[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Precordial inspection and palpation: apex beat, heaves and thrills [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # 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](https://durgical.com/en/anatomy/left-ventricle/) · [Right ventricle](https://durgical.com/en/anatomy/right-ventricle/) · [Sternum](https://durgical.com/en/anatomy/sternum/) · [Ribs (back part)](https://durgical.com/en/anatomy/ribs/) ## Key points - Normal apex: left fifth intercostal space, midclavicular line, small, one interspace. - Displaced and diffuse = dilation (volume); sustained in place = hypertrophy (pressure). - Left parasternal heave = enlarged right ventricle. - Thrill = murmur grade 4/6 or louder. ## 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. ## Memory aid 'Moves when it grows, pushes when it thickens': a dilated ventricle shifts the apex; a hypertrophied one makes it sustained. ## 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)](https://durgical.app/estudiar/?add=/en/clinical-exam/precordial-inspection-and-palpation-apex-beat-heaves-and-thrills/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Left ventricle](https://durgical.com/en/anatomy/left-ventricle/) - [Right ventricle](https://durgical.com/en/anatomy/right-ventricle/) - [Sternum](https://durgical.com/en/anatomy/sternum/) - [Ribs (back part)](https://durgical.com/en/anatomy/ribs/) ## Related - [Cardiac auscultation: the areas and the order](https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/) - [Murmurs: timing, grade, location and radiation](https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/) - [Heart sounds: S1, S2 and its splitting, S3 and S4](https://durgical.com/en/clinical-exam/heart-sounds-s1-s2-and-its-splitting-s3-and-s4/) - [Heart failure syndrome: left- and right-sided signs](https://durgical.com/en/clinical-exam/heart-failure-syndrome-left-and-right-sided-signs/) ## Related conditions - [Heart failure](https://durgical.com/en/conditions/heart-failure/) - [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/) - [Hypertrophic cardiomyopathy](https://durgical.com/en/conditions/hypertrophic-cardiomyopathy/) - [Pulmonary hypertension and cor pulmonale](https://durgical.com/en/conditions/pulmonary-hypertension-and-cor-pulmonale/) - [Dilated cardiomyopathy](https://durgical.com/en/conditions/dilated-cardiomyopathy/) [← All of the clinical exam](https://durgical.com/en/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](https://openstax.org/books/clinical-nursing-skills/pages/24-3-nursing-assessment) (OpenStax (Rice University), 2024); [18.2 Cardiovascular System - Clinical Nursing Skills | OpenStax](https://openstax.org/books/clinical-nursing-skills/pages/18-2-cardiovascular-system) (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. --- Source: https://durgical.com/en/clinical-exam/precordial-inspection-and-palpation-apex-beat-heaves-and-thrills/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/precordial-inspection-and-palpation-apex-beat-heaves-and-thrills/