SKILLS LABORATORY MANUAL

VENICE CHAIRIADI, MD FIHA

• The lungs extend from 4cm above the first rib to the 6 th rib
• Much of the anterior lung is upper lobes and right middle lobe or left lingula
(of upper lobe)
• Lungs extend from T1 to T9
• Posterior lung fields are mainly the lower lobes
• Laterally the lungs extend to the 8TH rib
• All three lobes are accessible
 Mendengar ?
 Dimana ?
 Untuk apa anda
dengar ?
 Bayangkan apa yang
anda dengar
 Ada 4 wilayah yang terpisah di kedua sisi
bagian depan, atas & bawah & belakang,
kanan & kiri.
Setiap area harus dengar baik fase inspirasi &
fase ekspirasi
 bayi 30-60
balita 24-40
anak prasekolah 22-34
Anak usia sekolah 18-30
remaja 12-16
dewasa 10-20
 Suara napas halus
Udara di sekitar paru-paru (pneumotoraks)
Cairan di sekitar paru-paru (efusi pleura)
Obesitas atau adanya penebalan pleura atau
jaringan parut
Gangguan pasase udara (penyakit paru
obstruktif kronis, atau asma)
 12 anterior locations
 14 posterior locations
 Auscultate symmetrically
 Should listen to at least 6 locations anteriorly and
posteriorly
 Normal  Adventitious
 Tracheal  Crackles (Rales)
 Bronchial  Wheeze
 Bronchovesicular  Rhonchi
 Vesicular  Stridor
 Abnormal  Pleural Rub
 Absent/Decreased
 Bronchial
 Created by turbulent air flow
 Inspiration
 Air moves to smaller airways hitting walls
 More turbulence, Increased sound
 Expiration
 Air moves toward larger airways
 Less turbulence, Decreased sound
 Normal breath sounds
 Loudest during inspiration, softest during expiration
 Technique
 Diaphragm Vs. Bell !!!
 Move from side to side
 Tracheal
 Very loud, high pitched sound
 Inspiratory = Expiratory sound duration
 Heard over trachea
 Bronchial
 Loud, high pitched sound
 Expiratory sounds > Inspiratory sounds
 Heard over manubrium of sternum
 If heard in any other location suggestive of consolidation
 Bronchovesicular
 Intermediate intensity, intermediate pitch
 Inspiratory = Expiratory sound duration
 Heard best 1st and 2nd ICS anteriorly, and between scapula
posteriorly
 If heard in any other location suggestive of consolidation
 Vesicular
 Soft, low pitched sound
 Inspiratory > Expiratory sounds
 Major normal BS, heard over most of lungs
 Crackles (Rales)
 Discontinuous, intermittent, nonmusical, brief sounds
 Heard more commonly with inspiration
 Classified as fine or coarse
 Normal at anterior lung bases
▪ Maximal expiration
▪ Prolonged recumbency
 Crackles caused by air moving through secretions and
collapsed alveoli
 Associated conditions
▪ pulmonary edema, early CHF, PNA
 Wheeze
 Continuous, high pitched, musical sound, longer
than crackles
 Hissing quality, heard > with expiration, however,
can be heard on inspiration
 Produced when air flows through narrowed
airways
 Associated conditions
▪ asthma, COPD
 Rhonchi
 Similar to wheezes
 Low pitched, snoring quality, continuous, musical
sounds
 Implies obstruction of larger airways by secretions
 Associated condition
▪ acute bronchitis
 Stridor
 Inspiratory musical wheeze
 Loudest over trachea
 Suggests obstructed trachea or larynx
 Medical emergency requiring immediate
attention
 Associated condition
▪ inhaled foreign body
 Pleural Rub
 Discontinuous or continuous brushing sounds
 Heard during both inspiratory and expiratory
phases
 Occurs when pleural surfaces are inflamed and
rub against each other
 Associated conditions
▪ pleural effusion, PTX
 Tricuspid valve: is best heard at the Rt half the
lower end of the sternum body
 Mitral valve: is best heard at the Apex of the heart
(Lt 5th intercostal space at the mid-clavicular line)
 Pulmonary valves: is best heard at the Lt medial
2nd intercostal space
 Aortic valve : is best heard in the medial 2nd Rt
inetercostal space.
 Listing by a stethoscope to the heart sound we
can hear:
 Lub (first heart sound) which is associated with
the closure of the AV valves
 Dub (second heart sound) which is associated
with the closure of the semilunar valves
 We have all heard the heart make the usual
sounds.

LUB----------DUB
 Lub is the first sound or S1

 Dub is the second heart sound or S2

 The time between the S1 and S2 sounds is:
Lub------------Dub

1. The ventricles contracting

2. Blood flowing from the heart to the lungs
and body
3. Blood flowing across the Pulmonic and
Aortic valves
 The time between S2 and S1 is :
1. The blood is flowing from the atria to the
ventricles.
2. The blood flowing across the bicuspid and
tricuspid valves.
3. The atrial contraction also occurs now.
The “lub” in the lub – dub.
 This sound is primarily because of the closing
of the bicuspid and tricuspid valves.
 Anatomically they are located between the
atria and the ventricles
 They close because the ventricles contract
 The Pulmonic and Aortic valves are opening
and blood is being forced into the arteries
S2 is the “dub” in the lub- dub
 The sounds are because of the closing of the
Pulmonic and Aortic valves as the pressure
from the arteries is greater then the pressure
in the ventricles.
 This is the end of systole
 Murmurs-usually indicate turbulence & they
range from 1 to 5 in loudness.
 Does it occur during diastole or systole?
 Does it crescendo (get progressively louder)?
 Does it decrescendo (get progressively
quieter)?
 Where do you hear it best? (Neck, Chest,
Axilla)
 Gallops- these are either S3 or S4 sounds.

 Rubs- pericardial or plural friction rubs and

usually indicated either pericarditis or
possible pleurisy ( must be careful to listen to
both heart and lung sounds)

 Rubs- sounds “sandpapery”

 Clicks- only occur in systole and represent the
loud valve closing
 Diastolic Knock- occurs because of a abrupt
arrest of ventricular filling by a non-compliant
& constricting pericardium.
 Continuous Murmurs- indicate a constant
shunt flow throughout systole & diastole i.e.
Coarctation, or patent ductus arteriosus.
 LUB-- DUB-------------LUB--DUB
 S1 S2 S3 S4 S1 S2

 Here is where you expect to hear the various

sounds
 First Heart Sound (S1)

 - Louder than usual - Mitral Stenosis

 - Variable Atrial Fib./Complete Heart Block
 -Diminished Mitral or Aortic Regurg.
Wide split sounds or fixed ( not moving with
respiration) may indicate:

 Atrial Septal Defect

 RBBB
 Pulmonic Stenosis
 Third Heart Sound (S3)  Markedly
Diminished Left Ventricular Function
 (Almost always present with Myocardial
Ischemia or early after an AMI)

 Fourth Heart Sound (S4) Modestly

Diminished Left Ventricular Function
 Stethoscope
 As quite an environment as possible
 Proper positioning of the patient
 Stethoscope must touch the skin
 Patient history
 Ability to observe the chest, abdomen & neck
 Left Ventricle Area- The apex of the heart is at
the 4th or 5th intercostal space (ICS) along the
midclavicular line (MCL).
 Right Ventricular Area- the 3rd to 5th ICS along
the left sternal border (LSB)
 Pulmonic Area- 2end ICS along LSB
 Aortic Area- 2end ICS along the right sternal
border (RSB)
 The 3rd heart sound: is the heard in the mid
diastole due to the blood that fills the ventricles.
 The 4th heart sound: also known as atrial heart
sound. It occur when the atrium contracts &
pumps blood to the ventricles. This sound is
almost never heard by the stethoscope.
 Tricuspid valve: is best heard at the Rt half the
lower end of the sternum body
 Mitral valve: is best heard at the Apex of the heart
(Lt 5th intercostal space at the mid-clavicular line)
 Pulmonary valves: is best heard at the Lt medial
2nd intercostal space
 Aortic valve : is best heard in the medial 2nd Rt
inetercostal space.
 Usually physiologic
 Low pitched sound, occurs with rapid filling of
ventricles in early diastole
 Due to sudden intrinsic limitation of
longitudinal expansion of ventricular wall
 Makes Ken-tuck-y rhythm on auscultation
 Best heard with patient supine or in left
lateral decubitus
 Increased by exercise, abdominal pressure, or
lifting legs
 LV S3 heard at apex and RV S3 heard at LLSB
 Seen with Kawasaki’s disease--disappears
after treatment
 If prolonged/high pitched/louder:
 can be a diastolic flow rumble indicating increased
flow volume from atrium to ventricle
 Nearly always pathologic
 Can be normal in elderly or athletes
 Low pitched sound in late diastole
 Due to elevated LVEDP (poor compliance)
causing vibrations in stiff ventricular
myocardium as it fills
 Makes “Ten-nes-see” rhythm
 Better heard at the apex or LLSB in the
supine or left lateral decubitus position
 Occurs separate from S3 or as summation
gallop (single intense diastolic sound) with S3
 CHF!!!
 HCM
 severe systemic HTN
 pulmonary HTN
 Ebstein’s anomaly
 myocarditis
 Tricuspid atresia
 CHB
 TAPVR
 CoA
 AS w/ severe LV disease
 Kawasaki’s disease
GradeDescription
 Grade 1Very faint, heard only after listener has
"tuned in"; may not be heard in all positions.
 Grade 2Quiet, but heard immediately after placing
the stethoscope on the chest.
 Grade 3Moderately loud.
 Grade 4Loud, with palpable thrill (ie, a tremor or
vibration felt on palpation)
 Grade 5Very loud, with thrill. May be heard when
stethoscope is partly off the chest.
 Grade 6Very loud, with thrill. May be heard with
stethoscope entirely off the chest.
 Murmurs of the aortic stenosis
In aortic stenosis, there is narrowing of the aorta resistance
to ejection of blood
As a result severe turbulence of blood at the root of the aorta
intense vibration  loud systemic murmur ( after 1st heart
sound).
 Murmur of the aortic regurgitation:
In aortic regurgitation, the aortic valves doesn’t close which is
essential during diastole. Therefore in aortic regurgitation
blood backflow in the ventricles causing diastolic murmurs
(after the 2nd heart sound).
 Murmurs of Mitral stenosis
In mitral stenosis there is narrowing of the mitral valve 
increase resistance of blood flow to the ventricles. After 1/3
of diastole when enough blood fills the ventricle, it causes
vibration which present as diastolic murmur. The murmur is
often not heard but could be felt as thrill at the apex of the
heart.
 Murmurs of Mitral regurgitation
In Mitral regurgitation the Mitral valves are unable to close
which is essential during systole  therefore blood flows
back to the atrium causing a systolic murmur.
 Machinery murmur of patent ductus
arteriosis
In PDA blood flows from the aorta to the pulmonary
arterymurmur during systole and diastole. The murmurs
during systole is much more tense than in diastole because the
pressure in aorta is higher during systole than diastole.
 Color- obvious cyanosis
 Does she/he look ill?
 Signs of respiratory distress

 Muscle wasting- cachexia

 Presence of cough
Posterior Chest

84. Inspection: For symmetry

 Palpate
 Symmetric Expansion- warmed hands – thumbs
@ T9-T10- pinch sm. Fold of skin
 Tactile Fremitus – palpable vibration of sound
from the larynx- use palmer base of fingers- “99”
or Blue Moon
 Symmetry important – vibration should feel the
same bilaterally.
 Avoid palpating over scapulae because bone
dampens out sound
 ↓ fremitus = obstructed bronchi, pleural
effusion, pneumothorax or emphysema
 Note any barrier that is b/t the sound and
your hand will↓ fremitus
 ↑ fremitus occurs only with gross changes
(Lobar pneumonia).
 Posterior Chest: Palpation

A. B.

A. Place hands on the patient’s B.Ask the patient to take a deep

posterior/lateral chest breath
Apply moderate pressure-- Feel and visualize the chest expanding
Move hands up and towards Your thumbs will move apart and the
the midline creating a “dimple” “dimple’ in the skin will go away
in the skin between the
thumbs.-
Arrows denote direction of hand movement
 Posterior chest: Palpation

86-87:Tactile Fremitus
Start above the scapula
•Use the ulnar aspects of the hands
•May use one hand and alternate from side to side or may use both hands
moving inferiorly
•Ask the pt to say “99” and feel the vibrations
 Entire Chest wall – gently palpate. Note
▪ Tenderness, skin temp., moisture, lumps, lesions
 Crepitus = coarse crackling sensation palpable
over skin surface. (Subcutaneous emphysema
when air escapes from lung into S/C tissue)
 Percuss start at the apices, across
shoulders, then interspaces side to side
(5cm. Intervals) Avoid scapulae & ribs
 Resonance predominates in healthy lung
 Hyperresonance – too much air, emphysema,
pneumothorax
 Dull = abnormal density, pneumonia, tumor,
atelectasis
Expected
Percussion notes
 Posterior Chest--Percussion

 88-91: Percussion: includes

percussion, diaphragmatic
excursion, and percussion
over the costovertebral
angle

Percussion--(At level of the diaphragm)

•This is done during normal (tidal) breathing
•Start above the scapula
•Alternate from side to side
•Continue inferiorly until dullness of percussion occurs
Posterior Chest-Percussion Percussion 88-91:
Diaphragmatic movement

•Once the level of the diaphragm has

been detected during tidal respiration
ask the patient to take a deep breath and hold i
•This will move the diaphragm more inferiorly

Begin to percuss moving more inferiorly until dullness is encountered again

•Begin to percuss moving more inferiorly until dullness is encountered again

Repeat this process for the other side

Anterior Percussion over costovertebral angle

•Place the ball of one hand firmly over the patient’s costovertebral angle.
•Use the ulnar side of your other hand to strike the hand you have placed on the
patient.
•Use enough force to cause a perceptible but painless jar or “thud”
 Posterior Chest Auscultation: 92-96

•Patient needs to be in the correct position with arms folded

and hands on opposite shoulders
•Use the diaphragm of the stethoscope
•Start above the scapula
•Ask the patient to take deep breaths with his/her mouth
open
•Listen to complete inspiration and expiration
•Move from side to side working your way inferiorly
 Lower lung borders in expiration & inspiration
 1st Exhale & hold- percuss down the scapulae
line until sound changes from resonant to
dull. Mark with marker
 Estimates the level of the diaphragm
separating the abd cavity. May be higher on
Rt. Due to liver
 Now take deep breath & hold.
 Percuss from mark to dull sound and mark.
 Measure the difference. Should be +
bilaterally 3-5cm in adult may be 7-8 cm in
well conditioned person
 Note hold your own breath when conducting
this test!!!!!!!!!
Exhale Inhale
 Auscultate
 Position client
 Instruct to breath through mouth, little deeper than usual
 Tell you if becomes light headed
 Use flat diaphragm & hold firmly on chest
 Must listen to at least 1 full respiration before moving
stethoscope side to side
 Compare both sides (lung fields)
Auscultation Sequence
 Bronchial – Anterior Chest only = over
trachea & larynx
 Quality = harsh, hollow, tubular
 Inspiration < Expiration
 Amplitude = Loud
 Bronchovesicular both anterior & posterior
 Over major bronchi, posterior b/t scapulae,
anterior upper sternum, 1st & 2nd ICS
 Pitch = high
 Inspiration = Expiration
 Moderate amplitude
 Vesicular – Anterior & posterior
 Quality = rustling, wind in trees
 Inspiration > Expiration
 Soft amplitude
Location
of Breath Sounds
 Decreased or Absent Breath Sounds
 Causes =
 obstruction of the bronchial tree by secretions, mucous
plug, F.B
 ↓ lung elasticity, emphysema = lungs hyperinflated
 Pleurisy, pleural thickening, pneumothorax (air), pleural
effusion (fld.) in the pleural space
 Increased Breath Sounds = dense lung tissue
enhances sound transmission as in
consolidation ie. pneumonia

 Silent chest = ominous

Not normally heard in the lungs. Caused by moving air
colliding with secretions or by popping open of previously
deflated airways
 Crackles (Rales)
 Fine – high pitched popping- not cleared by coughing. Simulate sound
by rolling strand of hair b/t fingers near ear or moisten thumb& index
finger & separate them near your ear
 Course crackles- (opening a velcro fastener)

 Pleural Friction Rub – coarse & low pitched, 2 pieces of

leather rubbed together close to ear
 Wheeze (Rhonchi)
 High pitched, musical squeaking = air squeezes - asthma
 Low pitched musical snoring, moaning, =obstruction

 Stridor – high pitched, inspiratory, crowing, louder

in neck = croup, acute epiglottitis
 Voice Sounds normal voice transmission is soft,
muffled & indistinct. Pathology that ↑ lung density
makes words clearer
 Bronchophony – “99”
 Egophony- ee-ee-ee if disease sounds like aa-aa-aa
Record as “E → A changes”
 Whisper pectoriloquy 1-2-3
 These tests are only done if lung pathology is suspected
 Inspect
 Shape & Configuration
 Expression- relaxed
 LOC – alert & cooperative
 Skin color & condition
 Quality of Respirations – reg. & even, no
retraction or use of accessory muscles
 Looking
 Listening
 Smelling
 Observe the rate, rhythm, depth and effort of
breathing
 Note the shape of the chest and the way it
moves
 Deformities or asymmetry
▪ Increased AP diameter in COPD
 Abnormal retractions of interspaces during
respiration
▪ Lower interspaces, supraclavicular in acute asthma
exacerbation
 Impaired respiratory movement
▪ Flail Chest and paradoxical movement with rib fx’s
 Chest shape
 Barrel chest
increased AP diameter- hyperinflation
 Pigeon chest- pectus carinatum
outward bowing of sternum and costal cartilages
 Funnel chest- pectus excavatum

 Kyphosis- forward curvature of spine

 Scoliosis – lateral curvature of spine
Anterior Chest
Anterior Chest (lying or
sitting or at 30 0)
73. Inspection: For
symmetry, fully exposed (in
female patient may cover
with gown as in photo)
 Palpate
 Symmetric Chest Expansion
 Tenderness, turgor, temp., moisture

 Tactile Fremitus
 Compare both sides
Palpation:
 Lymphadenopathy, trachea, chest expansion, vocal
fremitus
 BILATERAL comparison of
vocal vibrations
 Increased with alveolar
consolidation
 Decreased with increased
distance between lung and
chest wall
 Pneumothorax, Pleural
effusion
Symmetric
Expansion
Anterior Chest

74,75.
Palpati
on: For tactile
fremitus
Palpation:
Alternates from
side to side or
may use both
hands
simultaneously
Sequence
for percussion
& auscultation
Tactile fremitus
 Apices in Supraclavicular Areas
 Interspaces = Resonance
 Dullness
▪ Female breast tissue
▪ Liver – Rt. 5th intercostal space midclavicular
▪ Heart – Lt. 3rd intercostal space midclavicular
 Flat = muscle & bone
 Tympany = stomach (Lt. Side)
 Assess density of
underlying tissue
 Resonance – normal
 Dullness – increased density
 Atelectasis, alveolar filling/consolidation, pleural
effusion, fibrosis
 Hyperresonance – decreased density
 Hyperinflation (COPD), Pneumothorax
Anterior Chest: Percussion: 76-78

Percussion:
Must be done:
Bilaterally
Symmetrically
Good tone
Must alternate from
side to side
 Apices (supraclavicular) to 6th rib
 Bilateral moving down
 One full respiration
 Directly over chest wall – displace female
breast tissue
Expected Percussion
Notes
Location
Of Breath Sounds
Anterior Chest:
Auscultation

•(Starting above
clavicles, 3-4
places, listens
throughout
inspiration and
expiration)

 Patient instructed slow, deep

breath, mouth open
▪ Auscultation: Alternates
from side to side
▪ Auscultation: At least 3-
4 areas auscultated on
each side
INSPECTION

CARDIOVASCULAR PULSATION
PALPATION :
- ICTUS CORDIS
- OTHER PRECORDIAL PULSATION
PERCUSSION :
- RIGHT HEART BORDER
- LEFT HEART BORDER
- UPPER BORDER OF THE HEART
- BORDER OF THE HEART
- HEART CONTOUR
AUSCULTATION l
LOCATION:
AUSCULTATION
POSITION :
- SITTING POSITION
- SUPINE POSITION