What have we learned from the evaluation of the contour of our patient’s precordial impulse? Well, let us look again together using the cotton swabs to time the movement, that is, the carotid impulse is in systole and the other cotton swab, so that we can appreciate the contour of our patient’s apical impulse. [Cut-away] and what do we observe? We observe an impulse at the apex that is non-sustained and early systolic, non-sustained and early systolic. That is the description of a normal apical impulse.

Now, in patients such as this, the finding is not always normal. The apical impulse could have more than one movement. You could palpate a fourth sound and then the apical impulse, and on some occasions, even palpate a third sound. In addition to that, sometimes that apical impulse is more sustained than normal, because dyskinetic or infarcted areas of myocardium bulge out in almost paradoxic manner during systole as the rest of the ventricle contracts. So, carefully evaluate your patient’s precordial impulse in the setting of acute myocardial infarction.