The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Precordial Movements

Introduction: Observation of the chest may reveal the location of the PMI, which is usually but not always caused by the apex (hence ‘apical impulse’). Uncommonly, an enlarged right ventricle, a dilated pulmonary artery, left vertical movement associated with an S3 or S4 may cause the PMI. Palpation can confirm the presence, location, and ‘character’ of an impulse.


[Stanford 25 Video forthcoming.  Bates cardiac exam at bottom.]

Observation: tangent light with a penlight may help.

  • Note the following:
    • Precordial pulsations.
    • Precordial bulge.
    • Epigastric and other pulsations.

Palpation: finger pads are more sensitive than finger tips.

  • Note the following regarding the PMI:
    • Position.
      • Normally 5th intercostal space near the MCL.
    • Area.
      • Dime vs quarter?
    • Amplitude.
      • Normally ‘brisk’ or ‘tapping.’
      • Is it ‘heaving’ (i.e. is the ventricle doing ‘pressure’ work)?
      • Is it ‘hyperdynamic’ (i.e. is the ventricle doing ‘volume’ work)?
    • What is its character or shape (double in HOCM, etc)?

      Apex Cardiogram. Click for image credit via Wikimedia Commons.

      • Being able to draw a normal apex cardiogram (see image) allows one to better understand what one is feeling. Apex-cardiogram. A = left ventricular filling; C = systolic wave; E point = systolic peak; O point = start of rapid filling (mitral valve open); F = start of slow filling (diastasis).
    • Parasternal heave.
    • Pulsations in the pulmonic area (i.e. L 2nd interspace).
      • Prominent impulse suggests pulmonary hypertension.
    • Thrill.
      • Commonly felt in areas producing loud murmurs.


  • Hyperkinetic impulse: normal location, dime-sized diameter, forceful amplitude, lasts less than 2/3rd of systole.
  • Pressure overload: normal location, dime-sized diameter or smaller, forceful amplitude, lasts through S2.
  • Volume overload: location displaced laterally, quarter-sized diameter, diffuse amplitude.

Embedded Videos & Links (Not produced by Stanford, follow video app link for credit and source).

Clinical cardiac evaluation (good examples of a heave later) in Blaufuss Tutorial.


Written by stanford25admin

June 7, 2010 at 3:30 pm

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