In most cases, palpation has replaced percussion in the estimation of cardiac size. When you cannot feel the apical impulse, however, percussion may suggest where to search for it. Occasionally, percussion may be your only tool. Under these circumstances, cardiac dullness often occupies a large area. Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th, and possibly 6th interspaces.
A markedly dilated failing heart may have a hypokinetic apical impulse that is displaced far to the left. A large pericardial effusion may make the impulse undetectable.
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