Precordial inspection and palpation: apex beat, heaves and thrills !

Exam technique

Looking at and feeling the chest over the heart tells a lot: where the apex beats, whether a ventricle is enlarged and whether a murmur vibrates.

Updated 2026-11-01

See it in 3D: Left ventricle · Right ventricle · Sternum · Ribs (back part)

What it is

This is the part of the cardiac exam done with eyes and hand before the stethoscope. The apex beat reflects the left ventricle; a parasternal heave, the right ventricle; a thrill is a murmur loud enough to feel. Together they point to chamber size and overload.

Landmark anatomy

The normal apex beat is the left ventricular apex striking the chest wall in the left fifth intercostal space, at or just inside the midclavicular line.
The right ventricle lies behind the sternum and the lower left sternal border, so its enlargement is felt there.
The sternal angle (of Louis) marks the second costal cartilage: count the intercostal spaces from there.

Technique, step by step

Position the patient supine with the chest uncovered, the head of the bed at about 30 degrees and good tangential light.
Inspect the precordium: chest wall deformities, scars, visible pulsations at the apex, left sternal border and epigastrium.
Find the apex beat with the palm, then with two fingertips, in the left fifth intercostal space near the midclavicular line.
If it cannot be felt, turn the patient to the left lateral decubitus (the apex shifts toward the axilla: use it for quality, not position).
Describe location, diameter (normally coin-sized, one interspace), amplitude and duration.
Rest the heel of the hand on the lower left sternal border to feel for a right ventricular heave.
Palpate the four auscultation areas with the palm for thrills and for a palpable second sound at the pulmonic area.

Abnormal findings

Apex displaced down and out, diffuse: left ventricular dilation (volume overload: mitral or aortic regurgitation, dilated cardiomyopathy).
Sustained, forceful apex in its normal place: pressure-overload hypertrophy (aortic stenosis, hypertension, hypertrophic cardiomyopathy).
Left parasternal heave: right ventricular hypertrophy or dilation (pulmonary hypertension, mitral stenosis, atrial septal defect).
Thrill: a murmur of grade 4 or more; a palpable second sound at the pulmonic area suggests pulmonary hypertension.
Impalpable apex: obesity, hyperinflated COPD chest, pericardial effusion or simply a thick chest wall; not abnormal on its own.

Common errors

Locating the apex in left lateral decubitus and recording it as if supine.
Miscounting the interspace by not starting from the sternal angle.
Examining through clothing or with cold hands: thrills are missed and the patient is uncomfortable.

Test yourself

Think of the answer, then tap the question to see it.

Where is the apex beat normally felt in an adult?

In the left fifth intercostal space, at or just inside the midclavicular line, about coin-sized.

What does a diffuse apex beat displaced toward the axilla suggest?

Left ventricular dilation from volume overload, such as mitral regurgitation, aortic regurgitation or dilated cardiomyopathy.

What does a palpable thrill over an auscultation area mean?

A murmur of grade 4/6 or louder; the vibration is felt with the palm.

Add to my cards (3)

See it in 3D

The structures of Durgical's 3D anatomy where it is found.

← All of the clinical exam

Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024); 18.2 Cardiovascular System - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024).

Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake

Representative model, for educational purposes only.