Before commencing the cardiovascular exam, wash your hands, introduce yourself to the patient and gain consent.

Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination.

Always stand on the right side of the bed during the cardiovascular examination.

Skin pallor is classically a sign of anaemia, though may also occur due to low output or peripheral shutdown.

Cyanosis is a blue discolouration of the skin and mucous membranes - this may be either peripheral or central and suggests either severe hypoxia, or severe peripheral shutdown.

Dehydration occurs in the setting of poor oral intake or fluid loss (e.g. due to diarrhoea, vomiting, sweating or diuresis). Signs of dehydration include tachycardia, poor urine output, dry mucous membranes and reduced skin turgor.

Fluid overload may occur in the context of several conditions including, heart failure, renal failure, liver cirrhosis, SIADH, pregnancy or simply due to excessive IV fluid administration. Signs of fluid overload include bounding pulses, raised JVP, pulmonary crepitations and pitting oedema.

Note whether the pulse is regular, regularly irregular or irregularly irregular. The implication of an irregularly irregular pulse is likely atrial fibrillation; remember that this is associated with valvular (particularly mitral) pathology.

The cuff should measure ~80% of the patient’s arm circumference; inflate the cuff to 30mmHg beyond where the pulse is no longer palpable, then slowly deflate until the beating sound is first heard (this is the systolic blood pressure). Then deflate until the beating sound disappears entirely (this is the diastolic blood pressure). Never check the blood pressure on an arm with an AV fistula or axillary clearance for breast cancer.

Hypertension (increased BP >140/90) may have primary or secondary causes, and is associated with increased risk of both acute and chronic cardiovascular complications. Hypotension (reduced systolic BP <100mmHg) is associated with postural hypotension, cardiac disease, hypovolaemia and shock.

Note the patient’s pulse pressure, or the difference between the systolic and diastolic blood pressure. A narrow pulse pressure is a sign of severe aortic stenosis, severe mitral stenosis or hypovolaemia. A widened pulse pressure (often along with a collapsing pulse) is a sign of aortic regurgitation or patent ductus arteriosis.

Or, at least, mention that you would look for those things.

If the jugular venous pulsation is difficult to visualise, assess for hepatojugular reflux. Ask the patient if they have any pain in their abdomen, then gently press over the right upper quadrant for 10-15 seconds - this temporarily increases venous return, making the JVP more pronounced.

Auscultate the carotid arteries for the presence of a bruit, which suggests carotid artery stenosis. You may also hear the transmitted murmur of aortic stenosis.

Inspect the chest wall both anteriorly and posteriorly for thoracic scars, which may suggest previous chest surgery or trauma. A midline scar (sternotomy) suggests past cardiac surgery (bypass graft or valve replacement), while a scar over the left or right upper chest suggests an implantable device.

When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound. You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.

The first heart sound (S1) indicates closure of the mitral and tricuspid valves, and is normal heart best over the apex. Listen for presence of S1, and whether it is loud or soft.

The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves. Normally on expiration, S2 splits into separately audible A2 and P2 sounds. Note whether the second heart sound is loud or soft.

The third heart sound (S3) is a pathological finding associated with rapid ventricular filling. This is a gallop rhythm, with an extra heart sound heard just after S2.

The fourth heart sound (S4) is a pathological finding associated with turbulence during atrial systole. This is also a gallop rhythm, with an extra heart sound heard just before S1, usually best heard during inspiration.

A systolic murmur is present between S1 and S2. An ejection (or mid) systolic murmur is a classical sign of aortic stenosis, while a pansystolic murmur is associated with mitral regurgitation. Click to read more about murmurs that occur during systole.

A diastolic murmur is present between S2 and S1. An early diastolic murmur is classically a sign of aortic regurgitation, while a mid-diastolic murmur (usually heard with the bell of the stethoscope) suggests mitral stenosis. Click to read more about diastolic murmurs.

Continuous murmurs are uncommon and are associated with rare conditions such as patent ductus arteriosus and AV fistulas.

A fourth heart sound is also best heard during inspiration.

If you are running out of time, skip to the legs at this point as these will provide the highest yield.

Cool extremities are a sign of poor perfusion; localised hypoperfusion may occur due to arterial disease or compartment syndrome, while more generalised hypoperfusion is a sign of shock. Warm extremities have a wide variety of causes. Significant unilateral warmth suggests cellulitis or a DVT, while milder warmth suggests fluid accumulation due to venous insufficiency or lymphoedema.

Next, palpate for pedal oedema. Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release, looking for persistence of the depressed area after the finger is removed. If the oedema is pitting, this suggests fluid overload, right ventricular failure, venous pathology or hypoalbuminaemia; non-pitting oedema suggests lymphoedema.

Thank the patient, turn around and present your findings.

Ask for an electrocardiogram (ECG), urinalysis, and fundoscopy to complete your assessment.