The patient will appear anxious and dyspnoeic. Patients in chronic heart failure are usually malnourished and even cachectic. Chronic passive venous congestion may produce exophthalmos. Cyanosis, icterus and edema may be present.

Pulse

There is usually tachycardia associated with coldness of extremities due to adrenergic activity. Irregularly irregular pulse suggests atrial fibrillation, which could have precipitated heart failure.

Jugular Venous Pressure

Elevated jugular venous pressure reflects raised right atrial pressure. V-wave and y descent will be prominent if there is severe tricuspid regurgitation. Jugular venous pressure which is normal at rest gets abnormally elevated when right upper abdominal quadrant is compressed (hepato-jugular reflux)

Liver

The liver is often enlarged and tender. It is pulsatile in the presence of severe tricuspid regurgitation.

Edema

Peripheral, symmetrical, pitting edema, particularly in the dependent parts, noticeable in the ambulant patients towards evening is a cardinal feature of heart failure. In bed-ridden patients, the edema is seen over the sacral area. Long standing edema leads to skin pigmentation.

Pleural Effusion

Pleural veins drain into both systemic and pulmonary veins. When both the venous systems are involved, pleural effusion develops. It is usually bilateral, but when confined to one side, it is generally seen on the right side.

Ascites

Ascites denotes chronic systemic venous hypertension. In tricuspid regurgitation and constrictive pericarditis, ascites may be more prominent than peripheral edema.

Cardiac Findings

Findings related specifically to the underlying cardiac lesions like valvular lesions, shunts or pericardial disease will be present. There are some general findings:

Cardiac Enlargement

This is generally seen in chronic systolic heart failure. In acute heart failure and diastolic heart failure, cardiomegaly is not a feature. Heart  Sounds Presence of left ventricular third heart sound denotes systolic dysfunction. Fourth heart sound may be present. With tachycardia the extra sounds result in a gallop rhythm either early diastolic or presystolic gallop. With pulmonary hypertension, pulmonary component of the second sound is accentuated. Functional mitral and tricuspid regurgitation murmurs appear with ventricular dilatation.

Pulsus Alternans

It is seen in systolic heart failure and indicates advanced myocardial disease. It tends to disappear with successful treatment of heart failure.

Cheyne Stokes Respiration

 This is periodic or cyclical breathing, where periods of apnoea alternates with periods of hyperpnoea during sleep. Left ventricular failure leading to sluggish cerebral circulation is the cause.