The following highlights some of the special pulses and the pathologies with which they are associated.
Normal carotid pulse
Upon palpation, a normal carotid pulse should feel like a sharp knock, while an abnormal carotid pulse will feel like a weak nudge, followed by a slight pulsation or push
Normal carotid volume should be easy to feel with light palpation
Alternating strong and weak pulses palpable at radial or femoral arteries
Almost always indicates left-sided heart failure
Palpate right brachial artery with right thumb while simultaneously using the left index and middle finger to palpate the right radial artery
Use light pressure to avoid distorting or compressing the normal arterial pulsation
A noticeable delay between the brachial and radial pulsations is considered abnormal and indicative of aortic stenosis
Palpate the precordial apical impulse (point of maximal impulse), typically located in the 5th interspace (left side) with fingerpads of right hand while at the same time palpating the right carotid artery
A noticeable delay indicates an abnormality and suggestive of aortic stenosis
Due to large stroke volume and backflow of blood from the aorta into the left ventricle and indicative of aortic regurgitation
Palpate the radial pulse while the patient lies on the exam table, applying pressure until the pulse is obscured
Raise the arm straight over the patient’s head, perpendicular to the exam table
Palpate pulse for a sudden rise and collapse of radial pulse that feels "jumpy""
Palpate the radial pulse while the patient lies on the exam table while simultaneously palpating the femoral pulse on the ipsilateral side of patient
Palpate for a delay in pulsations between the radial and femoral pulse locations
A delay between the two pulses may indicate coarctation of the aorta
Perform if pulse varies in strength and amplitude when patient breathes or if percarditis or tamponade are suspected
While the patient breathes quietly, inflate the blood pressure cuff to 40 mm Hg above previously measured level
Deflate the cuff slowly while the patient is at the end of expiration. Note the systolic pressure. Repeat the process noting the systolic pressure at peak of inspiration. A difference of greater than 20mm Hg is positive for paradoxical pulse.
Paradoxical pulse suggests cardiac tamponade but may also be present in pericarditis
It is important to note that deep inspiration and the Valsalva maneuver accentuate the drop in systolic pressure during inspiration so paradoxical pulse should be assessed during normal respiration
Normally when inspecting the JVP, it declines during inspiration but the amplitude of the a wave increased. If there is an increase in the JVP or even a stable JVP on inspiration this is a positive Kussmaul’s sign.
Paradoxical drop in systolic blood pressure > 20/10 mmHg with inspiration (pericardial tamponade, constrictive pericarditis, pulmonary etiologies)
positive test indicates impaired venous return to the right heart
Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.