The next step in the bedside evaluation of our patient is an assessment of precordial movement. For some time, I’ve had my hand at the apex and I feel no movement, I feel no movement in the usual area nor in the displaced apical 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 enlarged. 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 palpating at the left sternal edge. When I do, I feel two impulses, one at the mid-to-lower left sternal edge and one in the upper left sternal edge area, in approximately the second interspace. Let's time that movement at the second interspace with the carotid vessel, using again the cotton swab. Everybody observe. [Cut-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 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
The timing of the murmur at the upper left sternal edge is systolic. That movement occurs when the carotid impulse occurs. Let's look together to confirm that fact. [Cut-away]
What is the cause of such a prominent movement of the chest wall second interspace in systole? That is the area of the pulmonary artery and what it tells us is that the pulmonary artery is dilated. And what can cause a dilated pulmonary artery? Think of pulmonary hypertension of some cause.