The document provides information on performing a precordial examination, including history, examination technique, inspection, palpation, and auscultation. It discusses examining the apical impulse in detail, including location, duration, size, force, and variations such as absence, tapping, hyperdynamic, and heaving. Characteristics and causes of a displaced or diffuse apical impulse are also covered.

1. PRECORDIAL EXAMINATION-
BASICS
Presentor- Dr.G.APARANJI
DM CARDIOLOGY RESIDENT
@SJICR,BANGALORE

2. Objectives
 History
 Introduction
 Examination technique
 Inspection
 Palpation
 Percussion
 auscultation

3. HISTORY
 Egyptian physicians and priests employed the technique of
palpation, and it was one of the techniques of the examination in
the ancient Greece.
 Practice of precordial palpation was recorded in the Ebers papurus
(1500 BC).
 William Harvey (1628) was familiar with the movements of the
chest wall and described, “Motion of the heart”.
 Jean Nicolas Corvisart, French physician pioneered the art of
bedside inspection and palpation of the precordium.

4. INTRODUCTION
 Precordium: It is the area of the anterior chest overlying the
heart.
 cardiac motion is represented by the apex beat or apex impulse,
which is produced by systolic contraction of the left ventricular
free wall and septum.
 Right ventricular activity is usually not palpable.
 When cardiac hypertrophy or dilatation is present, abnormal
systolic and diastolic events emanating from the left or right
ventricle may be detected on palpation and, on unusual
occasions, left and right atrial impulses may be felt.

6. LANDMARKS

7. Borders of the heart

8. Examination Technique
 Inspection:The subject should be lying comfortably in the
supine position or with the thorax elevated no more than
30 degrees.
 Examine the thorax tangentially, first from the foot end of
the bed and then from the patient’s right side directing a
beam of light across the precordium.

9.  Palpation of the precordium : is performed from the right side of
the supine patient with the upper trunk elevated to 300 and the
chest completely exposed.
 Palpation of the apex should also be done in the left lateral
position, rotated 45–600, which causes the heart to move laterally
and increases the palpability of apex.

11. INSPECTION
 Inspection of the anterior chest and precordium includes:
1. Examination of the chest: for its shape, symmetry , position of
the trachea
2. Examination of the precordium for any precordial bulging
3. Scars
4. Retraction
5. Distended vessels over the chest and back

12. 6. Examination of the cardiovascular pulsations
 Apex beat
 Left parasternal pulsations
 Pulsations in the right and left 2nd intercostal spaces (aortic and
pulmonary areas)
 Pulsations in the right and left sternoclavicular area
 Pulsations in the epigastrium
 Pulsations in ectopic areas.

13. Chest abnormalities
 The normal chest in an adult is bilaterally symmetrical and
elliptical in cross section
 Transverse diameter more than the AP diameter
Shape of the chest Causes
1. Barrel shape COPD
2. Muscular thorax with thin lower
limbs
Coarctation of aorta
3. Shield chest (broad chest) Turner and Noonan syndromes
4. Pigeon chest (pectus
carinatum)
Marfan and Noonan syndromes
5. Funnel chest (pectus
excavatum)
Marfan, Ehler-Danlos, Hunter-
Hurler syndromes and
Homocystinuria

14. Pigeon chest
Pectus excavatum

15. Precordial bulging
indicates RVH presenting since childhood
Precordial bulging Causes
1. Cardiac Pericardial effusion, cardiomegaly
2. Non-cardiac Skeletal abnormality: scoliosis,
kyphoscoliosis, rickety chest,
bronchogenic carcinoma,
mediastinal new growth
Precordial bulging due to
kyphoscoliosis

16. Cardiovascular pulsations

17. Apex beat
 DEFINITION - The outermost and lowermost area of definitive
cardiac impulse in early systole, which imparts a perpendicular
gentle thrust to a palpating finger, followed by medial retraction in
the late systole.
 Examined for location, extent and retraction
 In normal persons there may be a slight retraction of the thorax
medial to the apex impulse
 Whereas in hyperdynamic states and LV enlargement this
retraction becomes accentuated and assumes a rocking character.

18. Left Parasternal Pulsations
 RV inflow portion underlies the 4th and 5th intercostal space
 Outflow portion (infundibulum) lies behind the 3rd left
intercostal space.
 In normal adults , RV activity is neither visible nor palpable as
it retracts away from the anterior chest wall during systole.

19. Due to right ventricular
hypertrophy
Normal right ventricle
1. Pressure over-load :
Pulmonary hypertension
Primary pulmonary
hypertension Pulmonary
stenosis
1. Mod-severe mitral regurgitation
(squid effect)
2. Volume over-load:
Tricuspid regurgitation
(moderate)
ASD, VSD
2. Regional wall motion abnormality
(RWMA) of left ventricle

20. Pulsations in the (Aortic Area) Right and Left
(Pulmonary Area) 2nd Intercostal Spaces
Aortic area Pulmonary area
1. Aneurysm of ascending aorta 1. PH of any cause: mitral stenosis,
primary pulmonary hypertension
2. Chronic aortic regurgitation 2. Pulmonary artery dilatation:
idiopathic
or aneurysmal
3. Dilatation of ascending aorta 3. Increased pulmonary blood flow:
PDA,
ASD
4. Hyperdynamic circulation: fever,
pregnancy

21. Pulsations in the Sternoclavicular Area
Sternoclavicular pulsations Suprasternal pulsations
1. Aortic dissection 1. Aneurysm of arch of aorta
2. Aneurysm of aorta 2. Thyroidea ima artery
3. Aortic regurgitation 3. thyrotoxicosis
4. Right aortic arch 4.Coarctation of aorta
5. Blalock-Taussig shunt

22. Pulsations in the Epigastrium

23. Distended Vessels Over the Chest and Back
1. Veins -Distended veins on the anterior chest wall (with
caudal flow) suggest obstruction of superior vena cava,
while the distended veins with cranial flow indicate inferior
vena caval obstruction.
2. Prominent venous collaterals around the shoulder occur in
subclavian or axillary vein obstruction.

24. SVC Obstruction
Subclavian vein obstruction

25. 1. Arteries
 Collateral vessels may be seen in the interscapular
and infrascapular regions or in the posterior intercostal
spaces and are palpable in patients with coarctation
of aorta, when the patient stands and bends forward
with arms hanging down by the sides (Suzman’s sign).

26. Suzman’s sign

27. SCARS

28. PALPATION
 Apical impulse
 Position of trachea
 Parasternal heave/lift
 Thrills
 Palpable sounds/shocks
 Pulsations
 Direction of flow in veins
 Tenderness

29. Examination Technique
 Palpation of the precordium is performed from the right side of
the supine patient with the upper trunk elevated to 300 and the
chest completely exposed.
 Palpation of the apex should also be done in the left lateral
position, rotated 45–600, which causes the heart to move
laterally and increases the palpability of apex.

30.  High frequency movements such as ejection sounds, valve
closure sounds, mitral opening sounds and thrills are more
easily detected with the palm and proximal metacarpals held
firmly against the chest.
 the low frequency movements such as ventricular diastolic
filling events (S3, S4) are best felt by applying light pressure
with the fingertips.

31. Areas of palpation image

32. General rule
 Finger tips-to feel pulsations
 Base of fingers- Thrills
 Base of hand
or - Heaves
ulnar aspect

33. Apical impulse
 Definition-The outermost and lowermost point of maximum
impulse (PMI)/definitive cardiac impulse in early systole, which
imparts a perpendicular gentle thrust to a palpating finger,
followed by medial retraction in the late systole.
 In some patients, the most prominent or "maximal" impulse
may actually reflect ectopic LV motion, right ventricular
activity, or a vascular impulse, all of which are located at sites
distant from the true LV apex impulse.
 Retraction is better seen than felt.

34.  Mechanism: Anterior and counter clock-wise rotation of LV during
early systole lifts the apex and makes contact with the anterior chest
wall
 Intraventricular septum and anterolateral aspect of LV makes
contact with the precordium.
 Medial retraction during late systole is due to recoil of the heart as it
rotates clock-wise with the completion of the ejection.
 Coincides with opening of aortic valve and beginning of ejection

35. APICAL IMPULSE

36.  The impulse is sustained for a brief period (up to 0.08 seconds)
and then the outward movement ceases as the LV apex moves
inward
 The "true" anatomic LV apex actually is slightly lower and more
lateral than the palpable apical impulse.

38. Features Of Normal Apical Impulse
 Gentle , nonsustained tap
 Early systolic anterior motion that ends before the last third of systole.
 Located within 10 cm of the midsternal line in the 4th/5th ICS / within
7 to 8 cm from the left sternal edge
 Palpable Area 0f less than 2.0-2.5 cm2
 Detectable in only one ICS
 Right ventricular activity normally not palpable
 Diastolic events not palpable
 May be completely absent in older persons

39.  In tall, thin persons, the apex beat can be distal (6th interspace)
and more medial than usual
 There may be respiratory alteration in the amplitude of the
apical beat; peak amplitude occur during end expiration
 In the left lateral decubitus position the point of chest wall
contact of the apex beat is usually slightly more lateral and
inferior than in the supine position
 Character of apex better felt in left lateral decubitus position
 An apical impulse of 3 cm in area or greater in the left lateral
position is specific for left ventricular enlargement

40. What to look for
 The assessment of the apical cardiac impulse includes:
 (1) location-
- Note in which intercostal space the PMI or apex beat is located
- Localize the apical impulse with reference to the midclavicular
line, distance from the midsternum, or relationship to the left
anterior axillary line.
 (2) duration-
-The duration of the systolic outward motion is
probably the most important feature of the precordial exam
- sustained apex impulse in the supine position more sensitive than
the EKG in the diagnosis of left ventricular hypertrophy.

41.  The critical point to assess is whether or not the impulse "stays up" into the
second half of systole. Proper timing of the apex beat using simultaneous
auscultation of Sl and S2 is essential
 (3) size- Any impulse greater than 2 to 2.5 cm in the supine position, or more
than 3 cm in the left decubitus position, represents cardiac enlargement.
 (4) force or amplitude- An increase 'in force is consistent with LV hypertrophy
and preserved systolic function
 (5) contour - The normal apical impulse consists of a brief, nonsustained anterior
motion in early systole

43. Character of the Apical impulse
 The cardiac apex may be:
 Absent or feeble
 Tapping
 Hyperdynamic
 Heaving.

44.  TAPPING APEX
 A shortened outward movement of the apex during early
systole due to the reduced ventricular filling during diastole
gives the apex beat its sharp, short and tapping nature in
mitral stenosis.
 Palpable first heart sound

45.  Hyperdynamic/hyperkinetic/forceful apex beat
There is an increase in amplitude and duration of excursion of the
apical impulse, but is ill sustained i.e. duration of excursion is less
than 50% of systole with partial lifting of the examining fingers.
 In severe volume overload states, particularly with depression of LV
contractility and a decreased ejection fraction, the LV impulse may
become prolonged or sustained into the second half of systole .
 This response may be due both to a longer duration of LV ejection
and more globular chamber configuration

46.  Heaving/sustained apex beat
There is a sustained increase in amplitude and duration of
excursion( greater than 50% of systole) with sustained lift of
the examining fingers.
 The force of contraction is increased, but there is relatively
little chamber dilatation. Thus, the apex impulse is not usually
displaced but has an increased force.

47. VOLUME OVERLOAD PRESSURE OVERLOAD
Increased amplitude without change
in the contour
Increased duration of apical impulse
Downward and outward movement
of apex
Apex undisplaced
Features Heaving Hyperdynamic
Time Increased Normal
Amplitude Increased Increased
Duration >2/3 Of Systole >1/3 to <2/3 Of Systole
Location Occupies One ICS Occupies more than
One ICS
Causes Pressure Overload
Eg.
AS,HTN,HCM,coarctati
on Of Aorta
CAD-LV aneurysm,
severe LV dysfunction
Volume Overload-e.g.
AR,MR,VSD,PDA,
High output states

49. VARIATIONS OF THE APICAL IMPULSE
 Absent Apical Impulse: Could be due to
Non Cardiac Causes
 Behind the rib
 Muscular chest wall
 Obesity
 COPD including emphysema with barrel chest
 Left pleural effusion.
 Age 50 or over

50.  Cardiac causes
 Pericardial effusion.
 CAD with decreased apical motion
 Dextrocardia
 Double Apical Impulse
● HOCM (could be double or triple apical impulse)
● LV dyssynergy or LV aneurysm.

52. Video of double apical impulse

53. Displacement of Apical Impulse
Lateral displacement is often due to:
● Skeletal abnormalities: scoliosis, straight back syndrome, marked
pectus excavatum.
● Intrathoracic pathology: massive right-sided pleural effusion,
right-sided pneumothorax, or left lung collapse/fibrosis.
● Eccentric LVH due to mitral regurgitation or aortic regurgitation:
apical impulse is displaced outwards and downwards.
● RVH, e.g. due to mitral stenosis apical impulse is displaced
laterally.

54. LV vs RV Apical Impulse
LV APICAL IMPULSE RV APICAL IMPULSE
Down and outward outward
Localised Diffuse
Retraction noted medial to apex, apex
retracts laterally
Retraction noted lateral to apex, apex
retracts medially

55. Upward displacement
 In children; in 4th left intercostal space
 Intra-abdominal causes: ascites, massive abdominal tumor,
or advanced pregnancy.
 Pericardial effusion: (fluid, first collects in the lower portion
of the pericardial sac.)
Downward displacement
 Aortic aneurysm
 Mediastinal new growth

56. Right-sided apical impulse
● dextrocardia
● left-sided massive pleural effusion or pnuemothorax and
right lung collapse.
● Skeletal abnormalities such as scoliosis

57. Lateral Retraction of the Apical Impulse (Skoda’s Sign)
● Right ventricular hypertrophy (RVH), when RV occupies the
apex
● Adhesive pericarditis.
(Broadbent’s sign: It is a systolic in-drawing or retraction of 10th
and 11th left intercostal spaces, in the scapular or posterior
axillary line.)

58. Extent of Apical Impulse
 Diffuse apical impulse of >3 cm in diameter or apical impulse present
in more than one intercostal space may be due to:
Cardiovascular causes:
 Eccentric LVH as in aortic regurgitation
 LV aneurysm.
Non-cardiovascular causes:
 Subjects with thin chest wall
 Hyperdynamic circulation: fever, thyrotoxicosis
 Retraction of the lung due to fibrosis or collapse.

61. RV Examination
 The movements of the
examining hand and
fingers should be
carefully observed as
the low amplitude RV
activity is better seen
than felt

62. Subxiphoid palpation

63.  permits the detection of
gentle RV systolic
impulses but also
localizes the
movements to the inflow
portion (4th and 5th
ICS) or to the
infundibulum/outflow
portion (3rd ICS)

64. PARASTERNAL HEAVE/LIFT/IMPULSE
 In the normal subject, parasternal activity is usually not detectable
except in young or thin individuals.
 Forceful, sustained, or high amplitude parasternal motion is always an
abnormal finding
 Right ventricular abnormalities are only detectable in the supine
position.
 RV activity is usually low amplitude, it will not be detected without firm
compression.
 Held end expiration may be very useful in detecting a subtle or slight RV
lift.

65. AIIMS GRADING OF PARASTERNAL IMPULSE
 GRADE I- Visible but not palpable
 GRADE II- Visible and palpable and obliterable
 GRADE III- Visible and palpable but not obliterable
 CAUSES
 RV enlargement
 Left atrial enlargement

66. GRADE 1
 Light objects such as pencil
or scale kept along the
parasternal region, may make
it obvious.
 It disappears with the
application of mild counter
pressure.
 It is short of systole i.e. ill
sustained,<1/3rd of systole.
 1. Normal children and young
adults
 2. Thin chest wall
 3. Pectus excavatum

67. Grade 2
 An obvious lift that can be easily made out.
 It disappears/diminishes with the application of moderate
counter pressure.
 It is not well sustained i.e.>50% of systole but not throughout
the systole.
 It is usually seen in:
– RV volume overload conditions such as tricuspid
regurgitation, ASD, VSD
– Mild-moderate pulmonary hypertension of any cause e.g.
moderate mitral stenosis, left ventricular failure, left to right
shunts (VSD, PDA)
– Moderate-severe mitral regurgitation due to jet/squid effect.

68.  MR: Apparent RV impulse due to
systolic expansion of the left atrium
that displaces RV anteriorly. Out of
synchrony with LV apex
 PSL occurs in the second half of
systole following S1 and after the
cardiac apex is felt.
 It is short in duration (ill sustained)
and more diffused and indicates a
non compliant enlarged left atrium.

69. Dilated Atrium vs RV heave: In the former parasternal pulsation occurs
in the later part of systole after LV impulse is felt; in the later,parasternal
impulse occur together with LV apical impulse and is sustained
throughout systole.

70. GRADE 3
 It is a very prominent parasternal lift.
 Application of moderate counter pressure does not diminish the
PSL.
 It is well sustained i.e. PSL is present throughout the systole and
beyond A2.
 Characteristic of RV pressure overload conditions such as:
– Pulmonary stenosis (moderate-severe)
– Severe pulmonary hypertension due to severe mitral stenosis,
left to right shunts (PDA, VSD) and left ventricular failure.

71. No PSL in TOF: There is no PSL in RVH due to TOF
● As it can decompress easily into the overriding of aorta and
through VSD and
● RV is not excessively dilated

72. THRILLS

73. Palpable Murmurs—Thrills at the Apex
 Diastolic or presystolic thrill :
 Diastolic thrill of mitral stenosis is highly localized to the apex, which generally
indicates mobile and non-calcified mitral valve.
 Systolic thrills:
 These are not common at the apex. They may occur due to:
 Severe mitral regurgitation especially due to chordal rupture.
 Aortic stenosis: Thrill may be traced from 2nd right ICS to the apex and may
get conducted to the carotids. However, it may only be felt at the apex in
calcified aortic stenosis in the elderly patients.
 VSD: It is better felt in the 3rd–4th ICS at the left sternal edge.

74.  Palpable pericardial rub: It occurs in acute pericarditis and is best
felt at the left sternal border in sitting and leaning forward
positions.
 Thrills in tricuspid area
 Patient should be in supine position with right lateral rotation.
 Occasionally, diastolic thrill of organic tricuspid stenosis and rarely,
systolic thrill of severe tricuspid regurgitation may be palpable.

75. Palpable Murmurs—Thrills In aortic area
● Systolic thrill in the aortic area ccurs in aortic stenosis, which
may be conducted to the carotids.
● Rarely, a diastolic thrill may be palpable due to dilated aortic
root as in Marfan syndrome.
● Palpable diastolic thrill of aortic regurgitation along the left
sternal edge in the 3rd ICS (neo aortic area)  perforation or
eversion of an aortic cusp

76. Thrills In pulmonary area
● Systolic thrill in the pulmonary area may be felt in pulmonary
stenosis in sitting and leaning forward positions in held
expiration, while thrill of infundibular pulmonary stenosis is
best felt in the left 3rd ICS.
● Continuous thrill of PDA is felt maximal beneath the left
clavicle, which begins in systole, is reinforced before and after
S2 and proceeds into the diastole without interruption.
● Graham Steel murmur (early diastolic) of high pressure
pulmonary regurgitation may be palpable.

78. PALPABLE SOUNDS-SHOCKS

79. Palpable High Frequency Sounds at the Apex
 Opening snaps, tumor plops and ejection sounds (clicks) are best felt by
applying firm pressure to the chest with palm and proximal metacarpals
 Palpable loud S1: It occurs due to mitral stenosis, tapping type of apex beat
 Palpable opening snap: It occurs in early diastole due to mitral stenosis
with pliable mitral valve.
 Palpable tumor plop: early diastolic sound due to abrupt decelerationof a
mobile pedunculated LA or RA myxoma as the tumor sits in the mitral or
tricuspid orifice.
 Palpable ejection sounds
Ejection sound (click) of congenital aortic stenosis sometimes more readily
palpable over the apex than in the 2nd right intercostal space (ICS).

80. Low frequency sounds
 Low frequency sounds such as S3, S4 and pericardial knock are
best felt by light palpation with fingertips in held expiration, but
firm pressure would dampen them.
 PALPABLE S3-A palpable S3 is found in patients with a major
elevation in LV filling pressure and LV end-diastolic volume.
Typically, these hearts have a decreased ejection fraction
 In subjects with an increased volume and rate of blood flow
crossing the mitral valve, an S3 may be audible and palpable in
the presence of good left ventricular function-MR

81. Palpable LV S3
o Left ventricular failure
o Chronic mitral regurgitation
o Physiological: Children and pregnancy
o Hyperkinetic circulatory states: Anemia, thyrotoxicosis
Palpable pericardial knock:
It occurs in constrictive pericarditis with systolic retraction of
whole of the pericardium especially in the left 10th and 11th
intercostal spaces in the posterior axillary/scapular line
(Broadbent’s sign)

82.  Palpable LV S4
 Presystolic atrial contraction, felt in the non-compliant LV
when the left ventricular end diastolic pressure (LVEDP) is 15–
18 mmHg.
 Palpable S4
1. Aortic stenosis
2. Hypertrophic cardiomyopathy
3. Acute mitral regurgitation and acute
aortic regurgitation
4. CAD- Acute or chronic-Increased diastolic stiffnes

83. Tricuspid area
 Palpable Low Frequency Sounds
-RV S3 and S4 may be palpable in inspiration which is
attenuated or even disappears during expiration.
● RV S3 usually indicates RV dysfunction or failure, chronic
severe tricuspid regurgitation and ASD
● RV S4 is associated with pulmonary stenosis, decreased RV
compliance secondary to pulmonary hypertension.
 Palpable High Frequency Sounds
 Opening snap of organic tricuspid stenosis is sometimes
palpable with the fingers firmly applied in this area or in the
epigastrium.

84.  Palpation of Aortic and Pulmonary Areas
Palpated in the sitting and leaning forward positions in held
expiration, which increases the palpability of these areas .
 Palpable High Frequency Sounds
In aortic area: Palpable A2 in the aortic area occurs in
● Systemic hypertension, dilated aortic root and moderate aortic
stenosis
● Cyanotic congenital heart disease: When pulmonary trunk is small
as in TOF or when the aortic root is anterior to the pulmonary trunk
as in transposition of greatarteries (TGA).

85.  Palpable ejection sound originating in the dilated aortic root.
 Ejection sound of congenital aortic stenosis(bicuspid aortic valve) is
sometimes more readily palpable over the apex than in the right 2nd
ICS and should be differentiated from a loud S1.
 In pulmonary area
- Palpable P2 in the pulmonary area occurs in pulmonary
hypertension of any cause.
- Palpable ejection sound in the pulmonary area occurs in
pulmonary stenosis during normal expiration.

86.  Palpation of Sternoclavicular Areas
 Continuous/systolic thrill is palpable on the left side due to Blalock-
Taussig shunt operation, while it is felt on the same side in the modified
shunt operation.
 Palpation of Epigastrium
 The subxiphoid region, which allows the palpation of RV, should be
examined with the tip of the index finger. It should be done during held
inspiration and in supine position.
 While palpating the epigastrium, the pulsations due to RV hypertrophy
are felt by the fingertip, aortic pulsations by the palmar surface and
hepatic pulsations by the lateral surface of the examining index finger.

88. Palpation in the Ectopic Areas
 Ectopic LV Impulse
 It is usually palpable superior and medial to the normally
expected cardiac apex
 Due to dyskinesia of CAD, during the episodes of angina
pectoris or after acute myocardial infarction
 Ventricular aneurysm: Persistent paradoxical palpable ectopic
pulsations due to ventricular aneurysm because of myocardial
infarction or trauma.

89.  Ectopic LA Impulse
 In patients with severe mitral regurgitation with giant LA that
extends to the right, ectopic systolic pulsations of the enlarged LA
may be felt in the right anterior or lateral chest or in the left
axilla.
 Ectopic RA Impulse
 Normally RA impulse is not visible or palpable.
 if RA is enlarged as in tricuspid regurgitation, systolic expansion
of the enlarged RA may be palpable in the entire right lower chest
especially in the 4th right ICS.
 Due to PDA Palpable ectopic impulse beneath the left clavicle in
patients with PDA.

90. PRECORDIAL FINDINGS IN
COMMON HEART DISEASES

91. MITRAL STENOSIS

92. MITRAL REGURGITATION

93. AORTIC STENOSIS

94. AORTIC REGURGITATION

95. Hypertrophic Cardiomyopathy
 Left ventricular compliance is markedly decreased. Thus, the A
wave typically is very prominent and the left ventricular impulse
is forceful and vigorous
 A mid or late systolic secondary "bulge" may be present,
resulting in a double or bifid precordial impulse.
 When the A wave is palpable, the precordial motion actually
with be trifid in nature ("triple ripple")
 Systolic thrill superior and medial to apex.

96.  Cardiomyopathy: Sustained apex,palpable S3,
Presystolic A wave may be palpable
 ACS: palpable S4
 Old MI: Late systolic motion suggesting LV
dyssynergy
 ASD: hyperdynamic RV type apex. Palpable P2
 TR: parasternal heave,pulsations in right lower
parasternal area,hepatic pulsation with each
cardiac cycle

97. THANK YOU