Cardiovascular System Examination: Palpation

I. Precordial Palpation

Patient Position: Supine or Left Lateral Decubitus (for apex beat localization)

1. Apex Beat (Point of Maximal Impulse, PMI)

• Confirmation

  • Palpable / Not palpable

• Localization

  • Intercostal Space (ICS): ______ ICS

  • Distance from Mid-Clavicular Line (MCL): ______ cm medial/lateral to MCL

  • Example: Left 5th ICS, 1 cm medial to MCL

• Character

  • Tapping: Short, sharp, and localized (e.g., Mitral Stenosis)

  • Heaving/Sustained: Lifting, prolonged impulse (e.g., LVH due to aortic stenosis, hypertension)

  • Thrusting/Diffuse: Broad, forceful, sustained (e.g., LVH from mitral/aortic regurgitation)

  • Hyperdynamic: Forceful, but not sustained (may be normal variant or high-output states)

  • Displaced: Note displacement (location/direction; e.g., cardiomegaly, effusions)

• Size

  • Estimate diameter in centimeters (e.g., 2 cm x 2 cm)

2. Thrills (Palpable murmurs)

• Presence

  • Present / Absent

• Localization

  • Mitral Area: Apex

  • Tricuspid Area: Left lower sternal border (4th/5th ICS)

  • Aortic Area: Right 2nd ICS, parasternal

  • Pulmonary Area: Left 2nd ICS, parasternal

  • Other Areas: (e.g., carotids, suprasternal notch)

• Timing

  • Systolic / Diastolic / Continuous

  • Example: Systolic thrill at the aortic area

3. Left Parasternal Heave (Right Ventricular Heave)

• Presence

  • Present / Absent

  • Technique: Palpate along the left sternal border

• Character

  • Sustained, lifting impulse

  • Indicates: Right ventricular hypertrophy

4. Epigastric Pulsation

• Presence

  • Present / Absent

  • Technique: Palpate in the epigastrium (below the xiphisternum)

• Character

  • Normal, expansile/pulsatile, or sustained

  • Note: Differentiate from transmitted aortic pulsation

5. Palpable Heart Sounds

• Palpable S1

  • Present / Absent (e.g., at apex in mitral stenosis)

• Palpable S2 (P2)

  • Present / Absent (e.g., in pulmonary area for pulmonary hypertension)

Tip: Use gentle palpation with the palm and fingers. Always compare findings with the norm and document all positive and negative signs for optimal cardiovascular assessment.