Physical Exam

Precordial Palpation

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Video coming September 2026

How to Perform

With the patient supine, palpate directly on skin with the finger pads for a thrill in the second intercostal space at the right sternal border, the second intercostal space at the left sternal border, the lower left sternal border at the fourth or fifth intercostal space, and the fifth intercostal space at the left midclavicular line. Then place the heel of your hand firmly over the lower left parasternal region, over or just to the left of the sternum, and feel for a sustained systolic lifting impulse or heave.

How to Interpret

Chronic Obstructive Pulmonary Disease

Subxiphoid cardiac impulse

Rule in

Somewhat helpfulNo CI

Rule out

Not helpfulNo CI

Evidence:Limited

Pulmonary Embolism

Left parasternal heave

Rule in

Somewhat helpfulDerived CI

Rule out

Not helpfulDerived CI

Evidence:Limited

Pulmonary Hypertension

Left parasternal heave (sustained right ventricular lift)

Rule in

Somewhat helpfulDerived CI

Rule out

Not helpfulDerived CI

Evidence:Limited

Sustained left parasternal (right ventricular) heave

Rule in

Somewhat helpful

Rule out

Not helpful

Evidence:Limited

Palpable P2 (pulmonary-valve closure)

Rule in

Not helpfulDerived CI

Rule out

Not helpfulDerived CI

Evidence:Limited

References

Shellenberger RA, Imtiaz K, Chellappa N, Gundapanneni L, Scheidel C, Handa R, Bhat A. Physical Examination for the Detection of Pulmonary Hypertension: A Systematic Review. Cureus. 2021 Sep 16;13(9):e18020. doi:10.7759/cureus.18020. PMID: 34692270.
Braganza M, Shaw J, Solverson K, Vis D, Janovcik J, Varughese RA, Thakrar MV, Hirani N, Helmersen D, Weatherald J. A Prospective Evaluation of the Diagnostic Accuracy of the Physical Examination for Pulmonary Hypertension. Chest. 2019 May;155(5):982-990. doi:10.1016/j.chest.2019.01.035. PMID 30826305.
Munt B, Legget ME, Kraft CD, Miyake-Hull CY, Fujioka M, Otto CM. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. Am Heart J. 1999;137(2):298-306. PMID: 9924164.
Basta LL, Wolfson P, Eckberg DL, Abboud FM. The value of left parasternal impulse recordings in the assessment of mitral regurgitation. Circulation. 1973;48(5):1055-1065. PMID: 4751949.
Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871-9. PMID: 17904458.
Badgett RG, Tanaka DJ, Hunt DK, et al. Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med. 1993;94(2):188-196. doi:10.1016/0002-9343(93)90182-O. PMID: 8430714. Holleman DR Jr, Simel DL, Goldberg JS. Diagnosis of obstructive airways disease from the clinical examination. J Gen Intern Med. 1993. doi:10.1007/BF02599985. PMID: 8441077.
Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 9, 2026.