorce. Arrhyihmias may cause irregularity.

Atrial fibrillation produces a rtiythm that is irregular in both time and force.

(Panel 8)

(U

FEATURES THAT DISTINGUISH

VENOUS FROM ARTERIAL

PULSATION IN THE NECK

•    Venous pulse has two peaks in each cardiac cycle (artehal has one).

•    Venous pulse varies with respiration (falls on insptration) and position.

•    Abdominął compression causes the venous pulse to rlse.

•    Venous pulse is not palpablc and can be occluded by light pressure.

O EXAMINATION OF THE JUGULAR VENOUS PULSE

The internal jugular vein drains directly into the right atrium. and the height of a visible pulsation refiects r»ght atrial pressure. When the patient is piaced at 45°. with the head supported and turned a lew degrees to the left. the jugular venous pulse (JVP) is visiWe along the Ime of the sternocieidomasto<d muscie (see opposite).

•    The height of the JVP is determined by right atrial pressure and is therefore eievated in right heart fa>iure and reducod in hypovolaemia.

•    If the JVP is not easily seen it may be highlighted by gentle pressure on the iiver (hepato-juguiar refiux).

•    In normal sinus rhythm. an a and a v wave approximatir>g to atrial and ventricuiar systole can be seen.

•    The c wave and the x and y descents are subtle and require an expenenced observer.

•    Tricusp*d regurgitation produces giant v waves that coincide with ventricular systole.

The haemodynamśc effects of respiration are discussed on page 526.

See pages 557-560 for analysis and mterpretation of heart sounds and murmurs.

O PALPATION OF THE

PRECORDIUM

Te<hnique

•    Place heel of hand over left sternal edge and fingertips over apex. then feel the aortic and pulmonary areas by placing fingers in the ńb spaces.

Common obnormalitics

of the apex beat

•    Volume overtoad, e g. mitral regurgitation: dispiaced. active. rocking

•    F>ressure overload. e.g. aortic stenosis: discrete. thrusting

•    Dyskinetic. e.g. coronary dise3se/ aneurysm: dispiaced. incoordmate

Other abnormalities

•    Palpable S1 (tapping apex beat—mitral stenosis)

•    Palpable P2 (severe pulmonary hypertension)

•    Right ventricular hypertrophy (right ventricuiar heave or lift) felt by heel of hand

•    Aortic aneurysm

Palpabon of the prccordium.

O AUSCULTATION

OF THE HEART

•    Use the beli to examine k>w-pitched noises-first. second. third and fourth heart sounds. mid-diastolic murmurs.

•    Use the diaphragm for high-pitched noises—pansystoiic murmurs. eariy diastolic murmurs.

•    Time the sounds and murmurs by feeling the carotid pulse; systolic murmurs are synchronous with the pulse.

•    Usten to the noises like a piece of musie—what tune or cadence can you hear? Analyse each sound separateiy.

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