The next step in evaluating our patient is feeling for precordial movement. I’ve had my hand for some time on the apex and i just can’t be sure i feel an impulse, even when i feel inferolaterally on the chest wall. So, i’m not feeling an apical impulse either in the usual or the displaced area. this could be a clue to a diagnosis.
Absent apical impulse
An absent palpable apical impulse may occasionally occur in normal patients, particularly if they are obese. However, it may also be an important negative finding, especially if the patient has been examined in the left lateral decubitus position. It is strong evidence against the presence of disease that causes left ventricular enlargement where the apical impulse is usually enhanced. It may also be a clue to right ventricular enlargement where the anteriorly located right ventricle pushes the left ventricle posteriorly.
Precordial movement at the left sternal edge
Let’s continue our search for precordial movement by feeling at the left sternal edge. I feel not just one area of impulse, but two. Not just in the usual mid-to-lower left sternal edge area, but at the upper left sternal edge area. You have to time that movement. Let’s analyze the upper left sternal edge movement compared to the carotid vessel. We’ll put a cotton swab on the area and see if we can time this movement in the second interspace left parasternal edge. Let’s watch the tip of the those cotton swabs carefully and analyze together. [Cur-away]
Precordial movement at the left sternal edge discussion
Precordial impulses are not normally palpable at the left sternal edge. when present, they may occur in two areas.
The most common impulse is felt at the mid-to-lower left sternal edge. it reflects movement of the right ventricle, and is almost always due to hypertrophy and/or dilatation of this anteriorly located chamber.
More rarely, a dilated pulmonary artery can be felt at the upper left sternal edge. This movement only occurs during systolic expansion of the vessel.
Movement at the LLSE
What is the significance of this rather unusual movement at the upper left sternal edge? Well, first let’s time the movement together comparing it to the carotid impulse. One can readily see that the movement is systolic. Take a careful look. [Cut-away]
What can cause such a systolic impulse at the upper left parasternal edge? Well, we just have to know a little simple anatomy: the pulmonary artery lies right below there. By all odds, this is an enlarged pulmonary artery. So enlarged that in systole, as the right ventricle pumps, it expands and moves the chest wall. There just aren’t too many causes for that. Think about pulmonary hypertension. That’s one good choice.