PULSE

Pulse rate >120bpm

Main differential diagnoses and typical outline evidence

Fever	Suggested by: warm skin, erythema, sweats, temperature >38°C.
	Confirmed by: temperature chart, fever pattern and pulse rate↑.
Haemorrhage	Suggested by: signs of blood loss, pallor, sweats, low BP, poor peripheral perfusion.
	Confirmed by: low Hb (can be normal in initial stages), low central venous pressure.
Hypoxia	Suggested by: cyanosis, respiratory distress.
	Confirmed by: ↓PaO2.
Thyrotoxicosis	Suggested by: sweating, fine tremor, weight loss, lid lag, frequent bowel movements, sweats.
	Confirmed by: ↑FT4, ± ↑FT3 and ↓TSH.
	Management:
Severe anaemia	Suggested by: subconjunctival and nail-bed pallor.
	Confirmed by: ↓Hb (and indices).
Heart failure (LVF, RHF, CCF) associated with ischaemic heart disease, myocarditis etc.	Suggested by: 3rd heart sound, fine crackles at bases, raised JVP.
	Confirmed by: CXR showing large heart, pulmonary shadowing, upper lobe vein dilatation.
Pulmonary embolus	Suggested by: history of sudden breathlessness, cyanosis, raised JVP, loud p2. ECG: right axis deviation and RBBB.
	Confirmed by: V/Qscan showing mismatched defects, pulmonary angiography of spinal CT showing filling defect in pulmonary artery.
	Management:
Drugs e.g. amphetamines, β-agonists	Suggested by: drug history.
	Confirmed by: normal pulse rate if drug stopped.

Bradycardia (<60bpm)

Main differential diagnoses and typical outline evidence

Athletic heart	Suggested by: young/fit, asymptomatic.
	Confirmed by: above clinical findings.
Drugs	Suggested by: history e.g. beta blockers.
	Confirmed by: improvement when drug withdrawn.
Sinoatrial disease	Suggested by: elderly, ischaemic heart disease.
	Confirmed by: ECG: abnormal P wave or P-R interval.
	Management:
Ventricular or supraventricular begemini	Suggested by: known ischaemic heart disease.
	Confirmed by: ECG: premature ectopics with compensatory pause.
	Management:
Myocardial infarction	Suggested by: central, crushing chest pain (can be atypical pain).
	Confirmed by: ECG: Q waves, raised ST segments, and inverted T waves. ↑CPK and troponin.
	Management:
Hypothyroid	Suggested by: constipation, weight gain, dry skin, dry hair, slow relaxing reflexes.
	Confirmed by: ↑TSH, ↓T4.
	Management:
Hypothermia	Suggested by: history of exposure to cold temperature and immobility.
	Confirmed by: Core temperature <35(C.
	Management:

Pulse irregular

Main differential diagnoses and typical outline evidence

Atrial fibrillation caused by ischaemic heart disease, thyrotoxicosis, etc.	Suggested by: irregularly irregular pulse.
	Confirmed by: ECG showing no P waves, and irregularly irregular normal QRS complexes.
	Management:
Atrial flutter with variable heart block caused by ischaemic heart disease, etc.	Suggested by: irregularly irregular pulse.
	Confirmed by: ECG showing ‘saw tooth’ F waves, and irregularly irregular normal QRS complexes.
	Management:
Atrial or ventricular ectopics caused by ischaemic heart disease, etc.	Suggested by: regular rate with irregular dropped beat.
	Confirmed by: ECG showing normal sinus rhythm with irregular QRS complexes not preceded by P wave, and then compensatory absence of subsequent QRS.
	Management:.
Wenkenbach heart block caused by ischaemic heart disease, etc.	Suggested by: regular rate with regular dropped beat.
	Confirmed by: ECG showing progressive prolongation of P-R interval with normal QRS complex followed by an absent QRS complex.
	Management:

Pulse volume high

This is an indication of the width of the pulse pressure. It can be confirmed by a large difference between the systolic and diastolic blood pressure.

Main differential diagnoses and typical outline evidence

Aortic incompetence	Suggested by: striking ‘water hammer’ quality. Systolic BP high (say >160mmHg) and diastolic BP very low (say <50mmHg) early diastolic murmur, forceful, displaced apex impulse.
	Confirmed by: echocardiogram and cardiac catheterisation showing loss of valvular function.
	Management:
Arteriosclerosis	Suggested by: thickened arterial wall. Systolic BP high (say >160mmHg) and diastolic BP not low (say >80mmHg).
	Confirmed by: echocardiogram to exclude aortic incompetence.
	Management:
Severe anaemia	Suggested by: pallor. systolic BP high (say >160mmHg) and diastolic BP normal (say <85mmHg).
	Confirmed by: Hb ↓ (say <10grm/dL).
Bradycardia of any cause with normal myocardium	Suggested by: slow heart rate (e.g <50bpm).
	Confirmed by: ECG showing slow rate and type of rhythm.
Hyperkinetic circulation e.g. due to hypercapnia, thyrotoxicosis, fever, Paget's disease, AV fistula	Suggested by: warm peripheries and features of cause e.g. cyanosis, tremor, lid lag, fever, skull deformity, etc.
	Confirmed by: high pCO2 (if hypercapnia) or ↑FT4, ± ↑FT3 and ↓TSH (if thyrotoxic) or fever or ↑ hydroxyproline (if Paget's).

Pulse volume low

This is an indication of the width of the pulse pressure. It can be confirmed by a small difference between the systolic and diastolic blood pressure.

Main differential diagnoses and typical outline evidence

Poor cardiac contractility due to ischaemic heart disease, cardiomyopathy, cardiac tamponade, constrictive pericarditis	Suggested by: quiet heart sounds, ↑JVP, peripheral oedema, basal lung crackles.
	Confirmed by: ECG, echocardiogram to show evidence of cardiac muscle disease.
Hypovolaemia due to blood loss, dehydration	Suggested by: cold peripheries, thirst, dry skin, low urine output.
	Confirmed by: urea ↑, Hb ↓ (in loss) or ↑ (if haemo-concentrated).
Poor vascular tone due to septicaemic shock	Suggested by: warm peripheries, thirst, dry skin, ↓ eye tension, ↓ urine output.
	Confirmed by: urea ↑.
Aortic stenosis	Suggested by: slow rising pulse, systolic murmur.
	Confirmed by: echocardiogram and cardiac catheterisation.
	Management: