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Cardiac examination
The pulse
Rate
Count the rate using a watch. This is a traditional way of measuring time, but works better than a guess which is often startling inaccurate. Do not write down a spurious result if you haven’t actually measured it. Think about the result in clinical context too – it is not just a number to be recorded. A highish rate in a patient who is supposed to be on a beta-blocker suggests either its not being taken, or there is something else, which without the medication, would be causing a worrisome tachycardia. Normal or low rate in a patient with a high fever might also suggest either hypothroidism or typhoid.
Rhythm
This is usually fairly straightforward – if it is regular and not too fast, it is easy enough to document as such. If there are a few early or delayed beats, they are probably ectopics; if you can’t discern a rhythm, its probably atrial fibrillation. ‘Irregularly irregular’ refers to inconsistent variation in both rhythm and volume, but like much in clinical medicine is not quite as straightforward as it may seem1 – there may be some pattern to the rhythm in 30%, and pulses alternans may give a volume pattern in nearly 50%… There are also some suggestions the Bowditch effect (increased contractility at higher rates) might play a part.
Pulse character
ere is a rapid fall and rise there is probably run off either forward (vasodiatation) or back (aortic regurgitation) A slow rise/fall suggests outflow obstruction, such as that due to aortic stenosis
Pulsus alternans (beat to beat variation in volume) suggests myocardial dysfunction (e.g. CMO) and pulsus paradoxus may be a sign of cardiac tamponade (or severe obstructive pulmonary disease)
Eliciting a pulsus paradoxus
This is useful in asthma, COPD and cardiac tamponade? – there is an exaggerated fall in systolic blood pressure with inspiration.
Sit down at the patient’s bedside. Pump up the cuff to well above where you expect to hear the first sounds, and then come down slowly until you first hear them. Go back about 15 mmHg above this, and then come down very carefully in steps of 2 mmHg, pausing for an unforced full patient respiratory cycle at each step.
The systolic sound will come and go with respiration; the highest point at which you hear any sounds, even just a single one in each respiratory cycle, is the systolic pressure.
Drop down from this point until there is no respiration associated gap (i.e. till the sounds are continuous without even a single missed sound).
The difference between the first systolic reading and this reading is the paradoxus pressure. For example, if the sounds first appeared at a pressure of 120 and became constant at 102, then the paradoxus is 120-102 = 18 mmHg.
The JVP
Ensure you have adequate lighting – switch on a light or position the patient to use ambient light. A cellphone light is a popular option, but position carefully – you want to emphasize shadows by lighting the neck from a different angle to you view – holding it directly in front of you washes out the shadows and makes things more difficult. Try a profile view.
The patient should be relaxed – gazing at the neck of an elderly lady obligingly trying to do her first unassisted sit-up in decades is not a recipe for success. Taking a few seconds to ensure relaxation is well worth the time.
The 45-degree story is misleading – you may need to try a variety of positions to first identify the top of the venous pressure column. Once you have found it, position the patient at 45 degrees in order to measure its height, unless it disappears behind the mandible again, in which case use the sitting height.
The JVP, like the CVP, is relative. Conventionally it is measured as the vertical distance above the manubriosternal angle, and a figure of 3 cm or less is normal. Venous pulsations flicker because of the relatively complex waveform. If it isn’t really flickering it is probably arterial or perhaps a CV wave.
The right JVP is often a little higher than the left, so if you find the reverse, consider obstructive causes such as the anomalous drainage sometimes seen in patients with an ASD2 Another cause in the elderly is an ectatic aorta compressing the innominate vein. If you can confidently see the JVP in every patient, you are probably sometimes looking at something else (the carotid), because on occasion even the most caareful observers are not sure.
