Assessing Arterial Pulse

Question 1

What is the first thing you must do when starting the OSCE examination?

Answer 1

After putting on PPE, introducing yourself to the patient, identifying patient details and gaining consent for the procedure.

Question 2

In what order should PPE be put on?

Answer 2

Firstly, wash your hands. Then put on the apron, then mask, then eyewear/visor, then gloves.

Question 3

In what order should PPE be taken off?

Answer 3

Gloves should be taken off first (then wash hands), then the apron and eyewear (then wash hands), then the mask (then wash hands).

Question 4

Can you demonstrate the steps of hand hygiene?

Answer 4

Demonstrate.

Question 5

What are the seven sites where arterial pulse can be examined?

Answer 5

Radial pulse (wrist), brachial pulse (elbow), carotid pulse (neck), femoral pulse (top of leg), popliteal pulse (popliteal fossa), dorsalis pedis (foot) and posterior tibial (bottom of leg).

Question 6

Where exactly should the radial pulse be examined? How should the student be positioned to examine it?

Answer 6

Should be examined on the radial side of the wrist lateral to the flexi carpi ulnaris tendon. The right radial pulse should be examined with the palmer aspect of the fingers of the left hand, holding the fingers of the patient with the right hand in order to simultaneously assess peripheral perfusion.

Question 7

Where exactly should brachial pulse be assessed?

Answer 7

Medial to the antecubital fossa, or medial to the biceps tendon.

Question 8

Where exactly should the carotid pulse be examined?

Answer 8

Beside the medial border of the sternocleidomastoid muscle, just lateral to the larynx. (Don’t examine both at once - may induce syncope)

Question 9

Where exactly should the femoral, popliteal, dorsalis pedis and posterior tibial pulses be examined?

Answer 9

• just below the mid-inguinal point, half way between the anterior superior iliac spine and the pubic tubercle
• in the popliteal fossa behind the knee
• over the tarsal bones on the dorsum of the foot
• 1cm behind the medial malleolus

Question 10

What are the seven characteristics of the pulse that should be assessed?

Answer 10

• Rate
• Rhythm
• Character
• Volume
• Symmetry
• Character of blood vessel
• Presence of bruits

Question 11

Where should rate and rhythm be assessed?

Answer 11

The radial pulses in the wrists.

Question 12

Where should character and volume be assessed?

Answer 12

Larger pulses, such as the carotid pulse.

Question 13

What is the rate of a pulse? How should it be assessed? What is a normal pulse rate?

Answer 13

Rate of a pulse is how many pulses are counted per minute. This can be assessed by counting the number of pulses in 30 seconds and multiplying the result by two to get the BPM. Normal pulse rate is between 60-100bpm. Higher than this is tachycardia and lower than this is bradycardia.

Question 14

What is the rhythm of a pulse? How can this be assessed?

Answer 14

Rhythm is the measurement of the intervals between the pulses. A regular pulse will have a normal rhythm, with a similar interval between pulses. Sinus arrhythmia is a common condition in young people where there is changes in the vagal tone during the respiratory cycle, meaning there is an increase in the pulse rate during inspiration, and a decrease during expiration. An irregular pulse can either be:

• regularly irregular, where there is a repeated irregularity, due to conditions which alter the normal rhythm of the pulse (e.g., trigeminy, second degree heart block)
• irregularly irregular, where there is no pattern in the heart rate. This can be due to atrial fibrillation, where there is chaotic contraction of the atriums and loss of normal rhythmical contraction of the ventricles.

Question 15

What is the character of a pulse?

Answer 15

Character of a pulse is the pattern of the rise and fall of a pulse, which is in synchrony with cardiac ventricular contraction (systole) and cardiac ventricular relaxation (diastole).
The character of a pulse can either be collapsing (Water Hammer), where there is a steep rise and fall of the pulse. This can be as a result of aortic incompetence. This can be felt in the radial pulse and can be exaggerated by lifting the arm over the level of the shoulder.
The character of a pulse can also be slow-rising, usually a sign of aortic stenosis. This can also be detected in the carotid pulse.

Question 16

What is the volume of a pulse?

Answer 16

An estimation of the amount of blood pumped out by the heart during each contraction. Can be low volume, due to hypovolemia or conditions which prevent the heart from fully contracting. Can also be high volume (a bounding pulse), where lots of blood is pumped out during fevers, anemia, thyrotoxicosis and C02 retention.

Question 17

What is bruits and how can it be tested?

Answer 17

Bruits is noise caused by turbulent blood flow, and can be detected by auscultation over a large vessel, such as the carotid artery. The presence of bruits can indicate that the arterial lumen has been blocked by the formation of an atheroma.

Question 18

What can the character of a blood vessel wall indicate?

Answer 18

If the blood vessel wall is rigid, this may indicate that disease of the arteries in present, however this is not a reliable sign.

Question 19

How should pulses be symmetrical? What does it indicate if pulses are not symmetrical?

Answer 19

Pulses on both sides of the body should be symmetrical. Both radial pulses, and the radial and femoral pulses of the corresponding sides should be synchronized.
If the radio-radial pulse isn’t synchronized, a large arterial blockage (arterial occlusion) or coarctation of the aorta proximal to the left subclavian artery may be present.
If the radio-femoral pulse isn’t synchronized, it may indicate developmental problem (aortic coarctation) or a disease of the blood vessels (atheroscleroma).