Clinical presentation of the Pulmonary hypertension patient may reveal nonspecific symptoms, such as dyspnea, fatigue, angina, syncope, weakness, and abdominal distension. Symptoms at rest only occur in the very advanced stages of Pulmonary hypertension (WHOFC IV). Physical signs upon examination include a left parasternal lift, an accentuated component of the second heart sound, a pansystolic murmur of tricuspid regurgitation, a diastolic murmur of pulmonary insufficiency, and a right ventricular third sound. In advanced cases of Pulmonary hypertension, jugular vein distension, hepatomegaly, peripheral edema, ascites, and cool extremities may be present. Bilateral breath sounds are usually clear, unless an interstitial disease is involved, in which case crackles may be heard upon auscultation. Rashes, skin tightening, or telangiectasias may be present if a mixed connective tissue disorder, such as scleroderma, is present.