OLFU-Antipolo Campus

College of Physical Therapy

Cardiopulmonary Rehabilitation, Assessment & Treatment
Cardiovascular Physical Examination Checklist

PREPARATION
• Ask permission
• Explains what exactly is to be done to the patient
• Ensures privacy and patient’s comfort
• Ensures adequate lighting and exposure.

VITAL SIGNS

SYSTEMIC BLOOD PRESSURE

• Prepare sphygmomanometer and stethoscope
• Prepare paper and pen for immediate recording of blood pressure (BP)
• Explain procedure in a reassuring manner
• Ask permission
• Ask for intake of the following 30-60 minutes prior to BP determination: caffeinated drinks, alcohol, illicit
drugs, antihypertensive meds, NSAIDs and steroids.
• Ask for activities done 30-60 minutes prior to BP determination: smoking cigarettes, exercise or its
equivalent
• Ask and/or note for any condition the patient might be having prior to or during BP determination: anxiety,
pain, bladder distention, temperature change, noise
• Instruct patient to rest for 5 minutes in a quiet and comfortably warm room
• Instruct the patient to refrain from talking or doing anything from while blood pressure is taken
• Avoid talking during the procedure

Korotkoff Sound:
UPPER EXTREMITY BP
• Move to the right /left side of the patient
• If seated, patient:
A. should be comfortable
B. should not sit with legs crossed
C. should be positioned with the feet flat on the floor
D. should sit with the back supported against the chair
E. should have his/her bared arm resting on a standard table or other support such that the arm on.
the table is a little above the patient’s waist
F. should maintain the midpoint of the upper arm (brachial artery level) always at the level of the
heart (approximately at the 4th intercostal space at its junction with the sternum)
• If supine, patient:
A. should be positioned at a 30–45-degree angle
B. should maintain the midpoint of the upper arm (brachial artery level) always at the level of the
C. heart(approximately at the 4th intercostal space at its junction with the sternum) C. should be
draped properly
• If standing, patient:
A. should be supported in such a way that the arm is at mid chest level
B. should maintain the midpoint of the upper arm (brachial artery level) always at the level of the
heart (approximately at the 4th intercostal space at its junction with the sternum)
• Remove clothing around patient’s arm and avoid rolling up the sleeve in such a manner that it forms a
tight tourniquet around the upper arm
• Estimate by inspection, or measure with a tape, the circumference of the bare upper arm at midpoint
between acromion and olecranon
• Select and use an approximately sized cuff. The length of the inflatable bladder inside the cuff should
encircle 80% of the upper arm, almost long enough to encircle the arm proper and the width of the
inflatable bladder should be about 40% (12-14 cm) of the upper arm circumference
• Record if the available cuff is too small or too large
• Use index and middle fingers to palpate for the patient’s brachial and radial arteries
• Apply the cuff 2.5 cm above the antecubital fossa where the head of the stethoscope is to be placed
• Ensure that the center of the inflatable bladder of the BP cuff is over the brachial artery pulsation
• Wrap and secure the cuff snugly around the patient’s bare arm(make sure you are able to insert only 1
• finger underneath the cuff)
• Place the manometer at eye level where it is easily visible. In cases of aneroid sphygmomanometer, hook
the manometer to the clothe cover of the inflatable bladder
• Ensure the tubing from the cuff is unobstructed

MEASURE PALPATORY BP
• Use index and middle fingers to palpate the radial artery
• With the other hand, rapidly inflate cuff 10 mmHg increments while palpating radial artery pulse and note
when the pulse disappears.
• Countercheck by further increasing by 20-30 mmHg above the level the pulse disappears during cuff
inflation, after which deflate cuff by 2-3mmHg/sec and note at which level the radial pulse reappears
during deflation.
• Read BP on the manometer and states palpatory (systolic) BP
• Deflate the cuff thereafter

MEASURE AUSCULTATORY BP
• Wait 15-30 seconds after getting the palpatory BP
• Place the earpieces of the stethoscope into your ear canals, angled forward to fit snugly
• Palpate for the brachial artery again using index and middle finger
• Place the head of the stethoscope (the low frequency bell over the brachial artery pulsation), just above
and medial to the antecubital fossa but below the edge of the cuff, and hold it firmly (but not too tightly)
in place, making sure to make an air seal with its full rim by ensuring that the head contacts the skin
around its entire circumference
 • Inflate the BP cuff rapidly and steadily to a pressure 20-30 mm Hg above the palpatory (systolic) BP
previously recorded
• Partially unscrew(open) the valve and slowly deflate BP cuff by 2-3 mm Hg/sec while listening for the
appearance of the Korotkoff sounds
• As the pressure in the bladder falls, note the level of pressure on the manometer when the first Korotkoff
sound is heard (Phase I). Record this as the auscultatory systolic BP rounded off upward to the nearest
0-5 mmHg
• Continue to deflate slowly by 2-3 mm Hg/sec and note the level on the manometer when the Korotkoff
sound disappears (Phase V). State and record this as the diastolic BP rounded off upward to the nearest
0-5 mmHg
• Compare the BP on the left and the right upper extremities and state if the difference is within acceptable
limits.

PULSE RATE
Radial Pulse
• Position the patient’s arm in a relaxed position, palm downward or upward on top of the table, or the
patient’s upper thigh, or supported by your other
• Locate radial artery using the pads of your index and middle fingers aligned longitudinally over the course
of the artery by applying gentle but firm pressure in the medial and ventral side of the patient’s wrist just
below the base of his thumb. Do not occlude the radial pulse
• Counts the pulse rate for one full minute using a watch with a second hand
• Simultaneously palpate radial pulses on both sides
• Evaluate the pulse rhythm if regular or irregular
• Compare the volume of pulsation on each artery and grade

PERIPHERAL PULSE ASSESSMENT

Radial Pulse
• Position the patient’s arm in a relaxed position, palm downward or upward on top of the table, or on top
of the patient’s upper thigh, or supported by your other hand.
• Locate the right radial artery using the pads of your index and middle fingers aligned longitudinally over
the course of the artery by applying gentle but firm pressure in the medial and ventral side of the patient’s
wrist just below the base of his thumb. Do not occlude the radial pulse.
• Count the pulse rate on the right side for one full minute using a watch with a second hand.
• Locate the radial pulse on the left side using the same technique as above and count the pulse rate on
the left side for one full minute using a watch with a second hand.
• Simultaneously palpate the radial pulses on both sides.
• Evaluate the pulse rhythm and volume of pulsation on each artery. Grade the volume of pulsation.
Brachial Pulse
• Face the sitting or recumbent patient.
• Support the patient’s forearm with your left hand.
• With the patient’s right upper arm abducted, the elbow slightly flexed, and the forearm externally rotated,
palpate for the patient’s brachial artery with your right hand.
• Use the pads of your index and middle fingers (curling over the anterior aspect of the patient’s elbow to
apply gentle but firm pressure) to palpate along the course of the artery just medial to the biceps tendon
and lateral to the medical epicondyle of the humerus.
 • Locate the brachial pulse on the left side using the same technique as above with the positions of hand
switched.
• Simultaneously palpate the brachial pulses on both sides.
• Compare the volume of pulsation on each artery and grade the volume of pulsation.
• Note for any thrill.
Femoral Pulse
• Stand on the right side of the patient who is reclining on the bed in a 45-degree angle.
• Ask permission to expose the groin area.
• Expose the groin area.
• Use the pads of the index and middle fingers to locate the right femoral artery by applying firm pressure
at a point inferior to the inguinal ligament midway the anterior superior iliac spine and the symphysis
pubis.
• Locate the femoral pulse on the left side using the same techniques as above
• Simultaneously palpate the femoral pulses on both sides.
• Compare the volume of pulsation on each artery and grade the volume of pulsation.
• Note for any thrill.
Popliteal Pulse
• Put the patient in a supine position
• Using both hands, palpate the popliteal artery one at a time
• Flex slightly the patient’s knee
• Place the index and middle fingers of both hands in the midline behind the patient’s knee
• Press deeply into the popliteal fossa to palpate for the popliteal artery
• Do the same steps above on the other side
• Note for the volume of pulsation on both sides.
Posterior Tibial Pulse
• Put the patient in a supine position
• Stand at the foot or the side of the examining bed or table
• Use the pads of the index and middle fingers to locate the right posterior tibial artery by applying firm
pressure anteriorly around the ankle, indenting the soft tissues in the space between the medial malleolus
and the Achilles tendon, above the calcaneus.
• Apply your thumb to the opposite side of the ankle in a grasping manner to provide stability.
• Locate the posterior tibial pulse on the left side using the same techniques as above
• Simultaneously palpate the posterior tibial pulses on both sides.
• Compare the volume of pulsation on each artery and grade the volume of pulsation.
Dorsalis Pedis Pulse
• Put the patient in a supine position
• Stand at the foot or the side of the examining bed or table
• Use the pads of the index and middle fingers to locate the right dorsalis pedis artery by applying firm
pressure on the median dorsum of the foot.
• Use the other hand to dorsiflex the foot to various degrees to separate the dorsalis pedis artery from the
tendon overlying it.
• Locate the dorsalis pedis pulse on the left side using the same techniques as above
• Simultaneously palpate the dorsalis pedis pulses on both sides.
• Compare the volume of pulsation on each artery, and grade the volume of pulsation
Pulse Deficit Determination
• One examiner palpates for the radial pulse and counts the pulse rate for one full minute.
• Another examiner with prewarmed stethoscope simultaneously listens to the apical impulse and counts
the heart rate for one full minute.
• The first and the second examiner should start at the same time when counting the radial pulse rate and
heart rate, respectively.
• Compare and record the rate and rhythm of the radial and apical pulse.
 JUGULAR VENOUS PRESSURE
Identification of the JVP
• Examiner to stay on the right side of the patient
• Position patient properly
o Patient supine in bed and raise the patient’s heads lightly on a pillow
o Raise the head of the bed about 30-45° angle
• Turn the patient’s head slightly towards the left, exposing the right side of the neck
• Using a tangential white light over the right side of the patient’s neck, identify the right internal jugular
vein pulsation
• Identify the highest point of the right jugular venous pulsation (meniscus)
Measurement of the JVP
• Identify the sternal angle of Louis by starting from the suprasternal notch and slides finger down until a
hump is felt
• Place a ruler horizontally and parallel to the meniscus
• Place another ruler graduated in centimeters (cm) vertically on top of the sternal Angle of Louis and at a
90-degree angle to the previously placed horizontal ruler parallel to the meniscus of the JVP
• Note the vertical distance in cm above the angle of Louis at which the rulers intersect and state the JVP
in cm water.
• Note the different waveforms of the JVP and report/document.

CAROTID ARTERY PULSE

Assess the right carotid artery pulse (CAP)
• Position the patient sitting or supine. If supine, elevate the trunk about 30-45 degrees.
• Elevate patient’s chin and turn face to the left side without tightening the neck muscles
• Inspect for visible carotid pulsations.
• With index and middle fingers, locate the right carotid artery by palpating between the trachea and the
anterior border of the sternocleidomastoid muscle at the level of the cricoid cartilage.
• With your other hand, bend the patient’s head slightly to the side being examined.
• Apply varying degrees of pressure in palpating the pulse until the maximum pulsation is appreciated.
Assess the left carotid artery pulse (CAP)
• locate the carotid pulse on the left side using the same techniques as above
• NEVER PRESS ON BOTH CAROTID ARTERIES AT THE SAME TIME
Compare the following parameters:
• Amplitude
• Contour
• Rate or speed of pulse rise/upstroke,
• Rate or speed of pulse fall/downstroke,
• Thrill
• Bruit
o For detection of bruit, place bell of the stethoscope just behind the upper end of the thyroid
cartilage immediately below the angle of the jaw.
 PRECORDIAL EXAMINATION
• Stands on the right side of the patient
• With the patient in supine position, exposes the chest of the patient as far as decency permits

PRECORDIAL INSPECTION
• Illuminate the precordium from a single source (penlight) shining transversely or tangentially toward you
across the patient’s anterior chest surface.
• At eye level, checks for precordial bulging and visible pulsations
• Look for the apex beat

PRECORDIAL PALPATION

VISIBLE APEX BEAT

• Palpate for the apical impulse using the tip of the right middle and index fingers
• While palpating the visible apex beat, palpate for the angle of Louis with the other hand
• From the angle of Louis, slide fingers laterally to the left parasternal intercostal spaces and determine
what intercostal space the apex beat is located
• Using a graduated ruler in cm., note how far away from the left midclavicular line and from the midsternal
line is the apex beat
NON-VISIBLE APEX BEAT
• Starting from the sternal angle of Louis, using the tip of the right middle and index fingers, locate and
palpate for the apex beat in the 5th left intercostal midclavicular line OR adjust accordingly laterally to the
same intercostal space anterior, mid or posterior axillary line or the 6th intercostal space anterior, mid or
posterior axillary line
APEX BEAT DESCRIPTION
• Location
• Diameter - Estimate this by applying the tips of the fingers directly on top of the apex beat and note the
number of fingers needed to cover the apex beat OR use a ruler graduated in cm and measure the
diameter of the apex beat in cm; Describe this in finger breaths or in cm. A normal apical impulse is within
2 finger breaths or within 2 cm diameter.
• Amplitude - With fingertips, feel for the apex beat and note the height of pulsation of the apex beat,
whether normal, hypodynamic or hyperdynamic (very strong)
• Duration - While palpating the apex beat, auscultate for the first and second heart sound and note the
duration of systole.
• Note how much of systole does the apex beat occupy; the normal duration is when the apex beat
occupies only up to half of systole while sustained duration is when the apex beat occupies almost the
entire of systole
HEAVES
• Using the heel of right hand, palpate for abnormally strong pulsation (left ventricular heave) over the area
of the apex beat
• Using the heel of right hand, palpates for abnormally strong pulsation (right ventricular heave) over the
left side of the lower sternum/epigastric area
THRILLS
• Using the ball of hand, feel for fine vibratory sensations over the different clinical valve areas
o Apex beat of the 5th ICS, LMCL for mitral valve thrill
o Left lower sternum for tricuspid valve thrill
o 2nd ICS LPSL for pulmonic valve thrill
o 2nd ICS RPSL for aortic valve thrill
LIFTS
• Using the right middle and index finger pads, palpate for abnormal pulsation over the 2nd ICS LPSL for
pulmonary artery lift
• Using the right middle and index finger pads, palpate for abnormal pulsation over the 2nd ICS RPSL for
aortic artery dilatation
• Using the right middle and index finger pads, palpate for abnormal pulsation over the 3rd and 4th ICS
LPSL for left atrial lift
SUGGESTED SEQUENCE:
• Palpate for:

LV heave →RV heave → LA lift → PA lift → Aortic (Ao) lift → Ao thrill → PA thrill → Tricuspid thrill → Mitral thrill

PRECORDIAL AUSCULTATION

IDENTIFYING AUSCULATORY AREAS

• Using the angle of Louis, locate and identify the different auscultatory valve areas:
o At the area of the apex beat of the 5th ICS LMCL, identify the auscultatory area for the mitral
valve
o At he left lower parasternum, identify the auscultatory area for the tricuspid valve
o At the 2nd ICS LPSL identify the auscultatory area for the pulmonic valve
o At the 2nd ICS RPSL identify the auscultatory area for the aortic valve

PRECORDIAL AUSCULTATION PROPER

• Using the diaphragm of the stethoscope, auscultate at the different auscultatory valvular areas for the
different heart sounds (either from apex to base or base to apex in an inching manner).
• Describe the 1st heart sound in the mitral and tricuspid area (apex)
• Describe the 2nd heart sound in the mitral and tricuspid area (apex)
• Describe the 1st heart sound in the aortic and pulmonic area (base)
• Describe the 2nd heart sound in the aortic and pulmonic area (base)
• Compare the character of the heart sounds between the apical and the basal area
• Note for the time interval between the 1st and 2nd heart sounds (systole)
• Note for the time interval between the 2nd and 1st heart sounds (diastole)
• Note for splitting of the 2nd heart sound especially at the 2nd ICS LPSL and its relationship with
respiration

PRECORDIAL AUSCULTATION MANUEVERS

• Ask patient to assume a left lateral decubitus position to accentuate heart sounds in the apical area
(tricuspid and mitral)
• Ask patient to lean forward to accentuate heart sounds in the base

DETECTING ABNORMAL HEART SOUNDS

• Using the bell of the stethoscope, auscultate for 3rd and 4th heart sounds at the mitral and tricuspid valve
areas
o 3rd heart sounds are low pitch sounds that follow the second heart
o 4th heart sounds are low pitch sounds that follow the 3rd heart sound and are closer to the 1st
heart sound than to the second heart sound
• Using the diaphragm for high pitch and the bell for low pitch sounds, auscultate for other abnormal sounds
• Note for turbulent sounds (murmurs) noted during systole and diastole over the different valvular areas
• Note the character (high/low pitch), duration of the murmur(s), and grading of the murmur(s)
• Slowly inch away and notes the radiation of the murmur
• Perform appropriate maneuvers (dynamic auscultation)
o Valsalva maneuver-ask patient to take a deep breath then hold, pinch nose, close mouth, and
strain down; note change in murmur during Valsalva; note change in murmur after Valsalva
release
o Carvallo’s sign-ask patient to inhale deep while listening for any change in the heart sounds
• Describe noted murmur according to the following characteristics:
o Location and Radiation–identify point of maximum intensity and slowly inch away and note
radiation of the murmur
o Intensity or loudness– 1/6 to 6/6
o Duration–short or long
o Pitch or frequency– high, low, mixed
o Quality–blowing, rumbling, etc.
o Timing–systole or diastole or continuous
o Configuration–crescendo, decrescendo, plateau