The palm of your hand is placed just left of the sternal margin. A diffuse heaving impulse in this region indicates right ventricular enlargement. Prior to listening to the heart, check for an elevation in jugular venous pressure. Typically, the a-wave‚ is prominent and the overall level of pressure increased. With right ventricular failure, tricuspid regurgitation develops and the v-wave‚ becomes predominant (see jugular venous pressure below). Auscultation provides some valuable clues. The second sound tends to be narrowly split, and with concentration, the second (pulmonic) component will be noted to be increased. Finally, an audible S3 or S4 at the lower left sternal margin that increases on inspiration provides additional support for the diagnosis.