Ensure the patient is lying comfortably in a semi-recumbent position at 45 degrees, with the upper half of the body exposed. In the female patient, cover the breast with a loose garment. The cardiac examination begins with a general examination of the patient. The respiratory rate should be noted, the normal resting rate is between 12 and 16 breaths per minute.

Patients in heart failure are likely to have tachypnea (increased respiration rate) with often shallow, rapid breathing exceeding 20 breaths per minute. The presence of a reduced cardiac output leads to stagnant hypoxia, with evidence of peripheral and possibly central cyanosis. Look for cyanosis of the hands and lips, and, for central cyanosis (mucous membrane of the mouth and tongue).

Note clubbing (figure 37) of the fingers or toes, and examine the extensor tendons of the hands and later the tendo Achilles for xanthoma. In the hands also look for splinter hemorrhages (figure 38) and Osler’s nodes, that are features of bacterial endocarditis.