Patient’ appearance. The disheveled appearance of the patient may represent a combination of depression and inability to care for oneself because of cardiac failure, fatigue, etc. 

The untied shoes most likely reflects the edema of the feet.

Diaphoresis: Excess of sympathetic nervous system output

Labored breathing – complex mechanism including peripheral receptors and modulation by nervous system Use of accessory muscles of respiration.

Blue lips : Peripheral Cyanosis – poor peripheral circulation

Cold hands: poor peripheral circulation

Lowered BP – decreased stroke volume, pulse pressure is less than 30mmHg – primarily systolic pressure drop

Distended neck veins – right heart failure with elevated right atrial pressure. The veins are pulsatile.

Diminished S1 and S2 – high end diastolic pressure (A-V valves), decreased stroke volume (semilunar valves); dampening effect of pleural/pericardial effusions.

Holosytolic murmur: The left ventricle is dilated (failure – high end diastolic volume). At the same time, the annulus of the atrio-ventricular valve is dilated. 

S3: A third heart sound most likely represents a change in the compliance of the ventricular wall and vibrations set up when a column of blood enters a chamber with a high end diastolic pressure. Gallop sound.

Tachycardia:

 Irregular, irregular pulse: Atrial fibrillation. High pressure in the atrium leads to stretching the muscular wall – dilatation of the chamber – which induces a conduction abnormality.

Pulsus alternans:  Alternating weak and strong pulse indicative of depressed LV function

Palpable liver edge – passive congestion of the liver, right heart failure

Pitting edema – elevated capillary hydrostatic pressure, passive venous congestion, right heart failure 

Basal crackles:  Due to basal congestion of lungs the alveoli are atelectatic. They create a popping noise as they open at the end of inspiration.

Dullness in bases of lung fields: If there is pleural effusion there will be impaired note to percussion.