If an impulse is palpable, assess its location, amplitude, and duration. A brief systolic tap of low or slightly increased amplitude is sometimes felt in thin or shallow-chested persons, especially when stroke volume is increased, as by anxiety.
A marked increase in amplitude with little or no change in duration occurs in chronic volume overload of the right ventricle, as from an atrial septal defect.
An impulse with increased amplitude and duration occurs with pressure overload of the right ventricle, as in pulmonic stenosis or pulmonary hypertension.
In patients with an increased anteroposterior (AP) diameter, palpation of the right ventricle in the epigastric or subxiphoid area is also useful. With your hand flattened, press your index finger just under the rib cage and up toward the left shoulder and try to feel right ventricular pulsations.
In obstructive pulmonary disease, hyperinflated lung may prevent palpation of an enlarged right ventricle in the left parasternal area. The impulse is felt easily, however, high in the epigastrium and heart sounds are also often heard best here.
Asking the patient to inhale and briefly stop breathing is helpful. The inspi-ratory position moves your hand well away from the pulsations of the abdominal aorta, which might otherwise be confusing. The diastolic movements of S3 and S4, if present, may also be felt here.
The Left 2nd Interspace—Pulmonic Area. This interspace overlies the pulmonary artery. As the patient holds expiration, look and feel for an impulse and feel for possible heart sounds. In thin or shallow-chested patients, the pulsation of a pulmonary artery may sometimes be felt here, especially after exercise or with excitement.
A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary artery. A palpable S 2 suggests increased pressure in the pulmonary artery (pulmonary hypertension).
The Right 2nd Interspace—Aortic Area. This interspace overlies the aortic outflow tract. Search for pulsations and palpable heart sounds.
A palpable S 2 suggests systemic hypertension. A pulsation here suggests a dilated or aneurysmal aorta.
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