It is very easy to overlook the art of clinical examination when new technology can so easily be employed to make diagnoses. Systematic cardiovascular examination can provide a diagnosis quickly without need for invasive or expensive tests. Such routine examination can reveal an unexpected and timely diagnosis. Historically, in the Middle or Far East, doctors were expected to make many diagnoses on examination of the radial pulse alone. Still today, thorough examination of the pulse can provide a lot of information and help form an accurate diagnosis. It is important to develop a reliable routine for examining the pulse and to refine and improve the technique throughout a career. As with all clinical examination, there are aspects of the history which are particularly relevant to abnormalities in the pulse. There are many symptoms which may be relevant; however, some examples include:
Observe the patient whilst taking the history. Look for:
Arterial pulses can be examined at various sites around the body. Systematic examination normally involves palpating in turn radial, brachial, carotid, femoral and other distal pulses. Palpation of the abdominal aorta would also form part of this systematic examination (to identify abdominal aortic aneurysms for example). Other sites may be examined for pulses, in special circumstances - for example, the temporal artery (for tenderness in temporal arteritis) and the ulnar artery (if the radial cannot be felt or before arterial access at the radial site). Which pulse should be examined?
The pulses are felt in the various sites (located as in the table above). In general:
Finally, note the character of the pulse. This incorporates an assessment of the pulse volume (the movement imparted to the finger by the pulse) and what has been described as the 'form of the pulse wave'. The pulse character must be interpreted in the light of pulse rate.
Studies have correlated markers of arterial stiffness (eg, pulse-wave velocity and pulse pressure) with risk for the development of fatal and non-fatal cardiovascular events[3, 4]. This systematic examination of the pulse will give a great deal of information. Systematic examination of the pulse remains an essential part of clinical practice. Examination of the rest of the cardiovascular system should give a very clear idea of the diagnosis or at least put the examiner in a position to make a rational request for further investigations. See also the separate Cardiovascular History and Examination article. |