Examination checklist

    Cardiovascular examination

    The weighted 40-step cardiovascular mark sheet — where the extra marks are (JVP and positioning for murmurs), how to present, and what to discuss after.

    Internal Medicine
    Cardiovascular system
    All colleges

    Mark sheet

    40 steps · 40 marks

    #StepWellPartlyNot
    1. 1Greets the examiner½¼0
    2. 2Greets the patient, introduces self and asks permission½¼0
    3. 3Cleans hands½¼0
    4. 4Ensures privacy with a screen or chaperone½¼0
    5. 5Positions the patient at 45° and exposes the chest½¼0
    6. 6Inspects from the foot and the side of the bed½¼0
    7. 7Assesses pulse rate, rhythm and character1½0
    8. 8Feels for thickening of the arterial wall1½0
    9. 9Tests for a collapsing pulse1½0
    10. 10Compares both radial pulses together1½0
    11. 11Checks for radio-femoral delay1½0
    12. 12Feels both brachial pulses together1½0
    13. 13Feels the carotid pulses one side at a time1½0
    14. 14Feels both temporal pulses together1½0
    15. 15Feels the popliteal pulses one side at a time1½0
    16. 16Feels both posterior tibial pulses together1½0
    17. 17Feels both dorsalis pedis pulses together1½0
    18. 18Looks for locomotor brachialis1½0
    19. 19Asks to measure the blood pressure1½0
    20. 20Assesses the JVP properly — light across the neck, at 45°, with respiration, confirming it is impalpable, and with abdominojugular reflux210
    21. 21Measures the height of the JVP1½0
    22. 22Inspects the praecordium for visible pulsation1½0
    23. 23Locates the apex beat correctly1½0
    24. 24Palpates the apex for a heave or thrill1½0
    25. 25Palpates the left sternal edge for a heave or thrill1½0
    26. 26Palpates the base for palpable second sounds and thrills1½0
    27. 27Listens at the apex with the patient turned to the left210
    28. 28Follows an apical murmur towards the axilla1½0
    29. 29Listens with the bell at the apex1½0
    30. 30Listens along the left sternal edge with the appropriate manoeuvres210
    31. 31Listens with the bell along the left sternal edge1½0
    32. 32Listens over the aortic and pulmonary areas1½0
    33. 33Sits the patient forward and listens at the base in held expiration1½0
    34. 34Listens over the carotid arteries1½0
    35. 35Listens at Erb's point1½0
    36. 36Palpates for an enlarged liver1½0
    37. 37Palpates for an enlarged spleen1½0
    38. 38Listens at both lung bases1½0
    39. 39Completes with distress, pallor, cyanosis, clubbing, lymph nodes and ankle oedema1½0
    40. 40Thanks the patient and covers them1½0

    Summary of findings

    Present from the periphery to the heart, then say what the findings mean: the lesion, its cause, and its consequence.

    I examined the cardiovascular system of a woman in her thirties. The pulse is 100 per minute, regular and of small volume, with no radio-femoral delay; all peripheral pulses are present. Blood pressure is 110/70 mmHg. The JVP is raised 5 cm above the sternal angle. The apex is displaced to the sixth intercostal space in the anterior axillary line and is diffuse. There is a pansystolic murmur at the apex, grade 3, radiating to the axilla and louder with the patient on her left side, and a third heart sound. There are fine crackles at both bases, tender hepatomegaly and pitting ankle oedema. These are the signs of mitral regurgitation with biventricular heart failure, probably rheumatic.

    For every murmur state its timing, site, radiation, grade, and how manoeuvres change it.

    Differential diagnoses

    Causes of heart failure to offer in our setting

    • Hypertensive heart disease
    • Rheumatic valve disease
    • Dilated cardiomyopathy, including peripartum cardiomyopathy
    • Ischaemic heart disease
    • Endomyocardial fibrosis
    • Hypertrophic and restrictive cardiomyopathy
    • Pericardial effusion or constriction

    What tips a stable heart into failure

    • Arrhythmia, especially atrial fibrillation
    • Infection, including infective endocarditis
    • Anaemia
    • Stopping medicines, or too much salt and fluid
    • Uncontrolled blood pressure
    • Pregnancy, thyrotoxicosis
    • NSAIDs and other fluid-retaining drugs

    Investigations

    • ECG: rhythm, chamber enlargement (LVH with strain, left atrial enlargement), ischaemia or old infarction, bundle branch block
    • Chest X-ray: cardiomegaly, upper lobe diversion, Kerley B lines, alveolar oedema, effusions
    • Echocardiography: the key test — chamber sizes, wall thickness, ejection fraction, regional wall motion, valve structure and gradients, pulmonary pressure, pericardium, thrombus
    • Natriuretic peptides: in the clinic, heart failure is likely when NT-proBNP is 125 pg/mL or more under 50 years, 250 or more at 50–75 years, or 500 or more over 75 years; arrange echocardiography, within 2 weeks if it is above 2000 pg/mL. Levels read lower in obesity and in people of African ancestry, and higher with kidney disease and atrial fibrillation
    • Blood and urine: full blood count, urea, electrolytes and creatinine with eGFR, urine albumin–creatinine ratio, liver function, thyroid function, HbA1c, lipids, and iron status (ferritin and transferrin saturation); troponin if ischaemia is suspected; three sets of blood cultures if endocarditis is possible

    Treatment

    • Relieve congestion with a loop diuretic
    • Start the foundational drugs together and build up the doses: an SGLT2 inhibitor and a mineralocorticoid receptor antagonist at any ejection fraction, plus a beta-blocker and an ACE inhibitor or sacubitril/valsartan when it is below 50% — see Heart failure treatment at a glance
    • Treat the cause and the precipitant
    • Salt restriction, daily weights, stopping alcohol and smoking, graded exercise once stable
    • Devices and surgery where indicated: valve repair or replacement, revascularisation, resynchronisation, defibrillators

    Examiner questions

    References

    • Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, et al., eds. Harrison's Principles of Internal Medicine. 22nd ed. New York: McGraw Hill; 2025.

    Updated September 18, 2026