A. GENERAL EXAMINATION/VITAL SIGNS（一般检查）1. Introduce yourself to patient, usually last name and title and have a little conversation to relax the patient and to judge mental state.2. Wash hands before starting examinationPreferably, this should be done in view of the patient.3. Patient is seated in a chair4. Palpate radial (wrist) Pulses for at least 30 seconds and recordThe examiner places the pad of his index, middle and ring fingers over the radial artery. If properly done, the examiner should be able to feel the artery pulsating under the examiner’s fingertips. The radial pulse may be measured for 30 seconds, then the pulse perminute can be found by multiplying by two. Attention should also be paid to the rhythm. The examiner should not use his thumb to palpate any pulse.5. Palpate both radial (wrist) pulses simultaneously for symmetry for at least 30 seconds6. Measure respiratory rate for 30 seconds and recordThe examiner unobtrusively measures patient’s res piratory rate. This may be accomplished by the examiner leaving his hands on the patient’s wrists for another 30 seconds after measuring the radial pulses so the patient does not realize that the examiner is watching him breathe. The depth and rhythm should also be noticed. The respiratory rate can also be measured during the back exam.7. Measure blood pressure on right armBlood pressure may be measured with the patient in a sitting or lying position. In each position, the artery in which the blood pressure is to be measured should be at the level of the heart (at the level of the fourth intercostal space in the sitting position; at the level of the middle axillary line in the lying position). The patient’s arm should be resting on a smooth table or supported by the examiner, and slightly flexed at the elbow.8. Place cuff in correct location 2-3 cm above the atecubital creaseThe examiner secures the blood pressure cuff snugly over the upper, arm so that one finger can be admitted under the cuff. The cuff should be positioned 2～3 cm above the antecubital crease or elbow joint. Put the middle of the cuff over the brachial artery.9. Palpate brachial arteryThe examiner can locate the brachial artery which lies slightly medial to the tendon of the biceps muscle in the antecubital fossa. The mercury column on the manometer dial should be properly calibrated with the pointer at “0” before the cuff is inflated (i. e. , all the air should be pressed out of the cuff before it is inflated).The stethoscope is placed firmly over the brachial artery. The examiners inflates the cuff slowly but steadily. Until the brachial artery pulse disappears. Then he continues to inflate cuff 2.6～4.0kPa (20～30 mmHg higher, generally to about 21.3kPa (160mmHg)).10. Measure blood pressure over brachial artery twice and record the lower readingDeflate the cuff slowly at the rate of about 0.26kPa (2mmHg) Per second. The number where the examiner hears the first pulse sound is the systolic pressure. The pulse sound will waken and then disappear. The number where the pulse sound disappears is the diastolic pressure. If the difference between weakening of the sound and its disappearance is 2.6kPa (20mmHg) or greater, the examiner should record these two numbers. The cuff must be completely emptied with the pointer at “0” before it is reinflated. The same procedure may be followed for a second measurement of B. P. in the same or opposite arm. The lo wer pressure is recorded as the patient’s blood pressure. After finishing the measurement, the examiner deflates and rolls up the cuff, leans thein order, and closes the manometer.B. HEAD AND NECK（头颈部）Skull11. Palpate and observe scalp (parting hair, and observing hair density, color, lustre and distribution)The examiner palpates the entire skull using both hands and simultaneously examines symmetrical areas. The examiner parts the hair to observe the scalp, noting any scaliness, deformities, lumps, tenderness, lesions or scars. The examiner also observes the density, color, lustre and distribution of the hair.Eyes12. Visual screening:（omitted）13.Observe cornea, sclera, conjunctiva and lacrimal puncta by gently moving lower eyelids down. Cornea Examination-With oblique lighting inspect the cornea for opacities, foreign bodies etc. Inspect lower palpebral, fornical, bulbar conjunctiva and sclera. Ask the patient to look up as you depress lower eyelid with your thumb exposing lower palpebral, fornical, bulbar conjunctiva and sclera. Inspect the conjunctiva and sclera for color, and note the vascular pattern against the white scleral background.Lacrimal sac examination by digital compression for nasolacrimal duct obstruction-Ask the patient to look up. Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit. You are thus compressing the lacrimal sac. Look for fluid regurgitation out of the puncta into the eye. Avoid this test if the area is inflamed and/or tender(Figure 2-3).14. Observe sclera and bulbar conjunctiva by gently elevating upper eyelid while patient looks down, Instruct the patient to look down.Raise the upper eyelid slightly so that the eyelashes protrude, and then inspect sclera and bulbar conjunctiva. Be gentle so patient doesn’t tear (Figure 2-4).15.Check crn Ⅶupper division: raised eyebrows, wrinkle forehead or forced eyelid closing Nerve Ⅶis the facial nerve.Upper facial nerve-To test the upper division, the examiner observes the patient’s forehead and palpebral fissure, then asks patient to raise his eyebrows, wrinkle his forehead and close his eyes. When the patient closes his eyes tightly, the examiner attempts to pry them open to determine the strength. If one side of peripheral upper facial nerve is impaired (nuclear or below nuclear) the patient’s ability to wrinkle forehead decreases and the patient can’t close his eye on the affected side. If one side of ce ntral nerve is impaired, the patient’s ability to close his eyes and wrinkle forehead will not be influenced because the upper facial muscles are controlled by both sides of the corticocerebral motor area.16. Evaluate extraocular muscle function in both eyes in 6 directions (left, upper left, and lower left, right, upper right, lower right)The examiner positions himself in front of the patient and requests that, without moving the patient’s head, the patient’s eyes follow examiner’s finger or a penc il in six directions. Finger or pencil should be 30～40 cm away from patient’s head. The usual format is from mid left, to upper left and then down and then to the right (Figure 2-5).17.Observe pupillary direct response to lightThe examiner asks the patient to look forward and shines a penlight or the light of the ophthalmoscope into each pupil in turn. He should avoid shining the light into both pupils simultaneously and should ask the patient not to focus on the light source.When observing the direct pupillary response to light, the examiner will shine the light into one eye and inspect for pupillary constriction in the same eye. The pupillary constriction is reversed as soon as the lightmoves away. Use the same method to check the other eye.18.Observe pupillary consensual response to lightWith the same method as obove, the examiner shines the light into one eye and inspects for pupillary constriction in the opposite eye OR observes pupillary dilation in opposite eye as light is extinguished.19.Check for convergence and accommodationThe examiner, positioned in front of the patient, asks the patient to look into the distance and then at his finger. The examiners finger starts from 1 meter away, the examiner will immediately move 5 cm away from the bridgeof the patient’s nose. The examiner is observing the patient’s eyes for:a) pupillary constriction, and b) convergence (the coordinated movement of both eyes toward fixation at the same near point as the patient focuses on a near object). Accommodation includes convergence and pupillary constriction as the patient focuses on the near object. The accommodation will vanish when cranial nerve Ⅲis damaged.Ears and Temporomanaibular joint30. Observe and palpate the auricles and observe postauricular regions bilaterallyThe examiner pulls and palpates the auricles (outer ears), palpates the preauricular(in front of) and posterior auricular regions (behind the ears) bilaterally. Tenderness usually indicates inflammation.31. Palpate temporomandibular joint for tenderness and swelling (omitted)The temporomandibular joint (TMJ) is anterior to the external auditory canal of the ear. Examine for swelling and tenderness.32. Feel the movement of the TMJ with index fingers inside patient’s ears or over jointTo palpate the TMJ joint, the examiner presses both sides simultaneously with one or two fingers and asks the patient to open an d close his mouth, or the examiner places his index finger in the patient’s ear and gently pulls forward (anteriorly), asking the patient to open and close his mouth. (omitted)Nose38. Inspect and palpate external nose for malformation and inflammationBegin by examining the external nose. The examiner faces the patient. Observe skin color and shape of nose any palpate for and loss of structure or tenderness from bridge, to tip, to wings of nose.39. Observe nasal vestibule without otoscopeA view of the nasal cavities is obtained by tilting the patient’s head back and elevating the tip of the nose with the thumb. The examiner should use a light. The nasal vestibule contains the nasal hairs, or vibrissae. Pay attention to any folliculitis, fornicles, or deviated nasal septum.40. Turn the tip of the nose upwards and insert the tip of the speculum to inspect nasal vestibule and anterior part of nasal cavity for ulcer, crust, swelling, discharge, atrophy or perforation41.Test patency by inhaling through each nostril separately while the opposite nostril is held occluded (omitted)42. Palpate and/or percuss maxillary sinus for swelling and tendernessExamination of the paranasal sinuses is done more indirectly than other otolaryngeal procedures. The examiner cannot see into any of the sinuses. Palpation and percussion may be used over the maxillary sinuses. Simultaneous finger pressure over both maxillae will demonstrate differences in tenderness.43. palpate and /or percuss frontal sinus for swelling and tendernessThe frontal sinuses are palpated at the inner part of the upper border of the bony orbit by finger pressure directed upward toward the floor of the sinus where the sinus wall is thin. Tenderness may be elicited in this way. Swelling caused by tumors or retained secretions may cause a downward bulge in the floor of the frontal sinus. The frontal sinuses may also be percussed.Mouth, lips, Pharynx44. Observe lips, buccal mucosa, teeth, gums and tongueThe examiner inspects the lips, all surfaces of the tongue, gums, roof of mouth, and the buccal mucosa (thetissue lining the cheeks) by asking the patient to open his mouth and by shining a light into the area to be examined. The examiner may use a tongue depressor to aid inspection.Lips-The healthy lips are wet and red in color, This is caused by a rich capillary network.Buccal mucoss-To examine the buccal mucosa it is necessary to shine a light into the patient’s mouth. The healthy buccal mucosa is pink and smooth. The duct of the parotid gland opens onto the buccal mucosa opposite the upper second molar.Teeth-There are 32 teeth in the full adult dentition. The teeth are inspected for evidence of cavities and malocclusion.Gums-The gums should be inspected for the presence of swelling, bleeding or pigmentation.Tongue-The tongue is inspected for its shape, motion and ulceration.45. Observe the floor of mouthInspect the mouth for pigmentation, hemorrhage or masses (ask patient to touch tip of tongue to roof of mouth).Generally, palpation is not done in a normal exam. However, if a mass is found on the floor of the mouth, palpation is important. If neoplasms are suspected, they are detectable only by palpation. Also, the submaxillary, salivary ducts may contain calculi that are best felt by palpation. Bimanual examination, using one gloved finger inside the mouth and the other hand outside, is best.46. Inspect the posterior structures of the mouth for congestion, swelling or pus, position of uvula, and elevation of the palate.Press a tongue blade, positioned over middle 1/3 of tongue, firmly down to inspect tonsils, anterior and posterior tonsillar pillars, and posterior pharynx. The examiner can observe the elevation of the palate as the patient say s “ah”. Simultaneously, hoarseness can be detected. The conscious patient should not be gagged.47. Observe midline protrusion of the tongue (cr n Ⅻ)The examiner asks patient to stick out his tongue and observes midline protrusion, atrophy and fibrillation.48. Show teeth, puff out cheeks or purse lips (lower division of cr n Ⅶ) (omitted)49. Test contraction of masseter (jaw) muscle or forced opening of mouth against resistance (motor division cr n Ⅴ) (omitted)50. Test for facial sense of pain and touch (must check at least 2 out of 3 sensory divisions for cr n Ⅴ) (omitted)51. Expose neck correctly to observe appearance and skin of neckThe patient sits upright.Ask patient to expose neck entirely when the neck is to be examined. All clothing should be removed as far as the axillae, which allows the whole neck to be seen in relationship to the thorax and permits inspection and palpation of the supraclavicular fossae.Observe the appearance of the skin of the neck. The examiner should observe the neck for symmetry and pay attention to its appearance. Abnormal lumps and pulsations may be seen in this area. Generally, the thyroid cartilage will show convexity in a male. The examiner inspects the skin of the neck for erythema, spider angioma, infections, ulcers or scars.Facial and cervical lymph nodesPalpate lymph nodes bilaterally. The examiner may be positioned in front of or behind the patient and examine the lymph nodes with the pads of his index and middle fingers. This should be done slowly and carefully to make certain that there aren’t any abnormalities present. It is better if the examiner moves the skin over the underlying tissue rather than move his fingers over the surface of the skin. The examiner may have the patient position his head with his neck slightly flexed forward. The examiner palpates all nodes bilaterally.For palpation of lymph nodes, be sure to keep the skin and muscles relaxed. If the lymph nodes are enlarged,note their location, size, number, hardness, mobility, tenderness, adhesion, fusion, swelling, fistula or scars (Figure 2-14).52. Palpate preauricular nodes (front of ears)53. Palpate post-auricular nodes (back of ears)54. Palpate occipital nodes (base of skull)55. Palpate submaxillary nodes (by bending finger under patient’s jaw)56. Palpate submental nodes (by bending finger under patient’s chin)57. palpate anterior cervical nodes (superficial group under mastoid and in front of sternomastoid muscle)58. Palpate posterior cervical nodes (behind sternomastoid muscle)59. Palpate supraclavicular nodes (by bending finger above patient’s collarbone)Thyroid gland60. Palpate and/or move thyroid cartilage with two fingers checking for malformation and movability61. Palpate thyroid in correct anatomical location in front of or behind the patient withboth hands.The lateral lobes of the thyroid curve posteriorly around the sides of the trachea andthe esophagus. In addition, they are partially covered by the sternomastoid muscle.There areseveral different techniques for examining the thyroid gland. Many examiners will palpate thethyroid gland both in front of and/or behind the patient. The examiner should identify the thyroidgland which lies across the trachea below the cricoid cartilage. (If the examiner has the patientflex his neck or turn his chin slightly toward the side to be examined, it will secure the relaxationof the sternomastoid muscle, which is essential for adequate examination of the thyroid.)62. Palpate isthmus of thyroid with and without swallowing: using the pads of his fingers, the examiner feels below the cricoid cartilage for the isthmus of the thyroid gland. If examiner stands in front, he examines with his thumbs, from behind, with his index fingers. Examiner asks patient to swallow as he feels for the isthmus rising upward against his fingers. A good teaching point is that the thyroid gland is one of the few soft tissue structures in the neck that moves with swallowing.63. Palpate thyroid gland (lobes) with and without swallowingPalpation from the front-The thyroid is displaced to one side by applying pressure with the thumb upon the thyroid cartilage. With the opposite hand, the dislodged lobe of the thyroid can now be palpated between the thumb (held in front of the sternomastoid) and the 2nd and 3rd fingers (Placed behind the sternomastoid) This should be done before and during swallowing. The procedure is repeated for the opposite side (Figure 2-16). Palpation from behind-Procedure is similar to palpation from the front except the thyroid cartilage is displaced with the 2nd and 3rd fingers. The thumb of the opposite hand is now behind the sternomastoid muscle and the 2nd and 3rd fingers are in front of it. (Figure 2-17).If thyroid is enlarged, notice its size, symmetry, hardness, surface, tenderness, nodules, thrills, bruits, etc. Carotid Artery64. Gently palpate carotid arteryWith the pads of his fingers, the examiner exerts gentle pressure on patient’s carotid arteries in the lower half of the neck on the inside edge of patient’s sternomastoid muscle. One should not palpate both caroti ds simultaneously as the patient might flle faint if both carotids are palpated at the same time.Trachea65. Palpate the position of tracheaPlace the patient’s head erect and facing forward and make sure both shoulders are at the same horizontal le vel. Put index and fourth fingers at the sternoclavicular joints. Palpate trachea or the gaps between the trachea and the joints with the middle finger to determine the position of the trachea.Movement of Cervical Spine67. Extension (actively, if possible; if abnormal, do passively)68. Lateral bending [ear-to-shoulder]; (actively, if possible; if abnormal, do passively)69. Rotation (chin-to-shoulder), (actively, if possible; if abnormal, do passively)70. Test rotation of patient’s head against resistance or check resistance of shrugged shoulders (cr n Ⅵ)C. UPPER LIMBS (omitted)71. Expose upper limbsHands72. Inspect dorsa and palms and palpate all joints of hand73. Check fingernails for clubbing or cyanosis74. Ask patient to extend fingers75. Ask patient to make a claw76. Ask patient to make a fist77. Check patient’s ability to perform thumb opposition78. Check for distal muscle strengthWrist79. Observe and palpate wrist (for lumps, swelling, deformities, and tenderness)80. Extension of wrist (bend backward)81. Flexion of wrist (bend forward)Elbow82. palpate olecranon process and epicondyles83. Palpate epitrochlear lymph nodes84. Flexion85. Check for upper arm muscle strength86. Extension87. Pronation and supination (with elbows locked at patient’s side)Shoulder88. Palpate both shoulders89. Functional examination (3 screening maneuvers:hand over head to opposite ear, hands behind head, touch lower border of opposite scapula)90. Check for proximal muscle strength91. Test sense of pain or touch; at least 2 of 3 positions (upper arm, forearm, & hand) on each upper extremity bilaterally and symmetrically92.Barre’s upper limb test (test for drift of out stretched arms with eyes closed)Deep Tendon Reflexes(The reflexes should be checked bilaterally and both sides compared.)Deep Tendon Reflexes93. Biceps reflexThe examiner supports the patient’s arm which should be relaxed with the elbow bent at a bout 90 degrees with the palm up. The examiner places his thumb against the biceps tendon on the inside of the patient’s elbow and taps it with the reflex hammer. A reflex should be elicited. The normal reflex is contraction of the biceps causing a rapid flexion of the forearm. The reflex center is C5-6.The examiner should support the patient’s forearm or hold the patient’s arm flexed at the elbow away from the body and with a reflex hammer, taps the tendon of the triceps above the olecranon. The reflex elicited is extension of the forearm. The reflex center is C7-8.95. Brachioradialis reflexThe patient’s arm should rest in his lap or on examiners arm, relaxed, with his palm down. The examiner strikes the tendon overlying the radius (the bone on the side of the thumb) with the reflex hammer. The reflex clicited is flexion (bending) and pronation (moving the palm downward) of the forearm. The reflex center is C5-6. Coordination(The reflexes should be checked bilaterally and both sides compared.)96. Rapid alternating movement (omitted)97. Finger to nose test (with open eyes) (omitted)98. Finger to nose test (with closed eyes) (omitted)D. BACK99. Expose the back correctlyHave the patient undress except for his underwear. With the patient seated, the examiner stands behind the patient and carefully inspects the spine for any postural abnormalities, configuration and symmetry of chest, and landmarks of posterior thorax (midspinal line, scapula line, costovertebral angle)100. Palpate spinous processes one by one (check for scoliosis and tenderness)With the index and middle fingers, the examiner presses on the patient’s spinous processes from top to bottom rapidly. The skin shows a red line which should be straight. Normally, no tenderness exists.101. Test for percussion pain of spinal column one by one (or by indirect method)For the direct method, the examiner uses a reflex hammer or finger and directly percusses every spinous process. This method is used mainly for the examination of the lumbar and thoracic vertebeae. Normal individuals have no percussion pain. For the indirect method, the examiner places his left hand on the top of the patient’s head and makes a partial fist with his right hand and percusses the left hand with the hypothenar eminence. The examiner should note the patient’s expression, especially if it is painful.102. Test CV A for kidney tenderness by pressure and indirect fist percussionFirst, the examiner places both thumbs on both Costovertebral Angles and presses. If there is no pain, then the examiner uses his first to strike gently just below the costovertebral angle on both sides. If there is no pain, then the examiner should strike with moderate force. This also can be done by indirect first percussion over the examiners hand placed on the C. V. A. Pay attention to the reaction of the patient.103. Palpate thoracic expansion and symmetryConfirm expansion and symmetry of respiratory mo vement by putting both hands gently on the patient’s rib cage from behind with fingers between the ribs, thumbs vertical and parallel to the spinal column, at the 10th costal level, and have patient breath in and out. The thumbs and fingers are placed as in the figure. Estimate the movement of the chest and check the resistance of the shest wall at the same time. The examiner notes divergence of his thumbs and the symmetry of the pump handle effect of both his forearms.104. Have patient cross arms in front and touch opposite shoulderExamine the back of the patient’s lungs by asking the patient to bend slightly forward and have both hands touch the opposite shoulder to expose the interscapular area as widely as possible.To percuss, place the palmar surface of the distal interphalangeal joint of the midfinger of the left hand on the chest and keep the other fingers of the left hand off the chest wall. The midfinger tip of the right hand strikes over the distal interphalangeal joint on the chest wall. The strike should be sharp, occur repeatedly, with the movement coming from the wrist. Each point should be percussed two or three times.106. Percuss posterior lung fields comparatively and symmetricallyPercuss posterior lung fields comparatively and symmetrically from top to bottom and from lateral to medial. When percussing interscapular area, middle finger should be parallel to spine, below the scapulae area, middle finger should be parallel to ribs. Pay attention to the sound and the feeling on the left midfinger.107. Measure diaphragmatic excursionPercuss for bottom of lung during normal breathing and then ask patient to take a deep breath and hold it. Percuss to the lower border of the posterior lung fields. Ask patient to exhale completely. Percuss to the lower border of the posterior lung fields again, Note the difference between the two points, which should be 6～8cm 108. Instruct the patient to breathe a little deeply with mouth open slightly109. Auscultate posterior lung fields (see 110)110. Auscultate comparatively and symmetricallyAuscultate the lungs in the same order as percussed. Pay attention to the change of intensity and nature of the breath sounds. Differentiate normal breath sounds from abnormal including the presence of bronchial and bronchovesicular breath sounds that are heard in any area of the lungs that normally have vesicular breath sounds. Also note increased, decreased, or absent breath sounds, At each point listen to at least one or two full breath cycles. Use the diaphragmatic chest piece and place it between ribs with moderate pressure.111. Vocal audible resonanceThe examiner asks the patient to whisper “one”, “two”, “three” while examiner auscult ates lung fields. Compare both sides of lung fieldsbilaterally and symmetrically.F. ANTERIOR CHEST AND LUNGS128. Inspect and palpate configuration and symmetry of chest.Pay attention to the bony structure and topographical landmarks including: the sternal angle, suprasternal fossa, supraclavicular fossa, infraclavicular fossa, xiphoid process, epigastric angle, mid sternal line, mid-clavicular line, scapula line, mid spinal line, anterior axillary line, mid-axillary line, and posterior axillary line.Inspect thoracic shape and symmetry, direction of anterior lower ribs, size of epigastric angle, breathing motion and depth, and use of auxiliary muscles and retractions during breathing. Then palpate the anterior and lateral inferior chest wall with the whole hand, placing fingers between the ribs. Push the chest wall posteriorly and medially, then release quickly. Pay attention to elasticity and chest.129. Percuss supraclavicular fossae bilaterally and symmetrically.Ask the patient to relax and drop his arms to his sides. Percuss supraclavicular fossae bilaterally and symmetrically.130. Percuss anterior and lateral lung fields. Percuss top to bottom, lateral to medial, right to left. When percussing lateral fields, have patient raise his arms and put his hands behind his head. Percuss each ICS and compare to opposite side. Pay attention to sound and feeling of sensing finger. This can be combined with percussion of the posterior thorax.It might be helpful to use the bell of the stethoscope with firm pressure applied (to convert it acoustically to a diaphragm) to auscultate apices in the supraclavicular fossae, especially in female patients.132. Auscultate anterior and lateral lung fields.Ask patient to breathe a little deeply through slightly open mouth. Auscultate anterior and lateral lung field with diaphragmatic chest piece, bilaterally and symmetrically. Pay attention to changes in intensity and nature of breath sounds.E. BREASTS (FEMALE) (omitted)112. Expose both breasts completely113. Inspect both breasts symmetrically in sitting position114. Inspect both breasts symmetrically with patient leaning forward115. Inspect both breasts symmetrically with arms raised above head116. Inspect both breasts symmetrically with hands on hips and squeeze117. Palpate patient’s right breast with pads of fingers of right hand, applying gentle pressure118. Palpate right breast in the 5 following areas: superinternal, superlateral, tail, inferinternal, inferlateral (at least 4 of 5 parts of the breast should be palpated)119. Palpate nipples, areola, attempt to express discharge from nipple.120. palpate patient’s left breast with pad of fingers and palm, apply gentle gressure.121. Palpate left breast in the following areas: superinternal, superlateral, tail, inferinternal, inferlateral.122. Palpate nipples, areola, attempt to express discharge from nipple.123. Teach patient breast self-examination.Axillary Examination124. Inspect the patient’s right axilla.125. Palpate chains of lymph nodes on right: top, medial, anterior, posterior, lateral126. Inspects patients left axilla.127. Palpate chains of lymph nodes on left: top, medial, anterior, posterior, lateral.G. HEART133. Screening test for elevated venous pressure.Place patient in semirecumbent position with head elevated to 15～30 degrees.Observe neck and note distension of external jugular vein. Ask patient to change to a sitting position. In a normal patient, the distension of the vein will disappear. The distension level should be limited in lower two thirds of the distance between super clavicle and jaw at supine position.134. Observe precordium (view tangentially).Observe precordium with the patient supine. The character and location of any visible cardiac impulses should be noted. For example: the location, range and intensity of apical impulse should be observed. Normally the PMI can be located at the 5th left ICS,. 5～1cm medial to the midclavicular line. The area of the pulse will be 2～2.5cm in diameter. In some normal patients this may not be found. Minor precordial movements can be amplified by observing during expiratory apnea. Tangential lighting may be necessary to see these movements.。
