How do you localize the point of maximal im-pulse by palpation?
The patient may be lying supine, or lying supine with the head of the bed or examining table raised, or sitting. Best results are obtained with the sitting patient or, even better, with the sitting patient leaning forward and holding his or her breath in expiration. The patient should never be in an oblique position, such as the left lateral decubitus position, when you are trying to localize the point of maximal impulse. Wrap the palm and fingers of your hand around the patient’s left lower chest to see if you are able to feel the apical impulse (see diagram). If you can, localize it more precisely with the tip of your index or long finger. The normal apical impulse is located less than 10 cm lateral to the mid-sternal line. The apex is palpable in the sitting position in only 20% of these patients. What is the significance of a palpable apex beat in a sitting middle-aged or elderly patient with a thick chest wall or a barrel chest? The fact that the impulse is palpable suggests cardi
