Assessing Apical Impulse

• May require tangential lighting to accentuate any chest wall movement
• First look for any pulsations or retractions and describe the location by intercostal space (ICS) and distance in centimetres from the sternum or the midclavicular line (MCL)
• Pulsation created when the left ventricle rotates against the chest wall during systole
• Apical impulse may be visible around the 4th or 5th intercostal space at or inside the midclavicular line
• The impulse is more easily seen in children and individuals with thinner chest walls, and may not be visible in all people
• What is seen is an early systolic pulsation with a rapid upstroke and down stroke
• A late systolic retraction, 1-2 cm long, in the fourth or fifth ICS may also be normally seen and is produced by ventricular emptying

Abnormalities In Precordium Inspection

• Apical impulse below 5th ICS, lateral to the MCL or seen in more than one ICS,a sternal rise that is sustained after systole begins can be indicative of ventricular enlargement
• Pulsation over the 2nd right ICS can indicate aortic aneurysm
• Pulsation over the 2nd left ICS can represent increased filling pressure or flow in the pulmonary artery
• Paradoxical movement of the left anterior precordium can represent a left ventricular aneurysm