Apical Impulse

Point of Maximal Impulse (PMI)

Normal = 5th intercostal space (ICS) along the left mid-clavicular line (MCL).
Area = 2cm to 3cm in diameter.
Character = nonsustained (brief <0.5 systole). Examine the PMI placing the patient in the left lateral decubitus. Ask the patient to hold his/her breath in full expiration.

Left ventricular Hypertrophy: Sustained (>0.5systole), wide and displaced (lateral and down) apical impulse (Bard).

Impulses

Right Ventricular Hypertrophy (RVH) (under xiphoid process).

Hypertrophic Cardiomyopathy (HCM) (double systolic impulse).

Lifts

Pulmonary Artery : Systolic, 2nd ICS Left Sternal Border (LSB).

Pulsations

Pulmonary Artery: Over the right sternoclavicular joint.

THRILLS
Palpable, low frequency vibrations (rumbles, murmurs, snaps, gallops, knocks, etc).
Estimate: Location, timing and intensity.

Rubs

Pericardial Friction Rub: not constant, more in expiration.