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.