The pulse: What the pulse does not diagnose

Two maps over the same artery

At the same wrist you feel two different things: the pulse as a sign in this system and the pulse as a cardiovascular datum. The second is not interpretable from here, and some findings require medical assessment.

What does inform here

depth, strength, shape, comparisons

What does not

arrhythmias, murmurs, blood-pressure figures

Rule

a new irregular finding is referred

How to say it

without drama and without diagnosing

Common mistake: Reading a rhythm irregularity as «stagnation» and carrying on treating without saying anything.

The findings that get referred

There are few of them and they are worth memorising, because they appear without warning and in patients who came for something else.

A new irregular rhythm

medical assessment

Very slow pulse with dizziness or fainting

emergency

A sustained very fast pulse at rest

medical assessment

Absent pulse on one side

vascular emergency

Common mistake: Reassuring the patient that «the pulse is fine» when you do not know how to interpret what you felt.

What do you do with each finding?

• A wiry pulse in someone with menstrual painInterpret it as a signRepeat the readingRefer the patient
• A very fast pulse in someone who has just run inInterpret it as a signRepeat the readingRefer the patient
• An irregular rhythm the patient had never noticedInterpret it as a signRepeat the readingRefer the patient
• A thin, forceless pulse in someone pale and tiredInterpret it as a signRepeat the readingRefer the patient
• A large, new difference between the two wristsInterpret it as a signRepeat the readingRefer the patient
• A slow pulse in an athlete with no symptomsInterpret it as a signRepeat the readingRefer the patient

You detect an irregular rhythm the patient did not know about. How do you tell them?

1. «You have an arrhythmia, you should go to A&E right now»
2. «I noticed the rhythm is not quite regular. That is not something I can assess, so it is worth having it looked at; meanwhile we carry on with the rest»
3. Say nothing, so as not to alarm them

A clearly slippery pulse in a 32-year-old woman with no damp signs. What do you do?

1. Diagnose damp anyway
2. State that she is pregnant
3. Ask about the possibility of pregnancy before interpreting and before choosing points

Order what to do with a pulse finding that does not fit.

1. Rule out artefacts and repeat the reading after a few minutes↑↓
2. Check whether the finding repeats unchanged↑↓
3. Compare with the other wrist and with the rest of the examination↑↓
4. Decide whether it is a sign in this system or a datum that is not↑↓
5. Interpret or refer, and record it either way↑↓