X intensity of murmur
X intensity of murmur
T intensity of murmur
Pulsus Alternans. If you suspect left-sided heart failure, feel the pulse specifically for alternating amplitudes. These are usually felt best in the radial or the femoral arteries. A blood-pressure cuff gives you a more sensitive method. After raising the cuff pressure, lower it slowly to the systolic level and then below it. While you do this, the patient should breathe quietly or stop breathing in the respiratory midposition. If dyspnea prevents this, help the patient to sit up and dangle both legs over the side of the bed. >
Alternately loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines indicates a pulsus alternans (see p._).
The upright position may accentuate the alternation.
Paradoxical Pulse. If you have noted that the pulse varies in amplitude with respiration or if you suspect pericardial tamponade (because of increased jugular venous pressure, a rapid and diminished pulse, and dyspnea, for example), use a blood-pressure cuff to check for a paradoxical pulse. This is a greater than normal drop in systolic pressure during inspiration. As the patient breathes, quietly if possible, lower the cuff pressure slowly to the systolic level. Note the pressure level at which the first sounds can be heard. Then drop the pressure very slowly until sounds can be heard throughout the respiratory cycle. Again note the pressure level. The difference between these two levels is normally no greater than 3 or 4 mm Hg.
The level identified by first hearing Korotkoff sounds is the highest systolic pressure during the respiratory cycle. The level identified by hearing sounds throughout the cycle is the lowest systolic pressure. A difference between these levels of more than 10 mm Hg indicates a paradoxical pulse and suggests pericardial tamponade, possibly constrictive pericarditis, but most commonly obstructive airway disease (see p._).
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