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By inspection and palpation, you may detect ventricular move-

O ments that are synchronous with pathologic third and fourth heart ^^ sounds. For the left ventricular impulses, feel the apical beat gently with one finger. The patient should lie partly on the left side, breathe out, and C briefly stop breathing. By inking an X on the apex you may be able to see these movements.

A sustained low-amplitude (hypokinetic) impulse may result from dilated cardiomyopathy.

A brief middiastolic impulse indicates an S3; an impulse just before the systolic apical beat itself indicates an S4.

The Left Sternal Border in the 3rd, 4th, and 5th Interspaces— light Ventricular Area. The patient should rest supine at 30°. Place ie tips of your curved fingers in the 3rd, 4th, and 5th interspaces and try to eel the systolic impulse of the right ventricle. Again, asking the patient to wreathe out and then briefly stop breathing improves your observation.

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