Apex (clip six)
by Franklin B Saksena, Ranganathan Narasimhan, Sivaciyan Vahe

The Art and Science of Cardiac Physical Examination (With Heart Sounds, Jugular and Precordial Pulsations)

by Narasimhan Ranganathan, Vahe Sivaciyan, Franklin B Saksena
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This recording is made in a patient with severe primary pulmonary hypertension. The recording demonstrates the sustained right ventricular impulse pushing the tips of the fingers of the examiner's hand placed in the sub-xiphoid area on deep held inspiration. Careful observation may reveal the presence of a jerky movement with a little step on the outward movement. This was the atrial kick that this patient in fact had in the sub-xiphoid region indicating decreased right ventricular compliance and strong right atrial contraction. The technique of sub-xiphoid palpation for the right ventricular impulse involves placing the hand on the epigastrium with the fingers pointing towards the head of the patient. One needs to get the hand in place during the expiratory phase and then instruct the patient to take a deep breath. On deep inspiration, the diaphragm will descend and with it the right ventricle. If the latter were abnormal with significant pressure and/or volume overload, then one will be able to appreciate its impulse pushing the finger tips downward (towards the direction of the feet). If one feels the impulse hitting the palmar aspect of the fingers, then it will be most likely aortic pulsation and not likely to be right ventricular. In children one may be able to feel the normal right ventricle by this method. However, in the normal adult, one will not be able to feel any impulse by the sub-xiphoid palpation. Thus if one feels the right ventricular impulse by sub-xiphoid palpation in an adult, then one has an abnormal right ventricle with either pressure and/or volume overload.

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