PEP cardio

Performance Exam: Initial Setup & Hygiene

Action: Introduce self, wash hands, clean stethoscope bell and diaphragm. | SCRIPT: "Hello, my name is [Name], and I am a PA student. Today I will be performing your cardiovascular and peripheral vascular examination. I am going to sanitize my hands and clean my stethoscope before we get started."

General Survey: Key Observations

Action: Inspect patient for distress, cyanosis, diaphoresis, JVD, Levine's sign. | SCRIPT: "I am observing the patient for any signs of acute anxiety, respiratory distress, diaphoresis, cyanosis, venous distention, obvious jugular venous distention, or Levine's sign."

Vital Signs: Radial Pulse

Action: Palpate radial artery with finger pads for rate and rhythm. | SCRIPT: "I am going to check your wrist pulse. The radial pulse rate is approximately [Rate] beats per minute, and the rhythm is regular."

Vital Signs: Blood Pressure Assessment

Action: Check BP in 1 arm using a palpable systolic estimate, then auscultate using the bell. Inform the patient. | SCRIPT: "First, I am determining your palpable systolic pressure… Now I am listening with the bell of my stethoscope for your auscultatory blood pressure… Your blood pressure is 120/80 mmHg, which is within normal limits."

Heart (Sitting): Positioning & Thorax Exposure

Action: Seat patient leaning forward; expose anterior and lateral thorax to mid-axillary line. | SCRIPT: "Could you please sit up and lean slightly forward for me? I am going to lower your gown to inspect your chest while keeping you covered as much as possible."

Heart (Sitting): Precordial Inspection

Action: Use tangential lighting across precordium to inspect for lifts/heaves and the apical impulse. | SCRIPT: "Using tangential lighting, I am inspecting your chest for any visible lifts, heaves, or the point of maximal impulse at the apex."

Heart (Sitting): Precordial Palpation

Action: Palpate thrills at RSB, LSB, base, apex using palm/finger bases; palpate PMI with finger pads for location/width. | SCRIPT: "I am now palpating for any abnormal vibrations called thrills at your right sternal border, left sternal border, base, and apex… Now feeling for your apical impulse, located at the 5th intercostal space midclavicular line, measuring under 2.5 centimeters."

Heart (Sitting): Auscultation Sequence (5 Valves)

Action: State interspace and valve out loud; listen with diaphragm then bell at each site. | SCRIPT: "I am now listening to your heart sounds with both the diaphragm and bell: Right 2nd intercostal space, aortic valve; Left 2nd intercostal space, pulmonic valve; Left 3rd intercostal space, Erb's point or 2nd pulmonic; Left 4th intercostal space, tricuspid valve; Left 5th intercostal space at the midclavicular line, mitral valve."

Heart (Sitting): Friction Rub Assessment at Erb's Point

Action: Auscultate LICS3 with diaphragm while patient holds breath. | SCRIPT: "I am placing my stethoscope at your 3rd left intercostal space, Erb's point. Please take a breath in, blow it all the way out, and hold it for a few seconds… Thank you, you can breathe normally. I am evaluating for a cardiac versus pleural friction rub."

Neck Vessels: Positioning & Preparation

Action: Recline patient to 30–45 degrees with feet supported, head turned slightly left, tangential lighting ready. | SCRIPT: "I am reclining the bed to 30 to 45 degrees. Please rest your feet comfortably and turn your head slightly to the left. I will use a light to inspect the veins and arteries in your neck."

Neck Vessels: Venous Hum Auscultation

Action: Auscultate supraclavicular fossa lateral to SCM with bell; state expected findings. | SCRIPT: "I am listening over your right supraclavicular fossa with the bell for a venous hum. Expected findings are a continuous humming sound that is louder in diastole and disappears with light pressure over the internal jugular vein."

Neck Vessels: Carotid Artery Bilateral Auscultation

Action: Auscultate angle of jaw, mid-cervical, base of neck with bell BEFORE palpating; have patient hold breath. | SCRIPT: "Before I feel your pulse, I will listen to your neck arteries for bruits. Take a breath in and hold it… breathe normally. Now on the other side, hold your breath… breathe normally. No bruits auscultated bilaterally."

Neck Vessels: Carotid Artery Palpation

Action: Palpate carotid pulses one side at a time using finger pads; assess contour and amplitude without massaging carotid sinus. | SCRIPT: "I am gently palpating your right carotid pulse for contour and amplitude… and now your left carotid pulse, examining each side individually."

Neck Vessels: Jugular Venous Pressure Measurement

Action: Locate IJV pulsation top at 30–45°. Place vertical ruler at Angle of Louis, horizontal straight edge to pulse apex; report value. | SCRIPT: "Using tangential lighting, I identify the peak pulsation of the internal jugular vein. Placing a vertical ruler on your sternal angle and aligning a horizontal straight edge, your jugular venous pressure measures 2 centimeters above the sternal angle, which is normal."

Heart (Supine): Precordial Inspection & Palpation

Action: Patient reclines fully flat. Tangential light for lifts/heaves/PMI; palpate RSB, LSB, base, apex for thrills; palpate PMI. | SCRIPT: "Please lie completely flat for me. I am inspecting the chest for lifts, heaves, and the apical impulse… Now palpating the right sternal border, left sternal border, base, and apex for thrills, and palpating the PMI for size and position."

Heart (Supine): Auscultation Sequence

Action: Auscultate diaphragm and bell at all 5 locations; state each location. | SCRIPT: "Listening across the five areas lying flat with diaphragm and bell: Right 2nd intercostal space (aortic), Left 2nd intercostal space (pulmonic), Left 3rd intercostal space (Erb's point), Left 4th intercostal space (tricuspid), and Left 5th intercostal space midclavicular line (mitral)."

Heart: Left Lateral Recumbent Position Auscultation

Action: Roll patient onto left side. Auscultate mitral area (LICS5 MCL) with diaphragm and bell. | SCRIPT: "Please roll onto your left side toward me. This position brings your heart closer to the chest wall. I am listening at the mitral area with both the diaphragm and bell to evaluate for S3, S4, or mitral murmurs."

Peripheral Vascular: Femoral Arteries Auscultation & Palpation

Action: Auscultate bilateral femoral arteries with bell for bruits first; palpate pulses bilaterally. | SCRIPT: "I am going to listen to your femoral arteries in the groin crease with the bell for bruits… Now I am palpating both femoral pulses to evaluate amplitude and symmetry."

Peripheral Vascular: Upper & Lower Extremity Pulses

Action: Palpate bilaterally: Brachial, Radial, Popliteal, Posterior Tibial, Dorsalis Pedis. | SCRIPT: "I am now palpating your brachial pulses at the inner elbow, radial pulses at the wrists, popliteal pulses behind both flexed knees, posterior tibial pulses behind your inner ankles, and dorsalis pedis pulses on the top of both feet. All pulses are 2+ and symmetric."

Peripheral Vascular: Extremities Inspection

Action: Inspect BUE and BLE for atrophy; inspect BLE for color, hair distribution, trophic changes. | SCRIPT: "I am inspecting both upper and lower extremities for muscular symmetry or atrophy, and observing your legs for skin color, hair distribution, and any trophic changes."

Peripheral Vascular: Capillary Refill & Skin Palpation

Action: Check cap refill on fingers and toes (<2s). Palpate BLE warmth with back of hands, texture with palms. | SCRIPT: "Checking capillary refill on your fingers and toes, which is brisk and under 2 seconds. Using the back of my hands, your legs are warm bilaterally, and the skin texture is smooth with no dryness or thickening."

Peripheral Vascular: Pitting Edema Assessment

Action: Depress pretibial tissue along tibia from medial malleolus to tibial tuberosity for 5 seconds; report grade. | SCRIPT: "I am pressing firmly along your shin from the ankle up to the tibial tuberosity to check for fluid swelling. There is no pitting edema bilaterally, graded as 0."

Peripheral Vascular: Varicose Vein Inspection

Action: Have patient stand upright; inspect posterior and anterior lower legs for tortuous veins. | SCRIPT: "Could you please stand up for me? I am inspecting the front and back of your legs for any prominent or varicose veins."

Performance Exam: Wrap-up & Hygiene

Action: Instruct patient to dress, wash/sanitize hands, complete exam. | SCRIPT: "You may sit back down and adjust your clothing. That concludes our cardiovascular and vascular examination. I am washing my hands now. Do you have any questions for me?"