Using light pressure of the fingertips, feeling that apical impulse, we can now analyze contour. Sometimes that’s brought out a little better with the patient in the left lateral decubitus position. I am feeling the contour, but I must time is against something. So we shall time it against the carotid arterial pulse, and again, there is some utility in using these cotton swabs. We place one at the apex, so that we have that timed and observe its contour and, in addition, we place one over the carotid impulse, because that will tell us when systole is occurring. Time them carefully. Watch carefully, one against the other.

What have we learned about the contour in this case? Well, that impulse at the apex comes up just barely before you observe the carotid arterial pulse beginning. That tells us that that is occurring in very, very early systole. But in addition, we also felt it to be rather abrupt – the contour was flicking. So, when we think about the differential diagnosis of this type of apical impulse, is it volume or preload, such as shunts or regurgitant lesions, or is it a failing ventricle? That vigorous impulse we felt at the apex is more consistent with the shunt, the preload, the volume load – than with pump failure per se.