A double apical impulse is seen in

(D) HOCM# Physical findings of HCM are associated with the dynamic outflow obstruction that is often present with this disease.> Upon auscultation, the heart murmur will sound similar to the murmur of aortic stenosis.> However, a murmur due to HCM will increase in intensity with any maneuver that decreases the volume of blood in the left ventricle (such as standing abruptly or the strain phase of a Valsalva maneuver). Administration of amyl nitrite will also accentuate the murmur by decreasing venous return to the heart.> Classically, the murmur is also loudest at the left parasternal edge, 4th intercostal space, rather than in the aortic area.> If dynamic outflow obstruction exists, physical examination findings that can be elicited include the pulsus bisferiens and the double apical impulse with each ventricular contraction.> A double apical impulse may be recognized, particularly with the patient in the left lateral recumbent position.