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A HOW-TO UPDATE AND CLINICAL REVIEW OF PROCEDURES COMMONLY PERFORMED IN THE PRIMARY CARE SETTING
How do you position the light, the patient, and yourself for optimum inspection of the precordium?
* The patient may be sitting, lying supine, or lying supine with the head of the examining table elevated by 30-45°
* The light should be tangential to the precordium
* You should examine the precordium at a tangential angle (see Figure 24).
* What are the main things you are looking for when inspecting the precordium?
* The location and prominence of the point of maximal impulse (apex).
* The presence of a right ventricular heave.
How do you localize the point of maximal impulse by palpation?
The patient may be lying supine, lying supine with the head of the bed or examining table raised, or sitting, Best results are obtained with the sitting patient or, even better; with the sitting patient leaning forward and holding his or her breath in expiration (see Figure 25). The patient should never be in an oblique position, such as the left lateral decubitus position, when you are attempting to localize the point of maximal impulse.
Wrap the palm and fingers of your hand around the patient's left lower chest to see if you are able to feel the apical impulse (see Figure 26a). If you can, localize it more precisely with the tip of your index or long finger (see Figure 26b).
The normal apical impulse is located less than 10 cm lateral to the mid-sternal line (MSL).
In what percentage of middle-aged or elderly adults is...