Documenting a Pulse Examination in Cardiovascular Disease Patients
Document pulse rate, rhythm, amplitude, symmetry bilaterally in all major arterial sites (radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial), along with any bruits or abnormalities, as part of the comprehensive cardiovascular physical examination. 1
Essential Patient Demographics and Identifiers
Before documenting the pulse exam findings, ensure the following administrative elements are recorded:
- Patient identifiers: Full name, medical record number, date of birth, gender 1, 2
- Date and time of examination 1
- Race/ethnicity and birthplace (relevant for cardiovascular risk stratification) 1, 2
- Contact information and referring physician identification 1
Relevant Medical History to Document
Cardiovascular History
Document the following conditions as they directly impact pulse examination interpretation:
- History of heart failure including dates of onset and NYHA functional class 1
- Coronary artery disease: Previous myocardial infarction with dates, angina type (stable, unstable, variant), previous PCI or CABG with dates 1
- Arrhythmias: Atrial fibrillation, other rhythm disorders, pacemaker or ICD implantation with device type and date 1
- Peripheral arterial disease and history of peripheral embolic events 1
- Valvular heart disease and structural abnormalities 1
Risk Factors
- Hypertension with current blood pressure readings 1
- Diabetes mellitus status 1
- Hyperlipidemia 1
- Tobacco use and alcohol consumption 1
- Family history of premature coronary artery disease (male relatives <55 years, female relatives <65 years), sudden cardiac death, cardiomyopathy 1, 2
Current Medications
- All cardiovascular medications including anticoagulants, antiplatelets, beta-blockers, ACE inhibitors, diuretics with dosages 1, 2
- Over-the-counter medications and supplements 1, 2
Vital Signs Documentation
Record the following at each encounter:
- Blood pressure: Both arms, orthostatic measurements (lying, sitting, immediate standing, after 3 minutes upright) 1, 2
- Heart rate and rhythm 1, 2
- Respiratory rate and oxygen saturation 2
- Temperature 2
- Weight (serial assessments for volume status in heart failure patients) 1, 2
- Ankle-brachial index when peripheral arterial disease is suspected 1
Pulse Examination Components
Rate and Rhythm
- Pulse rate in beats per minute 1
- Rhythm regularity: Regular, regularly irregular, or irregularly irregular 1
- Specific arrhythmias detected (e.g., atrial fibrillation, premature beats) 1
Pulse Characteristics at Each Site
Document for radial, brachial, carotid, femoral, popliteal, dorsalis pedis, and posterior tibial arteries:
- Presence or absence of pulse 1
- Amplitude/volume: Grade 0 (absent), 1+ (diminished), 2+ (normal), 3+ (increased), 4+ (bounding) 1
- Symmetry: Compare bilateral pulses for equality 1
- Contour: Normal upstroke, delayed upstroke (pulsus parvus et tardus in aortic stenosis), bisferiens pulse, alternating amplitude (pulsus alternans in heart failure) 1
- Timing: Radial-femoral delay (coarctation of aorta) 1
Additional Vascular Findings
- Carotid bruits: Presence, location, radiation 1
- Femoral bruits 1
- Jugular venous pressure estimation in centimeters of water 1, 2
- Peripheral edema: Location, severity, pitting vs. non-pitting 1, 2
Clinical Context and Symptoms
Document presenting symptoms that prompted the examination:
- Chest pain or anginal equivalent: Type (noncardiac, atypical, stable angina, unstable angina, STEMI), CCS grade if stable angina 1, 3
- Dyspnea: At rest, on exertion, orthopnea, paroxysmal nocturnal dyspnea 1, 3
- Syncope or presyncope: Circumstances, prodromal symptoms, duration 1
- Claudication: Distance walked before onset, relief with rest 1
- Palpitations 3
Common Pitfalls to Avoid
- Failing to check bilateral pulses: Always compare symmetry as unilateral diminution suggests arterial occlusion 1
- Omitting distal pulses: Dorsalis pedis and posterior tibial pulses are critical for peripheral arterial disease assessment 1
- Not documenting orthostatic vital signs: Essential in syncope evaluation and heart failure management 1
- Ignoring pulse character: Amplitude and contour provide diagnostic clues about valvular disease and cardiac output 1
- Missing carotid bruits: Indicates cerebrovascular disease risk requiring further evaluation 1
Quality and Limitations
Document if examination quality was:
- Optimal, fair, suboptimal, or poor 1
- Specific limitations: Obesity, edema, patient cooperation, or technical factors that affected assessment 1
This structured approach ensures comprehensive documentation that supports clinical decision-making, quality measurement, and appropriate use of additional diagnostic testing. 1