Jugular venous distention is the most specific indicator of right heart failure. The examination is most reproducible if patients are examined sitting upright. The jugular venous pressure can then be measured as the distance from the top of the pulsation to the clavicle or manubrium. In almost all patients, if the jugular pulsation cannot be seen above the clavicle, the jugular venous pressure is normal.
Rales are usually, but not universally, present in left heart failure. They are, however, nonspecific.
The precordial examination is of key importance. Lateral displacement of the apical impulse indicates left ventricular enlargement. With systolic dysfunction, the impulse is enlarged, sustained, and not forceful. An atrial filling wave (corresponding to S4) or a late diastolic filling wave (corresponding to S3) is sometimes palpable. On auscultation, one should listen for S3 and S4. A soft holosystolic murmur from mitral or tricuspid insufficiency may be heard when the left or right ventricles are enlarged.
Hepatomegaly is common in right heart failure. The liver edge is soft to slightly firm and frequently tender. Sustained pressure on the liver may cause sustained elevation of the jugular venous pressure (hepatojugular reflux).
Pitting edema is present in dependent body parts, usually the feet and ankles. Edema should be graded by how deeply pitting is noted and by how far up the lower extremity it extends.
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