After the chest has been palpated with the fingertips, the examiner uses the proximal portion of his or her hand to palpate for any large area of sustained outward motion, called a heave or lift. The examiner again palpates each of the four main cardiac areas. The technique for assessing heaves is demonstrated in Figure 14-29. The presence of a right ventricular rock, which is a
sustained left parasternal impulse associated with lateral retraction, is suggestive of a large right ventricle.
Any condition that increases the rate of ventricular filling during early diastole can produce a palpable impulse that occurs after the main left ventricular impulse. This second impulse in the area of the PMI is usually felt in association with an S3. Frequently, an S3 is more easily felt than heard.
The use of a tongue blade or an applicator stick can be helpful to reinforce visually what has been palpated. The tip of the stick is placed directly over the area and held in place by the examiner's finger. This acts as a fulcrum, and the motions tend to be magnified by the movement of the stick. The technique is demonstrated in Figure 14-30.
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