EMQ: 2
Radial Pulse
a)
Anacrotic
b)
Collapsing
c)
Pulsus paradoxus
d)
Bisferiens
e)
Bounding
f)
Radio-femoral delay
g)
Radio-radial delay
h)
Small volume, irregular in rhythm and volume
i)
Jerky upstroke
j)
Pulsus alternans
Select the most likely pulse that will be felt in the
clinical scenarios given below:
1)
A young man with hypertension. He has visible pulsations in the
suprasternal notch, a heaving apex beat and there are prominent periscapular
blood vessels. There is a continuous bruit best heard over the back.
Answer: f) Radio-femoral delay
Hypertension in the young may be due to a number of
causes. However, in relation to abnormalities of the pulse there is probably
only one that should immediately come to mind and that is coarctation of the
aorta, which is associated with radio-femoral delay in the pulse.
The presence of visible pulsations in the neck is a sign
In favour of this as is the heaving apex beat, the prominent periscapular
vessels and the bruit over the back.
2)
An elderly female with a tapping apex beat, a loud first heart sound,
an opening snap and a rumbling mid-diastolic murmur best heard just medial to
the apex beat. There is no pre-systolic accentuation of the murmur.
Answer: h) Small volume, irregular in rhythm and volume
The tapping apex beat is representative of a loud first
heart sound and this should suggest mitral stenosis. The opening snap is more
evidence in favour of this as is the nature of the murmur described. In mitral
stenosis the patient is likely to develop atrial fibrillation and this have a
small volume pulse, which would be irregular in both rate and rhythm. The
absence of pre-systolic accentuation of the murmur also supports the diagnosis
of atrial fibrillation.
3)
An elderly man with a heaving apex beat, soft single second heart sound
and a harsh ejection systolic murmur radiating to the neck
Answer: a) Anacrotic pulse
The patient has a heaving apex beat and this would
indicate systolic overload (the heart is pumping out against resistance) this
would suggest aortic stenosis or severe systemic hypertension (coarctation of
the aorta is unlikely at this age).
The soft second heart sound would indicate aortic
stenosis rather than hypertension.
The murmur radiating to the neck would support this
diagnosis. In aortic stenosis the character of the pulse is small volume, slow
rising (anacrotic)
4) A teenager with severe breathlessness, showing signs
of respiratory distress. On auscultation of his chest there are bilateral
sibilant rhonchi.
Answer: c) Pulsus paradoxus
Severe obstructive airway disease results in pulsus
paradoxus the decreased venous return to the left atrium that normally occurs
is exaggerated.
5)
An elderly patient who is breathless and oedematous and has an elevated
JVP , displaced apex beat , a 3rd heart sound and bilateral basal
crepitations
Answer: j) pulsus alternans
Breathlessness and oedema in an elderly patient should
suggest heart failure. The elevated JVP is in keeping with this. The
displaced apex beat suggests left ventricular dilatation in keeping with heart
failure and the presence of a 3rd heart sound and bilateral basal
crepitations all fit in wit a diagnosis of heart failure.
Pulsus alternans refers to an alternating high and low
volume pulse that occurs in left ventricular failure
Revision Tip
Revise the abnormalities that may be detected on
examination of the radial pulse ACES for PACES
pages 190-195
