Double Apical Impulse (S4) Visualization on Physical Exam - Hi-Res Video Version: https://www.grepmed.com/images/7802/physicalexam-cardiology-impulse-double-gallop-apical-signs
On palpation, the PMI was found to be diffuse and laterally displaced, with presystolic outward movement of the cardiac apex and a double apical impulse. A prominent S4 sound was heard on cardiac auscultation. A wooden stick (coffee stirrer) taped to the chest wall over the PMI allowed for clear visualization of the double apical impulse. The S4 sound is created by the vibrations of the left ventricle during atrial contraction as blood is ejected into a stiff, noncompliant ventricle and is best heard over the apex, with the bell of the stethoscope, owing to the low frequency of the sound.
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