The normal apex beat lies in the 5th left intercostal space (the space below the 5th rib) within the midclavicular line which, in the male, is the intercostal space immediately below and approximately in line with the left nipple, The intercostal space can be located by counting down from the second rib which is at the level of the sternal angle. The normal apical impulse gently and briefly lifts the palpating lingers and is quite localised. I lowever, in some normal subjects, particularly if overweight or muscular, the apex beat may be impalpable. The apex beat may also be impalpable in patients with asthma or emphysema because the chest is hyperinflated.
□ Inspect the precordium with the patient sitting at 45° to the upright with the shoulders horizontal, looking for any surgical scars, pulsations or other abnormalities.
□ Lay the whole hand Hat on the chest to gel a general impression of cardiac activity (Fig. 3.24A).
□ Localise the apex beat (Fig. 3.24B): if necessary ask the patient to roll on to the left side (Fig. 3.24C).
□ Assess the character of the apex beat,
□ Count the rib spaces from the sternal angle.
□ Palpate for the right ventricle using the heel of the hand
• General examination may reveal features of disorders which can cause, or aggravate, cardiac symptoms, e.g. anaemia, hyperthyroidism.
• Atrial fibrillation produces a pulse which is irregular in both time and volume.
• Pulse character should be assessed from a large artery, e.g. the carotid.
• Use the thumb to palpate brachial and carotid pulses; never palpate both carotids simultaneously.
• Accurate measurement of arterial blood pressure requires care and attention to detail.
• Pulsatile elevation of the JVP is a valuable sign of elevated right atrial pressure,
• A transient rise in the jugular venous pressure during abdominal compression is normal.
Superior vena cava
Left atrial appendage
Mitral valve 5th rib
firmly applied to the left parasternal position while the breath is held in expiration (Fig. 3.24D). LJ Palpate for thrills at the apex and to both sides of the sternum,
□ Where a murmur is audible, palpate again for a thrill using the flat of the lingers while the patient is in the optimum position (see below).
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