**3.4 Physical examination**

In the non-obstructive HCM, the findings are subtle with minimal or no increase in LV impulse. A third or fourth heart sound may be auscultated at the apex. There may either be a soft systolic murmur or no murmur. In the obstructive HCM, increased LV impulse, double or triple impulse may be felt. Pulses bisfiriens may be felt in some subjects. An ejection systolic murmur is heard at the left mid and right upper sternal borders. The murmur changes with postural maneuvers: decreases in intensity on squatting which may increase in a standing position. The murmur of HCM is usually auscultated at the left mid sternal border and increases in intensity with the Valsalva maneuver.
