Palpating the precordium means using your hands to feel the chest wall over the heart, checking for the apex beat, abnormal lifts, and vibrations that signal valve or chamber problems. The key landmark is the point of maximal impulse (PMI), normally felt at the fifth intercostal space near the midclavicular line. A complete precordial palpation covers six regions: the apex, the lower left parasternal border, the pulmonary area, the aortic area, the suprasternal notch, and the epigastric area.
Setting Up the Patient
Start with the patient sitting upright at about 30 to 45 degrees with the chest fully exposed. This angle lets gravity bring the heart closer to the anterior chest wall while keeping the patient comfortable. If you cannot feel the apex beat in this position, roll the patient into the left lateral decubitus position (lying on the left side). This shifts the heart toward the chest wall and makes a faint or elusive impulse much easier to detect.
Before you touch the chest, take a moment to inspect. Look for any visible pulsations, asymmetry, or scars from prior surgery. The apical impulse may or may not be visible in a healthy person, so the absence of a visible beat is not automatically abnormal.
Finding the Point of Maximal Impulse
The PMI is the single most important finding on precordial palpation. To locate it, count down the intercostal spaces from the sternal angle (the bony ridge where the manubrium meets the body of the sternum, which marks the second rib). Once you reach the fifth intercostal space, move laterally to the midclavicular line, an imaginary vertical line dropped from the middle of the clavicle.
Use your finger pads rather than your fingertips. Finger pads are more sensitive to subtle cardiac impulses. Place two or three finger pads flat against the skin and feel for a brief, tapping outward movement that coincides with systole. In a normal heart, this impulse is localized to an area roughly the size of a coin, about 2 to 3 centimeters in diameter, and lasts only the first half of systole.
What a Displaced or Abnormal PMI Tells You
When the PMI is felt lateral to the midclavicular line, it suggests the left ventricle has enlarged. This is a classic finding in dilated cardiomyopathy. Displacement can also happen with conditions that push the heart to one side, such as a large pleural effusion or tension pneumothorax. If the impulse is sustained (lasting through all of systole rather than just the first half) or feels diffuse and covers a wider area, that points toward left ventricular hypertrophy or volume overload.
Checking the Lower Left Parasternal Border
After assessing the apex, move your hand to the left of the sternum at the third and fourth intercostal spaces. Place the heel of your palm flat against the chest here. You are feeling for a parasternal heave (sometimes called a lift), which is a sustained, rolling outward push that raises the heel of your hand with each heartbeat.
A heave at this location is a palpable lifting sensation under the sternum and anterior chest wall that suggests severe right ventricular hypertrophy. The right ventricle sits directly behind this part of the chest wall, so when it thickens or dilates significantly, it transmits enough force to produce this unmistakable feeling. In a normal exam, you should not feel any sustained outward movement here.
Palpating the Aortic and Pulmonary Areas
The aortic area is the second intercostal space to the right of the sternum. The pulmonary area is the second intercostal space to the left of the sternum. Place your finger pads over each spot in turn. Normally you will feel nothing, or at most a very faint tap.
A pulsation in the right second intercostal space may indicate an aneurysm of the ascending aorta. A pulsation in the left second or third intercostal space is less common but can occur with a dilated pulmonary artery, sometimes seen in pulmonary hypertension or conditions that increase blood flow through the pulmonary circuit. Either finding warrants further investigation with imaging.
Checking the Suprasternal Notch and Epigastrium
The suprasternal notch is the shallow dip at the top of the sternum between the clavicles. Gently press a fingertip into this notch and feel for transmitted pulsations from the aortic arch. A strong pulsation here can be normal in thin patients or during exercise but may also signal aortic pathology when prominent at rest.
For the epigastric area, place your flattened fingers just below the xiphoid process (the small cartilage at the bottom of the sternum) and angle them upward behind the rib cage. You are feeling for the downward thrust of the right ventricle. Epigastric and subxiphoid movements are usually seen with right ventricular hypertrophy, right ventricular dilation, or occasionally an abdominal aortic aneurysm. This location is especially important in patients with COPD, where hyperinflated lungs push the diaphragm down and shift the cardiac impulse away from its normal position. In emphysema patients, the apex beat may not be present in its usual location at all, and the subxiphoid area becomes the primary spot to feel the heart. Research in pulmonary medicine has shown that a subxiphoid apex shift in COPD correlates with an FEV1 below 50%, indicating significant airflow obstruction.
Feeling for Thrills
A thrill is a fine vibration felt on the skin, similar to the buzzing you feel when a cat purrs or when you place your hand on a running washing machine. It represents turbulent blood flow strong enough to transmit through the chest wall and corresponds to a loud heart murmur. On the standard murmur grading scale (grades I through VI), a thrill first appears at grade IV. Any murmur below grade IV is heard with the stethoscope but not felt with the hand.
To check for thrills, use the flat of your palm or the base of your fingers rather than the fingertips. Press lightly over each of the major valve areas in sequence: the aortic area (right second intercostal space), pulmonary area (left second intercostal space), tricuspid area (left lower sternal border), and mitral area (apex). A thrill at the aortic area suggests aortic stenosis. One at the apex suggests severe mitral regurgitation or mitral stenosis. The location of the thrill helps identify which valve is involved before you even pick up the stethoscope.
Challenges in Obese or Barrel-Chested Patients
In patients with a higher body mass, a thick layer of subcutaneous tissue dampens the impulse, making the PMI difficult or impossible to feel. The left lateral decubitus position becomes essential here, as gravity brings the heart into closer contact with the chest wall. Applying slightly firmer pressure with the finger pads (without causing discomfort) can also help.
In patients with COPD or emphysema, hyperinflated lungs increase the distance between the heart and the anterior chest wall, and the flattened diaphragm displaces the heart inferiorly and vertically. The result is that the standard apex location at the fifth intercostal space may yield nothing. Always include the subxiphoid area routinely in these patients. Palpating just below the xiphoid with fingers angled upward is often the only way to detect the cardiac impulse when emphysema is moderate to severe.
Putting the Exam Together
A systematic approach ensures you do not miss anything. Work through the six regions in a consistent order each time you examine a patient:
- Apex (fifth intercostal space, midclavicular line): locate the PMI, assess its size, duration, and character
- Left lower parasternal border (third and fourth intercostal spaces): feel for a right ventricular heave
- Pulmonary area (left second intercostal space): check for pulsations or thrills
- Aortic area (right second intercostal space): check for pulsations or thrills
- Suprasternal notch: feel for transmitted aortic pulsations
- Epigastric/subxiphoid area: feel for right ventricular impulse or aortic pulsation
At each location, note whether you feel a normal impulse, an abnormal lift or heave, a thrill, or nothing at all. Combine what you feel with what you later hear on auscultation. Palpation findings like a displaced PMI, a parasternal heave, or a thrill over a valve area narrow your differential before the stethoscope even touches the skin.