UNIVERSITY OF SANTO TOMAS

Faculty of Medicine & Surgery

Department of Medicine
Medicine 1
Cardiovascular Examination Checklist
Introduce self and greet the patient
Explain the procedure and secure consent
EXAMINATION OF THE NECK VESSELS
I. Jugular Venous Pressure (JVP)
A. Identification of the JVP
1. Examiner to stay on the right side of the patient
2. Position patient properly
a) Patient supine in bed and raise the patient’s head slightly on a pillow
b) Raise the head of the bed about 30-45o angle
3. Turn the patient’s head slightly towards the left, exposing the right side of the neck
4. Using a tangential white light over the right side of the patient’s neck, identify the right internal jugular vein pulsation
5. Identify the highest point of the right jugular venous pulsation (meniscus)
B. Measurement of the JVP
1. Identify the sternal angle of Louis by starting from the suprasternal notch and slides finger down until a hump is felt
2. Place a ruler horizontally and parallel to the meniscus
3. 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
4. Note the vertical distance in cm above the angle of Louis at which the rulers intersect and state the JVP in cm water.
5. Note the different waveforms of the JVP and draw.
II. Carotid Artery Pulse (CAP)
A. Assess the right carotid artery pulse (CAP)
1. Position the patient sitting or supine. If supine, elevate the trunk about 30-45 degrees.
2. Elevate patient’s chin and turn face to the left side without tightening the neck muscles
3. Inspect for visible carotid pulsations.
4. 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.
5. With your other hand, bend the patient’s head slightly to the side being examined.
6. Apply varying degrees of pressure in palpating the pulse until the maximum pulsation is appreciated.
B. Assess the left carotid artery pulse (CAP) – locate the carotid pulse on the left side using the same techniques as above
C. NEVER PRESS ON BOTH CAROTID ARTERIES AT THE SAME TIME.
D. Compare the following parameters: amplitude, contour, rate or speed of pulse rise/upstroke, rate or speed of
pulse fall/downstroke, thrill, bruit. 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.
E. Draw the CAP as part of the cardiac auscultogram
III. EXAMINATION OF THE PERIPHERAL PULSES
A. Brachial Pulse
1. Face the sitting or recumbent patient.
2. Support the patient’s forearm with your left hand.
3. 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.
4. 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.
5. Locate the brachial pulse on the left side using the same technique as above with the positions of hand switched.
6. Simultaneously palpate the brachial pulses on both sides.
7. Compare the volume of pulsation on each artery, and grade the volume of pulsation.
8. Note for any thrill.
B. Radial Pulse
1. 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.
2. 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.
3. Count the pulse rate on the right side for one full minute using a watch with a second hand.
4. 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.
5. Simultaneously palpate the radial pulses on both sides.
6. Evaluate the pulse rhythm and volume of pulsation on each artery. Grade the volume of pulsation.
C. Femoral Pulse
1. Stand on the right side of the patient who is reclining on the bed in a 45-degree angle.
2. Ask permission to expose the groin area.
3. Expose the groin area.
4. Use the pads of the index and middle fingers to locate the right femoral artery by applying firm pressure at a point inferior to

CVSY2017-2018
 UNIVERSITY OF SANTO TOMAS
Faculty of Medicine & Surgery
Department of Medicine
Medicine 1
Cardiovascular Examination Checklist
the inguinal ligament midway the anterior superior iliac spine and the symphysis pubis.

C. Femoral Pulse
5. Locate the femoral pulse on the left side using the same techniques as above
6. Simultaneously palpate the femoral pulses on both sides.
7. Compare the volume of pulsation on each artery, and grade the volume of pulsation.
8. Note for any thrill.
D. Popliteal Pulse
1. Put the patient in a supine position
2. Using both hands, palpate the popliteal artery one at a time
3. Flex slightly the patient’s knee
4. Place the index and middle fingers of both hands in the midline behind the patient’s knee
5. Press deeply into the popliteal fossa to palpate for the popliteal artery
6. Do the same steps above on the other side
7. Note for the volume of pulsation on both sides.
E. Posterior Tibial Pulse
1. Put the patient in a supine position
2. Stand at the foot or the side of the examining bed or table
3. 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.
4. Apply your thumb to the opposite side of the ankle in a grasping manner to provide stability.
5. Locate the posterior tibial pulse on the left side using the same techniques as above
6. Simultaneously palpate the posterior tibial pulses on both sides.
7. Compare the volume of pulsation on each artery, and grade the volume of pulsation.
F. Dorsalis Pedis Pulse
1. Put the patient in a supine position
2. Stand at the foot or the side of the examining bed or table
3. 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.
4. Use the other hand to dorsiflex the foot to various degrees to separate the dorsalis pedis artery from the tendon overlying
it.
5. Locate the dorsalis pedis pulse on the left side using the same techniques as above
6. Simultaneously palpate the dorsalis pedis pulses on both sides.
7. Compare the volume of pulsation on each artery, and grade the volume of pulsation
G. Grading of the volume of pulsation: (-) no pulse; + weak pulse; ++ normal pulse; +++ very strong pulse
H. Pulse Deficit Determination
1. One examiner palpates for the radial pulse and counts the pulse rate for one full minute.
2. Another examiner with prewarmed stethoscope simultaneously listens to the apical impulse and counts the heart rate for
one full minute.
3. The first and the second examiner should start at the same time when counting the radial pulse rate and heart rate,
respectively.
4. Compare and record the rate and rhythm of the radial and apical pulse.
EXAMIINATION OF THE PRECORDIUM
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
I. PRECORDIAL INSPECTION
1. Illuminate the precordium from a single source (penlight) shining transversely or tangentially toward you across the patient’s
anterior chest surface.
2. At eye level, checks for precordial bulging and visible pulsations
3. Look for the apex beat

CVSY2017-2018
 UNIVERSITY OF SANTO TOMAS
Faculty of Medicine & Surgery
Department of Medicine
Medicine 1
Cardiovascular Examination Checklist
II. PRECORDIAL PALPATION
A. VISIBLE APEX BEAT
1. Palpate for the apical impulse using the tip of the right middle and index fingers
2. While palpating the visible apex beat, palpate for the angle of Louis with the other hand
3. From the angle of Louis, slide fingers laterally to the left parasternal intercostal spaces and determine what intercostal space
the apex beat is located
4. Using a graduated ruler in cm., note how far away from the left midclavicular line and from the midsternal line is the apex
beat
B. NON-VISIBLE APEX BEAT
1. 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
C. APEX BEAT DESCRIPTION
1. Location
2. 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.
3. 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)
4. 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
D. HEAVES
1. Using the heel of right hand, palpate for abnormally strong pulsation (left ventricular heave) over the area of the apex beat
2. Using the heel of right hand, palpates for abnormally strong pulsation (right ventricular heave) over the left side of the lower
sternum
E. THRILLS
1. Using the ball of hand, feel for fine vibratory sensations over the different clinical valve areas
a.) apex beat of the 5th ICS, LMCL for mitral valve thrill
b.) left lower sternum for tricuspid valve thrill
c.) 2nd ICS LPSL for pulmonic valve thrill
d.) 2nd ICS RPSL for aortic valve thrill
F. LIFTS
1. Using the right middle and index finger pads, palpate for abnormal pulsation over the 2 nd ICS LPSL for pulmonary artery lift
2. Using the right middle and index finger pads, palpate for abnormal pulsation over the 2 nd ICS RPSL for aortic artery dilatation
3. Using the right middle and index finger pads, palpate for abnormal pulsation over the 3 rd and 4th ICS LPSL for left atrial lift
III. PRECORDIAL AUSCULTATION
A. IDENTIFYING AUSCULATORY AREAS
1. Using the angle of Louis, locate and identify the different auscultatory valve areas:
a.) At the area of the apex beat of the 5th ICS LMCL, identify the auscultatory area for the mitral valve
b.) At the left lower parasternum, identify the auscultatory area for the tricuspid valve
c.) At the 2nd ICS LPSL identify the auscultatory area for the pulmonic valve
d.) At the 2nd ICS RPSL identify the auscultatory area for the aortic valve
B. PRECORDIAL AUSCULTATION PROPER
1. 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).
2. Describe the 1st heart sound in the mitral and tricuspid area (apex)
3. Describe the 2nd heart sound in the mitral and tricuspid area (apex)
4. Describe the 1st heart sound in the aortic and pulmonic area (base)
5. Describe the 2nd heart sound in the aortic and pulmonic area (base)
6. Compare the character of the heart sounds between the apical and the basal area
7. Note for the time interval between the 1st and 2nd heart sounds (systole)
8. Note for the time interval between the 2nd and 1st heart sounds (diastole)
9. Note for splitting of the 2nd heart sound especially at the 2nd ICS LPSL and its relationship with respiration
C. PRECORDIAL AUSCULTATION MANUEVERS
1. Ask patient to assume a left lateral decubitus position to accentuate heart sounds in the apical area (tricuspid and mitral)
2. Ask patient to lean forward to accentuate heart sounds in the base
D. DETECTING ABNORMAL HEART SOUNDS
1. Using the bell of the stethoscope, auscultate for 3 rd and 4th heart sounds at the mitral and tricuspid valve areas
a.) 3rd heart sounds are low pitch sounds that follow the second heart
b.) 4th heart sounds are low pitch sounds that follow the 3 rd heart sound and are closer to the 1st heart sound than to the
second heart sound
2. Using the diaphragm for high pitch and the bell for low pitch sounds, auscultate for other abnormal sounds

CVSY2017-2018
 UNIVERSITY OF SANTO TOMAS
Faculty of Medicine & Surgery
Department of Medicine
Medicine 1
Cardiovascular Examination Checklist
3. Note for turbulent sounds (murmurs) noted during systole and diastole over the different valvular areas
4. Note the character (high/low pitch), duration of the murmur(s), and grading of the murmur(s)
5. Slowly inch away and notes the radiation of the murmur
6. Perform appropriate maneuvers (dynamic auscultation)
a.) 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
b.) Carvallo’s sign-ask patient to inhale deep while listening for any change in the heart sounds
7. Describe noted murmur according to the following characteristics:
a.) Location and Radiation – identify point of maximum intensity and slowly inch away and note radiation of the murmur
b.) Intensity or loudness – 1/6 to 6/6
c.) duration – short or long
d.) pitch or frequency – high, low, mixed
e.) quality – blowing, rumbling, etc.
f.) timing – systole or diastole or continuous
g.) configuration – crescendo, decrescendo, plateau
IV. DRAW PRECORDIAL EXAMINATION FINDINGS (AUSCULTOGRAM)
1. Draw the JVP
2. Draw the CAP
3. Describe the dynamicity of the precordium
4. Write the apex beat location, character, presence/absence of heaves, thrills, lifts
5. Draw the heart sounds (normal and abnormal) in the apical area
6. Draw the heart sounds (normal and abnormal) in the basal area
7. Draw the duration of the systole and diastole
8. Draw murmurs if present

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