The heart during systole, becoming smaller, generally withdraws from the chest wall except for the apex for the reasons explained above. The effect of this withdrawal on the chest wall can be observed as an inward movement of the chest wall during systole called "retraction." Although the heart is basically comprised of two separate pumps (right and left ventricles), these two pumps operate normally at two vastly different pressures. Left ventricular systolic pressures being approximately five times higher than that of the right ventricle, its wall tension is much higher, resulting in the increased wall thickness of the left ventricular chamber. The effect of the increased muscle mass on the left side leads to dominance of the left-sided hydrodynamic forces described above. This results in the left ventricular apex as the only area of normal contact during systole. The rest of the heart essentially retracts from the chest wall. In a normal heart, this retraction of the chest wall can be observed to be located medial to the apical impulse and involving part of the left anterior chest wall (20). Even the right ventricle, which is anatomically an anterior structure, is normally pulled away from the chest wall because of its own contraction (becoming smaller) and, more importantly, the septal contraction also pulling the right ventricle posteriorly. This retraction observed in normal patients is located medial to the apical impulse (23,24). It can be best appreciated with patients in the left lateral decu-bitus position with a palpating finger only on the apical impulse with clear view of the rest of the precordium for proper observation of the inward movement of the retraction (opposite in direction to the outward movement of the apical impulse). This "medial retraction" identifies and indicates that the left ventricle forms the apical impulse. The extent of the area of medial retraction may be variable depending on both cardiac and extracardiac factors such as the compliance of the chest wall. It may sometimes be noted only over a small area very close to the apex beat.

1. How to present a long case
in cardiology
Patients with CONGENITAL HEART DISEASE need a separate format

2. Contents
 Sequence Contents Explanation
 1 Demography Gender ,age ,profession and native place
 2 Chief complains With duration
 3 Present complains Details of each chief complain
 4 Past history
 5 Negative history
 6 Treatment history
 7 History of allergy
 8 Personal history
Family history
Menstrual history ,exercise/YOGA
Habits –alcohol ,smoking and tobacco
 9 Professional history
 10 Summery of history
 11 Provisional diagnosis
 12 Differential diagnosis 3 to 5 in numbers

3.  11 Provisional diagnosis Points in favour
 12 Differential diagnosis 3 to 5 in numbers
With points in favour and against
 13 General examination
 14 Cardiovascular system examination
 15 Other system examination
 16 Summery of clinical examination
 17 Provisional diagnosis Points in favour and against
 18 Differential diagnosis With points in favour and against
 19 Instigations Hemogram ,Blood culture ,ECG
,CHEST X-RAY,ECHO/TDI/SPECKLE
,cath data ,CT/MRI,PET etc

4.  20 Final diagnosis
 21 How to treat Treatment modalities with risk ratio

9. Precordium

10. Jugular venous
pulsation
• Normal is 3cm from sternal
angle
• From RA mid part to sternal
angle is 3cm

12. Apical impulse

13. Medial and lateral retraction of precordium
Medical retraction
• Medial part precordium retract
towards spine and apex
becomes closer to chest wall –LV
apex
• LVH
Lateral retraction
• Medial part of precordium
bulges out and apex becomes
diffuse –RV apex
• PAH/RVH
• ASD/PAH/PS
https://www.mitchmedical.us/cardiac-physical-examination/which-ventricle-is-causing-the-apical-impulse.html

18. In the end clinical history

20. Explain the basis
of your provisional
diagnosis
• Left or right heart lesions –
obstructive or regurgitations or
combined

26. Clinical
examinations

29. Three to five Differential diagnosis
• Be ready with points in favour
and against of provisional and
differential diagnosis

31. Happy
Friendship Day