KISII UNIVERSITY

SCHOOL OF MEDICINE
DEPARTMENT OF MEDICAL PHYSIOLOGY
PRACTICAL: ECG, SPIROMETRY, CLINICAL EXAMINATION OF THE HEART AND LUNGS
CLINICAL EXAMINATION OF THE CHEST:
The time- honored sequence of operations used in the clinical examination of any region or organ is inspection, palpation, percussion and
auscultation.
THE HEART
Inspection:
Activity 1: METHOD
Look at the chest, if the light is suitable, you may be able to detect a rhythmical movement near the left nipple, corresponding with the
heartbeat. You may also be able to see arterial pulsations in the neck region.
Palpation:
Activity 2: METHOD
1) Standing on the right side of the subject, place the pulps of the fingers of your right hand lightly on the chest wall over the heart (the
precordium-over the heart and lower chest). You should be able to feel the pulsation of the heart.
2) The furthest point downwards and laterally at which this can be felt is called the apex beat, mark this with a ball, point pen, and work
out its position with respect to intercostal space and the mid- clavicle line. Its located 8–10 cm from the midsternal line, in the left 5th
intercostal space.
3) Place your right hand flat on the chest wall between the apex beat and the midline. With practice it is possible to make an assessment
of the force of the heart’s contraction (the cardiac impulse). In the resting healthy subject this is not very pronounced, but it is
accentuated by exercise.
The apex beat may not be visible in some normal persons because:
I. It may be located behind a rib.
II. The chest wall may be thick due to fat or muscle.
III. The emphysematous lung may cover part of the heart.
IV. The breast may be pendulous.
Percussion: The procedure is to place the fingers of your left hand flat on the chest of the subject and strike the middle phalanx of the
middle finger sharply with the tip of the middle finger of the right hand. The sound that is produced varies with the character of the structures
that lie under the body wall.
Activity 3: METHOD
 On the right sternal margin, locate the position of the apex beat
 Conduct percussion in the 5th, 4th, and 3rd intercostal spaces, starting in the left midaxillary line and going towards the heart till the
notes change from resonance to dullness
Mark each point where dullness appears with ink and when these points are joined, the left border is marked. The area of cardiac dullness
increases in pleural effusion, while it may be decreased in emphysema (lung disorder)
Auscultation: listening to the internal sounds of the body, usually using a stethoscope. Stethoscopes- the bell, which is particularly good
for lower- pitched sounds provided that it is applied lightly to the chest wall and the diaphragm, which gives a greater overall sound
intensity but emphasizes the high- pitched sounds in particular.
The heart sound includes S1, S2, S3, S4 and heart murmurs. The relative contribution of the valves to the sounds that are heard varies
with the listening position, and selected areas are used for each. These areas do not correspond necessarily with the surface marking of the
valve; they are simply the places in which the particular valve can be heard more distinctly.
 Pulmonary area – Left 2nd intercostal space close to the sternum
 Aortic area –Right 2nd intercostal space close to the sternum
 Tricuspid area –4th intercostal space; lower left sternal border edge
 Mitral area – 5th intercostal space, mid-clavicular line; at the apex beat;
The first heart sound results from the closing of the mitral and tricuspid valves. The sound produced by the closure of the mitral
valve is termed M1, and the sound produced by closure of the tricuspid valve is termed T1. The M1 sound is much louder than the T1 sound due
to higher pressures in the left side of the heart; thus, M1 radiates to all cardiac listening posts (loudest at the apex), and T1 is usually only heard
at the left lower sternal border. This makes the M1 sound the main component of S1. A split S1 heart sound is best heard at the tricuspid listening
post, as T1 is much softer than M1. The M1 sound occurs slightly before T1. Because the mitral and tricuspid valves normally close almost
simultaneously, only a single heart sound is usually heard. This sound is called LUBB SOUND
The second heart sound is produced by the closure of the aortic and pulmonic valves. The sound produced by the closure of the
aortic valve is termed A2, and the sound produced by the closure of the pulmonic valve is termed P2. The A2 sound is normally much louder
than the P2 due to higher pressures in the left side of the heart; thus, A2 radiates to all cardiac listening posts (loudest at the right upper sternal
border), and P2 is usually only heard at the left upper sternal border. Therefore, the A2 sound is the main component of S2. A split S2 is best
heard at the pulmonic valve listening post, as P2 is much softer than A2. Like the S1 heart sound, the S2 sound is described regarding splitting
and intensity. S2 is physiologically split in about 90% of people. The S2 heart sound can exhibit persistent (widened) splitting, fixed splitting,
paradoxical (reversed) splitting or the absence of splitting. The S2 heart sound intensity decreases with worsening aortic stenosis due to
immobile leaflets. In severe aortic stenosis, the A2 component may not be audible at all. This sound is called the DUBB SOUND.
The third heart sound, also known as the “ventricular gallop,” occurs just after S2 when the mitral valve opens, allowing passive
filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant LV. A S3 heart sound is
produced during passive left ventricular filling when blood strikes a compliant LV.
If the LV is not overly compliant, as is in most adults, a S3 will not be loud enough to be auscultated. A S3 can be a normal finding in children,
pregnant females and well-trained athletes; however, a S4 heart sound is almost always abnormal. A S3 heart sound is often a sign of systolic

1
heart failure, however it may sometimes be a normal finding: Occurs in early diastole; Occurs during passive LV filling; May be normal at
times; Requires a very compliant LV; Can be a sign of systolic congestive HF. The sound is called LUB-DUB-TA

The fourth heart sound, also known as the “atrial gallop,” occurs just before S1 when the atria contract to force blood into the LV. If
the LV is noncompliant, and atrial contraction forces blood through the atrioventricular valves, a S4 is produced by the blood striking the LV. A
S4 heart sound occurs during active LV filling when atrial contraction forces blood into a noncompliant LV.
Therefore, any condition that creates a noncompliant LV will produce a S4, while any condition that creates an overly compliant LV will produce
a S3, as described above.
A S4 heart sound can be an important sign of diastolic HF or active ischemia and is rarely a normal finding. Diastolic HF frequently results from
severe left ventricular hypertrophy, or LVH, resulting in impaired relaxation (compliance) of the LV. In this setting, a S4 is often heard. Also, if
an individual is actively having myocardial ischemia, adequate adenosine triphosphate cannot be synthesized to allow for the release of myosin
from actin; therefore, the myocardium is not able to relax, and a S4 will be present. It is important to note that if a patient is experiencing atrial
fibrillation, the atria are not contracting, and it is impossible to have a S4 heart sound. Occurs in late diastole; Occurs during active LV filling;
Almost always abnormal; Requires a noncompliant LV; Can be a sign of diastolic congestive HF
The murmurs are heard as blowing and swooshing sounds over the the aortic and pulmonary valve area when the patient leans
forward and exhales, the aortic and pulmonary murmurs may be heard, they can be heard also at the apex beat
SI and S2 are heard best using the diaphragm of the stethoscope as they are high pitched sounds, S2 is louder at the base of the heart
(aortic and pulmonic valve) and S1 is louder at the apex of the heart (mitral and tricuspid valve). S3, S4 and heart murmurs are best heard
using the bell of the stethoscope as they are low pitched sounds at the apex of the heart. The patient may lie and turn to the left to enhance the
listening of the sounds in case they are there.

FIGURE I: HEART AUSCULTATION SITES

OBJECTIVES:
1. To determine if the rhythm is regular
2. Assess how heart valve are closing

ACTIVITY 4:
 Listen to these areas and note the difference
in intensity and quality of the sounds that are
heard.
 Note the time interval between the 1st and
2nd sounds of a cardiac cycle and between
the 2nd sound of one cycle and the 1st sound
of the next which of these intervals is longer?
 Let the subject take a deep inspiration; Listen
carefully over the pulmonary area to the 2nd
heart sound (P2) and note the changes in this
sound immediately after the inspiration.

NOTE: The second sound appears to be composed of two separate sounds (splitting). How may this be explained?

NB:

METHOD:

1. Locate the clavicle bone(collarbone), find the Angle of Louis and locate the 2nd intercostal space on the right near the sternum border
identify the Aortic valve; move over to the left side of the sternum within the 2nd intercostal space locate the Pulmonic valve; Locate
the 4th intercostal space, left side near the sternum and identify the Tricuspid valve; locate the 5th intercostal space-along the mid-
clavicular line and identify the Mitral (bicuspid valve)-point of maximal impulse also called the apex beat or the apex impulse.
2. Once these regions are located, listen to the heart sounds in the regions and distinguish between the first and second sound, identify the
spitting if there is any, in case you hear the third and fourth sounds or murmur.

RESULTS
REGION LUB OR DUB INTENSITY S3 OR S4
AORTIC VALVE
PULMONARY VALVE
MITRAL VALVE
TRICUSPID VALVE
PULMONIC AREA AFTER
INSPIRATION

THE LUNGS

2
Inspection
Activity 1
Note the degree of expansion of the chest in its different diameters during quiet respiration. Which region shows the greatest movement?
Palpation
Activity 2:
Place the palm of the hand on the subject’s chest and notice whether any vibrations are felt during normal respiration. Check the equality of
expansion of the two sides of the chest with inspiration.
Percussion
Activity 3:
Percuss over the back of the chest and note the character of the resonant sound produced by the normal air-filled lung.
Auscultation
Breath sounds are the turbulence which sets up as air moves through the airways in the lungs causing vibrations which can be heard by the
application of the ear to the chest wall, or more conveniently through a stethoscope.
Normal breathing sounds refer to how the normal typical eupneic breathing cycle composed of inspiration and expiration can be heard
from different locations over the chest, provided the breathing is performed in a normal rate and appropriate intensity (deeper than quiet rest
breathing). Sounds are physiologically classified as vesicular, bronchial, bronchovesicular and tracheal sounds. According to their location,
breath sounds are described by: duration (how long the sound lasts); intensity (how loud the sound is); pitch (how high or low the sound
is); timing (when the sound occurs in the respiratory cycle).

Normal breathing sounds

Vesicular sounds are soft, blowing or rustling sounds normally heard throughout most of the lung fields. They arise from the finer lung
parenchyma. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about
one third of the way through expiration. Appreciated well at the posterior lung base.
Bronchial sounds also called tubular sounds are present over the large airways in the anterior chest near the 2nd and 3rd intercostal
spaces, Bronchial sounds are high in pitch, louder and more tubular and hollow-sounding than vesicular sounds. Expiratory sounds last longer
than inspiratory sounds or duration is the same. Intensity of inspiration and expiration is the same. There is a short gap between inspiration and
expiration. Heard over the trachea or at the right apex. If heard in other areas of the lungs, they are abnormal.
Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest.
Bronchovesicular sounds are softer than bronchial sounds, have a mid-range pitch; but have a tubular quality. Bronchovesicular sounds are about
equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Adventitious sounds:
Wheezing: This is the sound of wheezing when auscultating breath or lung sounds. It can be heard when there is an airway obstruction
such as when you listen to a patient with mild to moderate asthma during an exacerbation. Wheeze is mainly expiratory and occurs during both
phases.
Fine Crackles- Rales are high pitched sounds mostly heard in the lower lung bases. This can be abnormal findings on physical exam
suggestive of things like congestive heart failure, pneumonia or atelectasis.
Coarse Crackles are low pitched lungs sounds heard in pathologies such as chronic bronchitis, bronchiectasis, pneumonia, and severe
pulmonary edema. Compared to fine crackles, they are often louder, longer in duration and lower in pitch.
Squawks short inspiratory wheezes (200 ms; 200 - 300 Hz) in late inspiration often preceded by late inspiratory crackles. Squawks are
found in: pulmonary fibrosis, pneumonitis, pneumonia, allergic alveolitis and bronchiolitis oblate-rans. They are produced by the oscillations of
peripheral airways in deflated lung zones opened in late inspiration.
Pleural rub is nonmusical, short, biphasic (inspiro-expiratory) explosive sound (grating, rubbing, creaky, or leathery). It occurs due to
inflamed pleural surface rubbing each other during breathing.
Stridor is loud, high-pitched, mainly inspiratory, Musical sound produced by upper respiratory tract obstruction. It is different from
wheezing: It is louder over the neck than chest wall. In expiration, it is biphasic. Stridor is caused by the turbulent flow passing through a
narrowed segment of the upper respiratory tract.

FIGURE 2: LUNG AUSCULTAION SITES

METHOD:

1. Ask patient to take deep breathes through the mouth

2. Use the diaphragm of the stethoscope to listen to the lung
sounds
3. Anterior side: start just above the clavicle to measure the
sounds at the apex of each lung
4. Move down to the upper lobe of the lungs
5. Move to the middle lobe of the lungs
6. Finally listen to the lung sounds at the lower lobes of the
lungs.
7. Posterior side: start just above the scapula
8. Move to the upper lobe of the lungs
9. Listen to the sounds in the middle lobes and finally to the
sound in the lower lobes of the lungs.
10. Note the difference in the timing of the inspiration and expiration, whether there is a pause between the inspiration and the expiration
pitch and the intensity of sounds in different sites.

ACTIVITY 5:
3
Working in groups or pairs, listen to the lung sounds.

RESULTS: