Macleod's Notes
Internal Medicine
Fourth Stage (4th)
It is written in one the medical colleges in Europe :
" You don't studying for the exam , but you study for the day
when you will be the separator between the patient and his grave "
{ Study smart , not hard }
, Macleod's Notes of Internal Medicine
Vital Signs :
1- Pulse : rate ( 60-100 bpm ) , Rhythm ( regular or not ),Volume ( low or high ),
Character , delay .
# pulse 65 bpm is normal in cases of HF due to neurohormonal activation of
sympathetic nercous system
#Rhythm : if regular ( normal ) , but if irregular has two types
- irregular irregularity : AF(complete irregular), AF , Multiple extrasystoles ,VF
- regular irregularity : pulsus bigeminus (2nd pulse longer than 1st with relatively
normal QRS complex , in cases of HOCM , and caused by hypo and
hyperkalemia, hypothyroidism , Beta blockers , digoxin , MI .
#Volume : pulse pressure (volume or amplitude) = Systolic – Diastolic
#always +ve number , due to systolic > diastolic
Causes of Low pulse volume :
1- low cardiac output (as seen in shock, congestive heart failure)
2- hypovolaemia as seen in blood loss , diarrhea , use of diuretics … etc
3- valvular heart disease (such as mitral stenosis, aortic outflow tract obstruction,
aortic arch syndrome)
4- Peripheral arterial disease like atherosclerosis
5- Pericardial effusion
2
,Character :
A- Water hammer pulse = Collapsing pulse = Corrigan's pulse = bounding
pulse : sharp ascending and descending pulse with high volume
#best exam on raising the are to decrease diastolic BP and to maximize the gap
between systolic and diastolic BP while palpating the forearm by palm.
Causes :
1- Physiological : Fever , Pregnancy
2- Cardiac lesions : Aortic regurgitation, PDA, Systolic hypertension,
Bradycardia, Aorto-pulmonary window .
3- high-output states : Anemia , Cor pulmonale (RVH) , liver Cirrhosis, Beriberi,
Thyrotoxicosis, Arteriovenous fistula , Paget's disease of bone .
4- Other causes: Chronic alcoholism
B- Plateau pulse or slow rising pulse : slow ascending and descending with low
volume .
Causes : Aging , Aortic stenosis or Calcification (Angiodysplasia is associated
with AS ).
C- Pulsus Paradoxus : Marked drop in systolic BP during inspiration ( more than
or equal 10 mmHg )
Causes :
1- Constrictive pericarditis
2- Cardiac tamponade
3- COPD ( especially severe asthma )
4- Severe congestive heart failure (CHF)
D- Pulsus Deficit : the rate of radial pulse (peripheral pulse) is less than apical
pulse (ventricular contraction rete) .
#Explain : during contraction of an empty ventricle , some beats are unable to
reach radial artery .
Causes : AF > 6 bpm , extrasystoles < 6 bpm .
3
, E- Pulsus Alternans : variation in pulse volume occurring with alternate beats due
to changing systolic BP , commonly associated with 3rd Heart sound .
Causes :
1- LVF
2- Systolic HF ( low left ejection fraction )
3- Diastolic HF ( preserved ejection fraction )
F- Pulsus bisferiens =bifid= double hump : best felt on carotid artery , which is
the presence of 2 systolic beat means a small one followed by strong and broad one
#Sign of mixed Aortic valve diases : Stenosis and regurgitation , and HOCM
Q/ Unequal carotid pulse atheroma , aneurysm , dissection
#Specific features of pulse in aortic problem :
1- Slow-rising pulse AS , 2- Collapsing pulse AR
3- Pulsus bisferiens mixed Aortic valve diases
Causes of absent or decreased peripheral pulsation :
1- Coarctation of Aorta , 2- Atherosclerosis , 3- Peripheral embolism
Note : normally , Vascular wall in not felt or felt elastic , but if palpable , this
indicates ( Systemic atherosclerosis , polyarteritis nodosa ) .
Anatomy of Pulsations :
1- Radial : lateral to flexor carpi-radialis tendon
2- Brachial : at elbow, medial to biceps tendon
3- Subclavian : above the middle of clavicle (pressing downward)
4- Carotid : medial to sternocleidomastoid muscle (at 6th cervical vertebral level)
5- Femoral : at mid-point of inguinal ligament
6- Popliteal : middle of popliteal fossa (assessed at supine position)
7- Posterior tibial : behind medial malleolus
8- Anterior tibial : midway between medial and lateral malleolus against ankle
joint
9- Dorsalis pedis : lateral to extensor hallicus longus tendon , agains naviular bone
Causes of Radio-femoral delay : Coarctation of Aorta , aneurysm , dissection
4
Internal Medicine
Fourth Stage (4th)
It is written in one the medical colleges in Europe :
" You don't studying for the exam , but you study for the day
when you will be the separator between the patient and his grave "
{ Study smart , not hard }
, Macleod's Notes of Internal Medicine
Vital Signs :
1- Pulse : rate ( 60-100 bpm ) , Rhythm ( regular or not ),Volume ( low or high ),
Character , delay .
# pulse 65 bpm is normal in cases of HF due to neurohormonal activation of
sympathetic nercous system
#Rhythm : if regular ( normal ) , but if irregular has two types
- irregular irregularity : AF(complete irregular), AF , Multiple extrasystoles ,VF
- regular irregularity : pulsus bigeminus (2nd pulse longer than 1st with relatively
normal QRS complex , in cases of HOCM , and caused by hypo and
hyperkalemia, hypothyroidism , Beta blockers , digoxin , MI .
#Volume : pulse pressure (volume or amplitude) = Systolic – Diastolic
#always +ve number , due to systolic > diastolic
Causes of Low pulse volume :
1- low cardiac output (as seen in shock, congestive heart failure)
2- hypovolaemia as seen in blood loss , diarrhea , use of diuretics … etc
3- valvular heart disease (such as mitral stenosis, aortic outflow tract obstruction,
aortic arch syndrome)
4- Peripheral arterial disease like atherosclerosis
5- Pericardial effusion
2
,Character :
A- Water hammer pulse = Collapsing pulse = Corrigan's pulse = bounding
pulse : sharp ascending and descending pulse with high volume
#best exam on raising the are to decrease diastolic BP and to maximize the gap
between systolic and diastolic BP while palpating the forearm by palm.
Causes :
1- Physiological : Fever , Pregnancy
2- Cardiac lesions : Aortic regurgitation, PDA, Systolic hypertension,
Bradycardia, Aorto-pulmonary window .
3- high-output states : Anemia , Cor pulmonale (RVH) , liver Cirrhosis, Beriberi,
Thyrotoxicosis, Arteriovenous fistula , Paget's disease of bone .
4- Other causes: Chronic alcoholism
B- Plateau pulse or slow rising pulse : slow ascending and descending with low
volume .
Causes : Aging , Aortic stenosis or Calcification (Angiodysplasia is associated
with AS ).
C- Pulsus Paradoxus : Marked drop in systolic BP during inspiration ( more than
or equal 10 mmHg )
Causes :
1- Constrictive pericarditis
2- Cardiac tamponade
3- COPD ( especially severe asthma )
4- Severe congestive heart failure (CHF)
D- Pulsus Deficit : the rate of radial pulse (peripheral pulse) is less than apical
pulse (ventricular contraction rete) .
#Explain : during contraction of an empty ventricle , some beats are unable to
reach radial artery .
Causes : AF > 6 bpm , extrasystoles < 6 bpm .
3
, E- Pulsus Alternans : variation in pulse volume occurring with alternate beats due
to changing systolic BP , commonly associated with 3rd Heart sound .
Causes :
1- LVF
2- Systolic HF ( low left ejection fraction )
3- Diastolic HF ( preserved ejection fraction )
F- Pulsus bisferiens =bifid= double hump : best felt on carotid artery , which is
the presence of 2 systolic beat means a small one followed by strong and broad one
#Sign of mixed Aortic valve diases : Stenosis and regurgitation , and HOCM
Q/ Unequal carotid pulse atheroma , aneurysm , dissection
#Specific features of pulse in aortic problem :
1- Slow-rising pulse AS , 2- Collapsing pulse AR
3- Pulsus bisferiens mixed Aortic valve diases
Causes of absent or decreased peripheral pulsation :
1- Coarctation of Aorta , 2- Atherosclerosis , 3- Peripheral embolism
Note : normally , Vascular wall in not felt or felt elastic , but if palpable , this
indicates ( Systemic atherosclerosis , polyarteritis nodosa ) .
Anatomy of Pulsations :
1- Radial : lateral to flexor carpi-radialis tendon
2- Brachial : at elbow, medial to biceps tendon
3- Subclavian : above the middle of clavicle (pressing downward)
4- Carotid : medial to sternocleidomastoid muscle (at 6th cervical vertebral level)
5- Femoral : at mid-point of inguinal ligament
6- Popliteal : middle of popliteal fossa (assessed at supine position)
7- Posterior tibial : behind medial malleolus
8- Anterior tibial : midway between medial and lateral malleolus against ankle
joint
9- Dorsalis pedis : lateral to extensor hallicus longus tendon , agains naviular bone
Causes of Radio-femoral delay : Coarctation of Aorta , aneurysm , dissection
4
