Examination of the pulse – PACES

1. Ask permission
2. Approach from right side
3. Face – malar flush (myxoedema, mitral stenosis), thyroid disease
4. Neck – Corrigan’s pulse(vigourous arterial pulses seen in neck), raised JVP, thyroidectomy scar, goitre
5. Chest – thoracotomy scar
6. General survey – ascities, clubbing, pretibial myxoedema, ankle oedema,etc
7. RADIAL pulse
8. rate – 15 seconds
9. Rhythmn – slow atrial fibrillation (concentrate on length of pauses) – pauses vary from beat to beat in slow AF
10. Character – assess at radial, brachial and carotid. Can be normal, collapsing, slow rising or jerky. Collapsing palpate radial and lift patients hand above head. Palpate brachial with other hand. If waterhammer pulse is present you feel a flick running along all four fingers while you may feel a flick at the brachial. Sensation of sharp knock – present in haemodynamically significant aortic incompetence and patent ductus arteriososis. Less pronounced collapsing pulse can be felt in moderate AI, PDA, thyrotoxicosis, fever, pregnancy, moderate severe mitral incompetence, anaemia, atherosclerosis. Slow-rising pulse – palpate brachial pulse with thumb. Bisferiens pulse – combination of plateau and collapsing effects.
11. Carotid –Confirmation of slow-rising and collapsing pulse
12. Radio-radial delay - ?fallots with blacklock shunt
13. Radiofemoral delay - coarctation of the aorta
14. all other peripheral pulses
15. additional diagnostic clues