The initial examination and physical examination allows the internist to make a conclusion. Medical history is very important in the determination of heart failure. Exertion-related or position-related dyspnea is a typical symptom of heart failure. On physical examination, it is common to find that the apical beats are shifted to the lower left (suggesting left heart enlargement), the jugular veins are angry, the liver is enlarged with percussion pain, the peripheral limbs are edematous, and sometimes there is pleural effusion. On auscultation of the lungs, pulmonary rales may be heard, suggesting pulmonary stasis. On cardiac auscultation, pathological heart sounds may be heard. x-ray chest radiographs may indicate enlarged heart shadow and a cardiothoracic ratio >50%. Cardiac ultrasound is one of the most important tools to assess the systolic and diastolic function of the heart and provides information on chamber diameter values and valve function. In heart failure, blood pressure is increased, unchanged or decreased.