Student Book Block A.3 Cardiorespiratory System (2020) FINAL

Student’s Book
Block A.3
CARDIORESPIRATORY SYSTEM
Eighth Edition
2020
School of Medicine
Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Yogyakarta
School of Medicine UGM 1

Block A.3 Cardiorespiratory System
Student’s Book
Arranged by Block Coordination Team of Block A.3

© Undergraduate Program in Medicine,
Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada
ISBN: 978-602-5486-70-8
Published by Undergraduate Program in Medicine

Jl, Farmako, Sekip Utara, Yogyakarta, 55281
All rights reserved
Eighth edition, November 2020
This publication is protected by Copyright law and permission should be obtained from
publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission
in any form by any means, electronic, mechanical, photocopying, and recording or likewise
2 Student’s Book - Block A.3. Cardiorespiratory System

BLOCK A.3 TEAM
CARDIORESPIRATORY SYSTEM
YEAR COORDINATOR
dr. Santosa Budiharjo, M.Kes, PA(K)
Department of Anatomy
BLOCK COORDINATORS TEAM
dr. Arta Farmawati, Ph.D

Department of Biochemistry
Dra. Dewajani Purnomosari, M.Si, Ph.D

Department of Histology and Cell Biology
dr. Junaedy Yunus, M.Sc, Ph.D

Dr. Med. dr. Putrika Prastuti Ratna Gharini, Sp.JP

Department of Cardiology and Vascular Medicine
dr. Rahmaningsih Mara Sabirin, M.Sc

Department of Physiology
SECRETARIATE
Muh. Rachman Endar Sasongko, S.Pd

CURRICULUM MAP – CBC
FACULTY OF MEDICINE UNIVERSITAS GADJAH MADA 2013
Phase 3: Clinical Rotation – Becoming a

Competent Doctor Compre
Year 6 Exams
2
Clinical Rotation
Phase 3: Clinical Rotation - Becoming a Competent Doctor
Year 5
Clinical Rotation
Phase 3: Clinical Rotation - Becoming a
Phase 2: Transition from Theory to Practice
Competent Doctor
Year 4: Emergency, Health System & Elective
Year 4
Block D.1 Block D.2 Block D.3
Comprehensive Examination
Health
Emergency System & Elective
Disaster
(6 weeks) (6 weeks) (6 weeks)
• Community & Family Health Care-Inter
Professional Education (CFHC – IPE) CLINICAL ROTATION
(Ethics and Professionalism: Family
Medicine) Semester 7
• Basic Clinical Competence (Patient Safety,
Evidence Based Practice, Clinical Skills
Lab)
• Learning Skills
• Agama
O
X X X
Year 3: Life Cycle and Diseases
Block C.1 Block C.2 Block C.3 Block C.4 Block C.5 Block C.6
Conception, Safe Childhood Adolescent & Elderly Lifestyle
Fetal Growth Motherhood & Adulthood Related
& Congenital Neonates Diseases
Anomaly
(6 weeks) (6 weeks) (6 weeks) (6 weeks) (6 weeks) (6 weeks)
Holiday
• Community & Family Health Care-Inter Professional Education (CFHC – IPE) (Ethics
Professional Education (CFHC – IPE) (Ethics and and Professionalism: Family Medicine)
Professionalism: Family Medicine) Semester 5 Semester 6
• Basic Clinical Competence (Patient Safety, • Basic Clinical Competence (Patient Safety,
Evidence Based Practice, Clinical Skills Lab) Evidence Based Practice, Clinical Skills Lab)
• Learning Skills • Learning Skills
• Religion • Citizenship
• Skripsi • Pancasila
• Skripsi
O
X X X X X X

Year 2: Human Body Structure & Function Problem, Basic Medical Practice and Research
Block B.1 Block B.2 Block B.3 Block B.4 Block B.5 Block B.6
Chest Problems Limited Abdominal Sense Organ Basic Medical Research
Movement & Problems Problems Practice
Neurosensory
Problems
Holiday
Professional Education (CFHC – IPE) (Ethics
Professional Education (CFHC – IPE) (Ethics and
and Professionalism: Family Medicine)
Professionalism: Family Medicine) Semester 3
Semester 4
Evidence Based Practice, Clinical Skills Lab)
• Learning Skills
• Learning Skills
O
X X X X X X
Phase 1: Foundation in Medicine
Year 1: Human Body Structure and Function
Block A.1 Block A.2 Block A.3 Block A.4 Block A.5 Block A.6
Being A Medical Digestive Cardiorespiratory Genitourinary Nerve System Blood and
Students and System and System System & Sense Immune
Locomotor Metabolism Organs System
System
Holiday
Professional Education (CFHC – IPE) (Ethics
Professional Education (CFHC – IPE) (Ethics and
and Professionalism: Family Medicine)
Professionalism: Family Medicine) Semester 1
Semester 2
• Learning Skills
• Learning Skills
O
X X X X X X
X Block Examination
V Progress Test
O Clinical Skills Exams

TABLE OF CONTENTS
Block A.3 Team.......................................................................................................... 3

Curriculum map......................................................................................................... 4
Preface......................................................................................................................
Table of contents....................................................................................................... 7
Overview .................................................................................................................. 8
Topic Tree ................................................................................................................. 10
Learning activities...................................................................................................... 11
Blue print assessment............................................................................................... 14
WEEK 1
Module 1.......................................................................................................... 15
Learning Unit 1................................................................................................ 15
Lectures........................................................................................................... 15
Practical sessions............................................................................................ 15
Basic clinical competence training.................................................................. 16
Time allocation................................................................................................ 16
WEEK 2
Module 1.......................................................................................................... 17
Learning unit 2................................................................................................. 17
Scenario 1....................................................................................................... 17
Lectures........................................................................................................... 17
Time allocation................................................................................................ 18
WEEK 3
Module 2.......................................................................................................... 19
Learning Unit 3................................................................................................ 19
Scenario 2....................................................................................................... 19
Lectures........................................................................................................... 19
Time allocation................................................................................................ 20
WEEK 4
Module 2.......................................................................................................... 21
Learning unit 4................................................................................................. 21
Scenario 3....................................................................................................... 21
Lectures........................................................................................................... 21
Time allocation................................................................................................ 22
WEEK 5
Module 3.......................................................................................................... 23
Learning unit 5................................................................................................. 25
Lectures........................................................................................................... 23

Time allocation................................................................................................ 24
References...................................................................................................... 25
Practical Session of Anatomy ................................................................................... 31

Thoracic Wall......................................................................................................... 32
Blood Vessel.......................................................................................................... 38
The Lower Respiratory Tract................................................................................. 48
Integrated Macrostructures Of Cardiorespiratory System..................................... 55
Practical Session of Physiology................................................................................ 56
Blood Pressure Regulation.................................................................................... 57
Volume And Capacity Of The Lung....................................................................... 62
Harvard Step-Up Test............................................................................................ 70
Practical Session of Histology .................................................................................. 75
Microstructure of Cor, Valva Atrioventricularis, Musculus Papillaris
dan Vasa Sanguinea............................................................................................. 77
Microstructure of Tractus Respiratorius................................................................. 82
Practical Session of Biochemistry ............................................................................ 89
Oxydative Phosphorylation.................................................................................... 90
Practical Session of Medical Education.................................................................... 95
Accepting Constructive Feedback.........................................................................
Manual For Contructive Feedback........................................................................ 96
Priinciples for Constructive Feedback...................................................................
Lesson Plan For Academic Writing 2..................................................................... 103
Basic Clinical Competence Material Book

Thorax Examination ................................................................................................. 107
Procedural & Therapy Skills Electrocardiography 1 ................................................. 145
Procedural & Therapy Skills Adult Basic Life Support .............................................. 185
Introduction of Basic of Radiology ............................................................................ 225

OVERVIEW
This is the third block in the first year that guides students to study the cardiorespiratory system.
The block integrates the basic sciences: i.e. anatomy, physiology, histology, biochemistry, and
clinical pathology into one package of the cardiorespiratory system. In this block, specific aspects
of the heart, vascular, circulation, respiration, and introduction to possible cardiorespiratory
system disturbance and inter relation between these systems will be discussed. Students
will be guided to understand the fundamental knowledge of the normal structures, functions,
regulations, and interactions of the cardio-respiratory system. Basic physical and radiological
imaging diagnostic skills for cardio-respiratory system will also be trained. These knowledge
and skills are prerequisite for other blocks of the second year and after.
This block consists of three modules with three scenarios and is accompanied by tutorials,
lectures, practical sessions, and basic clinical competence training.
The feedback of the lecturers, tutors, instructors, block materials and managements are also
scheduled to be obtained at the 6th week after computerized based testing is completed.
General Instructional Objectives

Students able to:
1. Implement the noble values of UGM, Pancasila and religiosity during study in the Faculty
of Medicine.
2. Mastering the concept related to cardiorespiratory system comprehensively and
systematically.
3. Explain the basic concepts of structure, topography and function of the respiratory and the
cardiovascular system.
4. Explain homeostasis’ basic concept of the respiratory and cardiovascular as a whole system
starting from cells, tissue, and organ to organ systems.
5. Mastering the basic skills of clinical examination.
Specific instructional Objectives

Students able to:
1. Implement the noble values of UGM, Pancasila and religiosity during the learning process
and in daily life.
2. Describe the shape, structure and location of the respiratory and cardiovascular system
starting from the cell, tissue, organ to organ systems.
3. Explain the physiological basic concepts of respiratory and cardiovascular system starting
from the cell, tissue, organ to organ systems.
4. Explain the homeostasis mechanism of problems in the respiratory and cardiovascular
system after exposure.
5. Understanding the basic concepts of relationship of the respiratory and cardiovascular
system with other systems in the body.
6. Perform simple laboratory tests related to the respiratory and cardiovascular system.
7. Perform basic clinical examination of the respiratory and cardiovascular system.
8. Explain the principles of informed consent.
9. Describe professionalism of a doctor.
Topic list
Anatomy, Physiology, Biochemistry, Histology, Cardiology, Pulmonology, and Angiology

Basic Clinical Comptence Skills
1. General Physical Examination
Heart examination
- Heart examination
- Capillary refill and peripheral arterial examination
- Jugular venous presssure examination
Lung Examination
- Universal precaution
- Lung examination
2. Procedure and therapy
- Basic Life Support (BLS)
- ECG (1): Recording procedure and normal interpretation
3. Integration & reasoning
Assessment of Integrated skills including profesional behaviour in simple education
4. Lecture
Introduction of normal basic radiology (1)
Preparation BLS
Practical session list

Anatomy, Physiology, Histology, Medical Educationand Biochemistry
Related Disiplins
1. Anatomy and Embriology
2. Physiology
3. Biochemistry
4. Histology and Cell Biology
5. Cardiology and Vascular Medicine
6. Clinical Pathology
7. Radiology
8. Internal Medicine
9. Medical Education
10. Family Medicine
Relation with Other Blocks

Block A.1, Block A.2, Block A.4, Block A.5, Block A.6, Block B.1, Block B.5, Block C6 and Block
D.1
Block Coordinators

TOPIC TREE
TOPIC TREE
MACROSTRUCTURE
DEVELOPMENT
MICROSTRUCTURE
STRUCTURE
ELECTRICAL
FUNCTIONS
MECHANICAL NEURAL
HEART INTRODUCTION REGULATION

TO HORMONAL
DISTURBANCE HEART
CARDIO-
EXAMINATION
VASCULAR CLINICAL
SYSTEM
EXAMINATION
ECG
MACROSTRUCTURE
STRUCTURE
MICROSTRUCTURE
VASCULAR
HEMODYNAMIC
FUNCTIONS
REGULATION
EXERCISE
HOMEOSTASIS
RESPONSE DEEP SEA - UNDERGROUND
CARDIO - HIGH ALTITUDE

RESPIRATORY
SYSTEM
OUTER SPACE
RADIOIMAGING
DIAGNOSTIC
X - RAY
CLINICAL BASIC LIFE

EXAMINATION SUPPORT
DEVELOPMENT
MACROSTRUCTURE
STRUCTURE
MICROSTRUCTURE
MECHANICAL
NEURAL
REGULATION
HORMONAL
FUNCTION GAS EXCHANGE
RESPIRATORY
SYSTEM
ACID-BASED
BALANCE
INTRODUCTION TO
DISTURBANCE
CLINICAL LUNG
EXAMINATION EXAMINATION
10 10
Student’s Book - Block A.3. Cardiorespiratory System
LEARNING ACTIVITIES
Block A.3 is divided into three modules (Cardiovascular, Respiratory and Cardio-respiratory
system) and three scenarios. The following learning activities are prepared to guide students
to obtain the learning objectives of this block:
1. Group discussion with Tutors using online meeting tools

During the discussion, the group needs to make sure that they bring relevant learning
resources, which may be referred to in the tutorials. In order to achieve the learning
objectives, the “seven-jump” method will be used in the group discussion. Usually, the first
group discussion covers Steps 1-5, and the remaining steps are carried out in the second
group discussion within the same scenario.
The seven jumps are:
Step 1: clarifying unfamiliar terms and concepts;
Step 2: define the problems/issues;
Step 3: brainstorm by using prior knowledge/pre-exist knowledge;
Step 4: analyzing the problem/issues/make systematic inventory of various explanations
found in step 3/ makes schemata;
Step 5: formulating learning objectives/issues;
Step 6: self-study for collecting additional information outside the group discussion/search
for relevant literature to answer the questions in the learning issues/prepare for
reporting; and
Step 7: reporting: synthesize and test acquired information using elaboration and
collaboration approach.
2. Independent learning (Self-Study)

As an adult learner students are expected to perform independent learning, a skill that
is essential for future career and development. This skill includes discovering their own
interests, searching for more information from available learning resources, understanding
the information by different learning strategies and using various learning activities, assessing
their own learning, and identifying further learning needs. They will never be satisfied to learn
merely from the lecture notes or textbooks. Independent learning is an important feature of
the PBL approach and at some stage; learning will become a never-ending journey without
limits.
Students learn independently based on block’s objectives and scenario’s objectives,

nevertheless, it can be developed according to references which are already recommended
or the new comparative literature study from the Internet.
3. Expert lectures using online tools synchronous and or asynchronous

Expert lectures are addressed to basic concepts of cardiovascular and respiratory system.
Introduction to possible disturbances of the cardiovascular and respiratory system will be
taught to the student in order to enrich the understanding as well as apply those basic
concepts in clinical condition.
During block A.3 there will be several lectures that are associated with the module topic in
the running week. The students are encouraged to ask questions and ask for explanations
of unsolved problems in tutorial.

Duration
Week Title Department
(Hour)
Block Coordinator
Overview of block A.3 1
Team
Anatomy of the heart Anatomy 1
Histology of cardiovascular system Histology 1
1 Development of the heart Anatomy 2
Electric activity of the heart Physiology 1
Mechanical activity of the heart Physiology 2
Biochemistry of cardiac muscle Biochemistry 1
Electrocardiography 1 Skills Lab 1
TOTAL 10
Physiology of hemodynamics Physiology 1
Capillary exchange Physiology 1
Anatomy of blood vessels and lymphatics Anatomy 1
2
Cell membrane and permeability Histology 1
Biochemical regulation of blood vessels Biochemistry 1
Regulation of regional blood flow Physiology 1
Introduction to functional disturbance of the heart Cardiology 1
TOTAL 7
Structure of the respiratory tract Anatomy 2
Development of the respiratory organ Anatomy 1
Microstructure of respiratory tract. Histology 1
Physiology of respiratory system Physiology 1
3
Mechanic and control breathing Physiology 1
Physical of pulmonary gas exchanges Physiology 1
Maintenance of acid base balance by respiratory Biochemistry 1
system
TOTAL 8
Neuronal regulation of cardiorespiratory system Physiology 1
Hormonal regulation of cardiorespiratory system Biochemistry 1
Diffusion and transportation gas Physiology 1
4 Cellular Respiration Biochemistry 1
Introduction to functional disturbance of the Internal Medicine 1
respiratory system
Basic virology Microbiology 1
TOTAL 6
Basic principles of cardiorespiratory function Physiology 1
during exercise
5 The enzymes of cardiorespiratory system Biochemistry 1
Basic principles of blood gas examination Clinical Pathology 1
Radiological imaging of normal of the heart & lung Radiology 1
TOTAL 4
4. Panel discussion
Duration
(Hours)
5 Homeostasis responses in high altitude and Air Force, Physiology, 2
outer space Internal Medicine,
Cardiology

5. Practical sessions
During block A.3 there will be several practical sessions held by departments to develop
and enrich students’ understanding associated with the module topic in the running week.
Duration
(Hours)
The thoracic walls Anatomy 2
1
Anatomy of the heart Anatomy 2
Microscopic structure of heart, Histology and Cell Biology 2
atrioventricular valves, papillary muscles and
2 blood vessels
Blood vessel Anatomy 2
Blood Pressure Regulation Physiology 2
The upper respiratory tract (included nasal Anatomy 2
cavity)
3
Volume and Capacity of the Lung Physiology 2
Constructive feedback Medical Education 2
The lower respiratory tract Anatomy 2
Microstructure of upper and lower respiratory Histology and Cell Biology 2
4
system
Oxidative phosphorylation Biochemistry 2
Harvard step-up test Physiology 2
Academic writing: paraphrasing Medical Education 2
5
Integrated macrostructure of Anatomy 2
cardiorespiratory system
5. Basic clinical competence training

Duration
(Hour)
1 Thorax examination 4
2 Basic electrocardiography 1 2
3 Basic life support 2
Skills Lab
4 Introduction of basic radiology 2
BCCPT (Basic Clinical Competence Process
5 2
Test)

BLUE PRINT ASSESMENT AND BLOCK EXAMINATION REQUIREMENT
Session Total Indicator for

Activity Component Weighting Percentage
hours hours assessment
Tutorial 4x 3 12 Tutorial 10 15 %
Lectures 35 55 %
Panel 37 MCQ 90
2
Discussion
Practical Anatomy,
Session Embryology
6x2 12 46
and
Anthropology
Practical 30%
Histology and
2x2 4 Session 15
Cell Biology
Examination
Physiology 3x2 6 31
Biochemistry 1x2 2 2
Medical
2x2 4 6
Education
TOTAL 100%
BLOCK EXAMINATION REQUIREMENTS

To be able to participate in the examination, students must:
1. Attend all tutorial activities. The absence in the tutorial with 3 main reasons maximum are
25% of tutorial meeting on those block and replaced with a special assignment or counseling
session.
2. Attend all laboratory activities. Absence in practical session with 3 main reasons are replaced
by following “inhall” regulated by related section.
3. Attend lectures at least 75%.
Absence may be permitted by the 3 main reasons, those are:

1. Sick, as evidenced by letter from doctor,
2. Have (parent, spouse, child, or sibling) passed away,
3. Get assignments from faculty as evidenced by a letter of assignment

WEEK 1
MODULE 1: CARDIOVASCULAR SYSTEM 1
LEARNING UNIT 1
Lectures
1. Title : Overview of block A.3
Department : Block Coordinators Team
Duration : 1 hour
Content : Overview about the relation between this block with other blocks as well
as the importance of the topics and the assessment
2. Title : Anatomy of the heart

Department : Anatomy
Duration : 1 hour
Content : An overview of the circulatory system, topography, design and unique
properties of the heart related to the functions and connections with other
systems in the human body
3. Title : Histology of cardiovascular system

Department : Histology and Cell Biology
Duration : 1 hour
Content : Heart, blood vessel and lymphatic vessel
4. Title : Development of the heart

Duration : 2 hours
Content : This lecture discusses the development of the heart
5. Title : Electric activity of the heart

Department : Physiology
Duration : 1 hour
Content : Electric impulse generation and spreading in the heart and its role in cardiac
muscle contraction and how the cardiac muscle contracts
6. Title : Mechanical activity of the heart

Duration : 2 hour
Content : This lecture discusses about cardiac cycle (systolic and diastolic phase),
the Frank-Starling mechanism, heart sounds, refractory period and cardiac
output
7. Title : Biochemistry of cardiac muscle

Department : Biochemistry
Duration : 1 hour
Content : Myocardial substrate metabolism, regulation of metabolic pathway in the
heart, specificity of cardiac metabolism
Practical sessions
1. Title : The thoracic walls
Content : Structure (bones, muscles, joints and connective tissue) morphology and
topography of the thoracic wall
Duration : 2 hours

2. Title : Anatomy of the heart
Content : Anatomy of heart chambers and great vessels
Duration : 2 hours
Basic clinical competence training

Title : Thorax examination
Laboratory : Skills Laboratory
Duration : 4 hours
Time allocations
Lectures : 10 hours
Practical Sessions : 4 hours
BCCT : 2 hours
Total : 15 hours
Self Study : 25 - 45 hours

WEEK 2
MODULE 1: CARDIOVASCULAR SYSTEM 2
LEARNING UNIT 2
Scenario 1 (for week 2)

Orientation Day
New student (female, 19 years old) overslept on the first day of the campus orientation
period (PPSMB). As she arrived late at the location and still breathless from running, the head
coordinator scolded her. She felt palpitation and dizzy, then fell down. When her friends were
helping her to stand, they felt her palm was cold and sweating, her face looked pale. Due to
her condition, she was taken to the P3K tent and examined by medical doctor. When the doctor
wanted to examine her vital signs, he was unable to palpate her pulse at her radial artery.
Therefore, he palpated the pulse in her carotid artery and it was found 110 times per minute,
regular and strong enough. Her systolic and diastolic blood pressure was 90 and 60 mmHg
respectively. She was asked to lie down and examined by means of palpation, percussion and
auscultation using a stethoscope on some parts of the thoracic wall. The doctor said that the heart
size and sounds were normal, so she didn’t need to be brought to the clinic for ECG recording.
Thirty minutes later, her blood pressure, heart rate and pulse rate had returned to normal.
Lectures
1. Title : Physiology of hemodynamics
Duration : 1 hour
Content : This lecture discuses about blood flow, blood pressure and its factor
(neuronal regulation for vasoconstriction and vasodilatation)
2. Title : Capillary exchange

Duration : 1 hour
Content : Capillary exchange
3. Title : Anatomy of blood vessels and lymphatics

Duration : 1 hour
Content : Anatomy of systemic, pulmonary and lymphatic circulation
4. Title : Cell membrane and permeability

Duration : 1 hour
Content : Molecular structure of cell membrane; ion, molecule and macromolecule
transport through cell membrane)
5. Title : Biochemical regulation of blood vessels

Duration : 1 hour
Content : Endothelial agent processes and exchanges on blood vessels and
blood flow
6. Title : Regulation of regional blood flow

Duration : 1 hour

Content : Autoregulation of blood flow on special organs (brain, heart, lung, kidney
and liver)
7. Title : Introduction functional disturbance of the heart

Department : Cardiology and Vascular Medicine
Duration : 1 hour
Content : Introduction to cardiovascular problems (arrhythmia, hypertension,
coronary arterial disease, myocardial infarct)
Practical sessions
1. Title : Microstructure of heart, atrioventricular valves, papillary muscles and
blood vessels
Duration : 2 hours
Content : Microstructure of heart (cardiac muscles cells, conducting systems),
atrioventricular valves, papillary muscles, aorta, artery, vein and
capillary
2. Title : Blood vessel

Duration : 2 hours
Content : Anatomy of blood vessels (artery, vein, capillary)
3. Title : Blood Pressure Regulation

Duration : 2 hours
Content : Regulation of blood pressure by baroreceptor
Basic Clinical Competence Training

Title : Basic electrocardiography 1
Duration : 2 hours
Time allocations
Tutorial : 4 hours
Lectures : 7 hours
BCC Training : 2 hours
Total : 19 hours

WEEK 3
MODULE 2: RESPIRATORY SYSTEM 1
LEARNING UNIT 3
Scenario 2 (for week 3)

Smoking Experience
A thirteen years old boy hung-out with his friends in the school canteen and was
persuaded to smoke. Upon inhalation of cigarette, he coughed and felt shortness of breath, but
he was embarrassed to stop. After he arrived at home, he was still coughing and experiencing
shortness of breath so he was taken to the hospital by his parents. Doctor examined his
respiratory rate and checked his thorax by means of inspection, palpation, percussion and
auscultation using a stethoscope on some parts of the thoracic wall. The doctor asked him to
inhale and exhale to examine the breathing sound and pattern. Afterward the doctor performed
lung function test using the spirometer. No abnormalities were found. Doctor advised the boy
not to smoke anymore because smoking is not good for his body as it is damaging the airway,
interfering with gas exchange and transport, disturbing acid base balance and cellular respiration.
Lectures
1. Title : Structure of the respiratory tract
Duration : 2 hours
Content : Anatomy of the upper and lower respiratory tract that participate in the
breathing process.
2. Title : Development of the respiratory organ

Duration : 1 hour
Content : Development of the respiratory organs
3. Title : Microstructure of respiratory tract

Duration : 1 hour
Content : • Microstructure of nasal cavity, paranasal sinuses, pharynx and larynx.
• Microstructure of tracheo-bronchial tree and pulmonary system
4. Title : Physiology of respiratory system

Duration : 1 hour
Content : • The role of respiratory system in homeostasis
• The function of respiratory organs (nose, paranasal sinuses, pharynx
and larynx), gas exchanges and transport
5. Title : Mechanic and control breathing

Duration : 1 hour
Content : Mechanism of inspiration and expiration and its regulation by respiratory
center Including sneeze, cough reflex and hiccups
6. Title : Physical of pulmonary gas exchanges

Duration : 1 hour
Content : Physical properties of pulmonary gas

7. Title : Maintenance of acid base balance by respiratory system
Duration : 1 hour
Content : The role of respiratory system in buffering, gas diffusion, oxy-hemoglobin
dissociation curve and both Haldane and Bohr effects
Practical sessions
1. Title : The upper respiratory tract (included nasal cavity)
Duration : 2 hours
Content : The macroscopic structure of upper respiratory tract
2. Title : Volume and Capacity of the Lung

Duration : 2 hours
Content : Measure lung volumes
3. Title : Constructive feedback

Department : Medical Education
Duration : 2 hours

Title : Basic life support
Duration : 2 hours
Time allocations
Tutorial : 4 hours
Lectures : 8 hours
Total : 20 hours

WEEK 4
MODULE 3: CARDIOVASCULAR AND RESPIRATORY SYSTEM
LEARNING UNIT 4
Scenario 3 (for week 4 & 5)
High Altitude La Paz Marathon
La Paz annual marathon is organized by city government of Bolivia, South America. La

Paz is the world highest administrative capital, located 11.975 ft (3.650 m) above sea level. In
this altitude, running is particularly difficult. The local champion said that running in La Paz is for
the brave, because the (physical) stress is high and the (atmospheric) pressure is also difficult.
To run they need more sacrifice.
One of Yogyakarta’s marathon athletes is interested to join this competition next year. He
and his coach start to arrange strategies to win the competition. What are the best strategies for
Yogyakarta athelete in order to compete local (La Paz) athelete considering the most challenging
factor for La Paz Marathon is high altitude.
Lectures
1. Title : Neuronal regulation of cardiorespiratory system
Duration : 1 hour
Content : The mechanism of neuronal regulation to control cardiorespiratory system
2. Title : Hormonal regulation of cardiorespiratory system

Duration : 1 hour
Content : The mechanism of hormonal regulation to control cardiorespiratory system
3. Title : Diffusion and transportation gas

Duration : 1 hour
Content : Explain the ventilation and perfusion process to fulfill oxygen demand.
4. Title : Cellular respiration

Duration : 1 hour
Content : Electron transport chain in mitochondria
5. Title : Introduction to functional disturbance of the respiratory system

Department : Internal Medicine
Duration : 1 hour
Content : Introduction to respiratory problems (rhinitis, dyspnea, apnea, cough)
6. Title : Basic virology

Department : Microbiology
Duration : 1 hour
Content : a. Viral structure and reproduction
b. Virus in respiratory tract as examples

Practical sessions
1. Title : The lower respiratory tract
Duration : 2 hours
Content : This practical session is conducted to enhance student’s understanding
about macroscopic structure of the lower respiratory tract
2 Title : Microstructure of upper and lower respiratory system

Duration : 2 hours
Content : Microstructure of nasal cavity, trachea, bronchus, bronchioles and
alveolus
3. Title : Oxidative phosphorylation

Duration : 2 hours

Title : Introduction of basic radiology
Duration : 2 hours
Time allocations
Tutorial : 4 hours
Lectures : 6 hours
Total : 18 hours
Self Study : 30 – 42 hours

WEEK 5
MODULE 3: CARDIO-RESPIRATORY SYSTEM
LEARNING UNIT 5
Lectures for regular class

1. Title : Basic principles of cardiorespiratory function during exercise
Duration : 1 hour
Content : Adjustment of regulation and function of the cardio-respiratory system
during exercise
2. Title : The enzymes of cardiorespiratory system

Duration : 1 hour
Content : a. Various types of cardiorespiratory enzymes
b. Function of cardiorespiratory enzymes
c. Characteristic of cardiorespiratory enzyme
d. Regulation of cardiorespiratory enzymes activities
3. Title : Basic principles of blood gas examination

Department : Clinical Pathology
Duration : 1 hour
Content : Basic principles of blood gas examination
4. Title : Radiological imaging of normal of the heart & lung

Department : Radiology
Duration : 1 hour
Content : X-Ray examination of normal of the heart and lung
Panel discussion
Title : Homeostasis responses in outer space
Department : Physiology, Cardiology, Air Force
Duration : 2 hours
Practical sessions
1. Title : Harvard step-up test
Duration : 2 hours
Content : This practical session is conducted to enhance student’s understanding
about how cardiorespiratory fitness should be achieved to meet
metabolism demand of the body
2. Title : Academic writing: paraphrasing

Department : Medical Education
Duration : 2 hours
3 Title : Integrated macrostructure of cardiorespiratory system

Duration : 2 hours

BCCT
Title : Basic Clinical Process Test
Duration : 2 hours
Time allocations
Lectures : 4 hours
Panel Discussions : 2 hours
Total : 12 hours
Self Study : 36 – 48 hours

References
Brooks GF, Bufel JS & Marse SA. 2004. Jawetz Melnick & Adelberg’s Medical Microbiology,
23rd ed. Lange Basic Science. Philadelphia.
Newsholme E A, Leech TR. 2010. Functional Biochemistry in Health and Disease. Wiley-
Blackwell. A John Wiley & Sons, Ltd.
Hall JE. 2011. Guyton and Hall Textbook of Medical Physiology, 12th ed. Saunders Elsevier.
Philadelphia.
Murray RK. 2009. Harper’s Illustrated Biochemistry (a Lange Medical Book), 28th ed. McGrawHill
Medical. Philadelphia.
Mescher AL. 2010. Junqueira’s Basic Histology Text & Atlas, 12th ed. McGrawHill Medical. New
York.
Koolman J, Roehm KH. 2005. Color Atlas of Biochemistry, 2nd ed. Thieme, Stuttgart, New York.
Martin DW. 1983. The Chemistry of Respiration in Harper’s Review of Biochemistry 20th ed.
Mohrman DE and Heller LJ. 2006. Cardiovascular Physiology, 5th ed. Mc Graw-Hill, New York.
Moore KL, Dalley AF and Agur AMR. 2010. Clinically Oriented Anatomy. 6th ed.
Taylor NAS and Groeller H. 2008. Physiological Bases of Human Performance During Work
and Exercise. Churchill Livingstone. Edinburg.
Tortora GJ and Derrickson BH. 2009. Principles of Anatomy and Physiology 12thed. Vol 2. John
Wiley & Sons, NJ.

Manual Penggunaan Aplikasi
AR Heart
AR Heart merupakan aplikasi anatomi jantung dengan menggunakan teknologi augmented

reality. Aplikasi ini dikembangkan dengan harapan dapat membantu pembelajaran anatomi
dengan memungkinkan pengguna mempelajari anatomi jantung secara 3D dengan mudah
dan praktis.
Manual Installasi untuk android

1. Aplikasi dapat diunduh melalui tautan https://bit.ly/30N4i16 atau dengan men-scan QR
code di bawah
2. Aktifkan “Allow installation from unknown source” pada smartphone.
3. Instal aplikasi
4. Setelah instalasi selesai, buka aplikasi AR Heart
Manual installasi untuk iOS

1. Pertama Unduh terlebih dahulu Aplikasi iFunbox pada link berikut : http://i-funbox.com
2. Siapkan file IPA, anda bisa mengunduh filenya pada tautan https://bit.ly/30RUpPN atau
dengan men-scan QR code di bawah.
3. Kemudian Hubungkan iPhone, iPad atau iPod Touch anda ke PC/Mac
4. Jika sudah di kenali oleh komputer maka lanjutkan dengan Install Apps dan arahkan ke
aplikasi IPA yang akan anda instal
5. Jika sudah berhadil akan di tandai dengan tulisan Succees di iFunbox jika aplikasi berhasil
anda install
6. Namun jika tampil pesan error silahkan cari File IPA lainnya kemungkinan File tersebut
rusak atau tidak Support pada Device anda.
Manual penggunaan
1. Setelah instalasi selesai, buka aplikasi AR Heart
2. Arahkan kamera smartphone ke key image AR Heart atau Kartu AR Heart
3. Apabila kamera dapat menangkap gambar tersebut, pada layar smartphone akan nampak
3D virtual gambar jantung utuh. Gerakkan smartphone/ kartu AR Heart untuk merubah
sudat pandang model 3D.
4. Pilih “show/hide Anatomica Text” untuk memunculkan/menghilangkan nama struktur
anatomi jantung.
5. Untuk melihat bagian dalam jantung, aktifkan “potongan belakang” atau “Potongan depan”
sesuai kebutuhan.

BLOCK A.3
PRACTICAL SESSION OF ANATOMY
Name : ........................................................
NIM : ........................................................
Group : ........................................................
Date : ........................................................
Faculty of Medicine, Public Health, and Nursing
Yogyakarta
2020

REGULATIONS
1. Students must attend all practical sessions (100% attendance).

2. If students are unable to accomplish full attendance (100%), they are not allowed to attend
the laboratory exam.
3. If students are unable to attend one or more practical sessions because of an acceptable
reason, students must reschedule the practical session before the laboratory exam. The
replacement will be arranged regarding to each block schedule.
4. In each practical session, students must submit the workplan and will be checked by the
instructor. The students cannot attend the practical session if they have not submitted the
workplan. A pretest will also be conducted which will influence the mark and professional
behavior. This test will be used as a proof of attendance and conducted at the beginning of
each practical session. If the pretest score is not satisfying (below half of the highest score
at that time) in two consecutive practical sessions, students have to do an assignment that
will be announced later. The assignment should be collected on the next practical session
and will be checked by the instructor. The final mark will not be published if the students
have not completed any assignments.
5. If the examination score is less than 60% (<60%), students should take a remedial practical
examination. The remedial practical examination could be taken only once. The maximum
score of remedial practical examination is 60%, if the score >60% will be converted to
60%, if score <60% will be not converted (original score).
6. Further items regarding the practical session regulation will be informed later.

PREFACE
These Anatomy practical sessions support the learning process and content of Block A.3
(Cardiorespiratory System) in order to make easier understanding and explanation of concepts
to be learned from the scenarios. The topics of these practical sessions are anatomy of thoracic
wall, anatomy of heart, blood vessels, and anatomy of upper and lower respiratory tracts. All
materials of those topics are in basic Anatomy area.
These Basic Anatomy practical sessions in 2007 Competence Based Curriculum are given
mainly in the first year, from block A.1 until block A.5 which involve the blocks concerned with the
human body systems. On the other hand, the regional Anatomy topics with clinical orientation
are given starting in the second year which involve the blocks concerned with human growth
and development, and continued in the third year with topics of blocks concerned with body
complaints.
We hope that after completion of the Basic Anatomy practical sessions, students can increase
their capabilities of basic reasoning in learning of the problems and solutions of the Block A.3
scenarios and competencies in skills, especially thorax physical examination and procedural
skills. For improving this manual of Basic Anatomy practical sessions, we accept any correction
and suggestion.
Contributors:
Dr. dr. Dwi Cahyani Ratna Sari, M.Kes, PA(K)
dr. Santosa Budiharjo, M.Kes, PA(K)
dr. Ch. Tri Nuryana, M.Kes
dr. Nur Arfian, Ph.D
dr. Junaedy Yunus, M.Sc, Ph.D

Checked and Signed by the Instructor
Date : …………………………
Instructor : …………………………
ANATOMY PRACTICAL SESSION 1

THORACIC WALL
After attending the first anatomy practical session, students should be able to:
1. Understand, describe, and identify the structure which forms the thoracic wall:
a. Describe and identify the layer of thoracic wall from skin to the parietal pleura.
b. Describe and identify the bones which form the thoracic wall.
c. Describe and identify the muscles which form the thoracic wall and also assist in the
process of respiration.
2. Understand, describe and identify the vascularization and innervation of the thoracic wall:
a. Describe the arterial vascularization of the thoracic wall.
b. Describe the venous drainage of the thoracic wall.
c. Describe the lymphatic drainage of the thoracic wall.
d. Describe the innervations of the thoracic wall.
3. Understand, describe and identify the mediastinum:
a. Explain the definition of mediastinum.
b. Describe and identify the division of mediastinum.
c. Describe and identify the structures located in the mediastinum.
d. Describe the major blood vessels located in the mediastinum.
1. Identify the layers of the thoracic wall!

Cutis, subcutis, fascia overlying the thoracic muscle (fascia pectoralis, fascia clavipectoralis),
m. pectoralis major, m. pectoralis minor, and m. subclavius, the rib bones (costae) and the
muscle in the intercostal space (spatium intercostale), fascia endothoracica, pleura parietalis.
2. Identify the bones which form the thoracic wall! Costae (12 pairs), Vertebrae Thoracicae,
Sternum.
Identify sulcus costae and describe the neurovascular structure located in it (arteriae and
venae intercostales, nervi intercostales), describe the collateral branch of each vessels and
nerves and its position from superior to inferior.
3. Identify the joint of the thoracic wall. Fill the blank column with appropriate answers!
Joint Type Articulation
Intervertebralis Symphysis ………
Costovertebralis ……… Caput costae and fovea costalis of
corresponding vertebral body.
Tuberculum costae and fovea costalis
processus transversi of corresponding
vertebra
Costochondralis Synchondrosis ………
Interchondralis ……… Articulation between costal cartilages of
6th–7th, 7th–8th, and 8th–9th ribs
Sternocostalis 1st: Synchondrosis ………
2nd–7th: Articulatio plana
Sternoclavicularis ……… Extremitas sternalis os clavicula with
manubrium sterni

4. Identify the thoracic apertures and the relation between the thoracic cavity and other cavities!
Fill the blank column with appropriate answers!
a. Describe and identify apertura thoracis superior. What structures pass through the
aperture? What is the significance of the aperture?
b. Describe and identify apertura thoracis inferior!
5. Identify the intercostal muscles and the muscles in the thoracic wall which assist in the
process of respiration!
Muscle Origo Insertio Function
M. intercostalis externus Inferior border of Superior border of Elevate ribs
M. intercostalis internus the ribs the lower ribs ……
M. intercostalis intimus ……
M. subcostalis …… Superior borders of ……
2nd or 3rd rib below
M. transversus thoracis Posterior surface …… ……
of lower sternum
M. serratus posterior …… …… Elevate ribs
superior
M. serratus posterior …… Inferior border costa ……
inferior VIII - XII
M. levator costae …… …… Elevate ribs
M. subcostalis …… …… Weakly depress ribs
6. Identify the diaphragm!

Part
Parts of diaphragm Tendo centralis/centrum tendineum diaphragma
Crura diaphragmatica; crus dextrum et sinistrum
Apertures in the diaphragm Foramen venae cavae; Hiatus ……; Hiatus ……
Other small foramen for vessels and nerves
7. Describe the vascularization and innervations of the thoracic wall:

a. Describe the vascularization of the thoracic wall.
b. Describe the venous drainage of the thoracic wall.
c. Describe the lymphatic drainage of the thoracic wall.
d. Describe the innervations of the thoracic wall.
8. Describe and identify the mediastinum!

Mediastinum is the central compartment of the thoracic cavity, it is covered on each side by
pleura mediastinalis and contains all the thoracic viscera and structures except the lungs.
a. Describe the boundaries of the mediastinum: superior border, inferior border, anterior
border, posterior border!
b. Describe the division of the mediastinum:

1. Describe and identify the boundary between the superior and inferior mediastinum.
Identify the transverse thoracic plane (planum transversum thoracis). Describe the
content of the superior mediastinum!
2. Describe and identify the inferior mediastinum. Describe the division of the inferior
mediastinum to mediastinum anterius, medium, and posterius. What structure
demarcates between each part of inferior mediastinum. Describe the content of the
inferior mediastinum!

Content
Mediastinum anterius Lig. ……
Inferior part of thymus gland (in children), etc.
Mediastinum medium ……
…….
Mediastinum posterius Aorta descendens, pars thoracicae; Esophagus, pars
thoracicae; Ductus thoracicus; V. azygos, etc.
c. Identify and describe the course of the blood vessels in the superior mediastinum. Observe
the relationship of the blood vessels to the surrounding tissues or organs:
1. V. brachiocephalica dextra and v. brachiocephalica sinistra
2. V. cava superior
3. Arcus aortae
4. Truncus brachiocephalicus
5. A. subclavia sinistra and a. subclavia dextra
6. A. carotis communis dextra and a. carotis communis sinistra
d. Identify the pleura parietalis (pleura costalis, diaphragmatica, pleura mediastinalis, cupula
pleurae)!

Date : …………………………

THE HEART
After attending the second anatomy practical session, students should be able to:
Understand, describe and identify the anatomy of the heart:
1. Explain the pericardium.
2. Explain the external projections of the heart on the anterior thoracic wall.
3. Explain the surface marking and the chambers of the heart.
4. Explain the internal structure of each chamber.
5. Explain the innervations and vascularization of the heart.
1. Describe and identify the pericardium:

Parts
Pericardium Pericardium ……; lamina parietalis, lamina visceralis; Pericardium ……
Lig. sternopericardiaca; Lig. pericardiophrenica
Cavitas pericardiaca; Sinus …… pericardii; Sinus …… pericardii
Describe the vascularization and innervation of the pericardium!
2. Describe and identify the chambers of the heart and its superficial marking:
a. Describe and identify basis and apex of the heart:
The apex of the heart (apex cordis) is formed by the inferolateral part of ventriculus
sinister while the base of the heart (basis cordis) is the heart’s posterior aspect and is
formed mainly by the atrium sinistrum, with a lesser contribution by the atrium dextrum.
b. Describe and identify the border of the heart and identify the external projection to the
anterior wall!
c. Describe and identify the surface of the heart! Identify the wall of the heart!
Identify the epicardium, myocardium, and the endocardium. What is the difference
between myocardium of the atrium and the ventricle? What chamber has the thickest
wall of myocardium and what is the reason?
d. Identify the grooves in the surface of the heart:
Grooves Location Structures pass In the groove
Sulcus interventricularis …… R. interventricularis anterior (branch of a.
anterior coronaria sinistra); V. ……
Sulcus interventricularis …… ……
posterior
Sulcus atrioventricularis/ …… Sinus coronarius
sulcus coronarius ……
Sulcus terminalis …… ……
3. Describe and identify the structure in each of the heart chamber:

Heart Chamber Structure
Atrium dextrum Septum ……; Ostium venae cavae superioris
Ostium venae cavae inferioris; Ostium sinus coronarii
Ostium …… dextrum; Foramina ……
Sinus venarum cavarum; Fossa ovalis; Limbus ……;
Auricula dextra; Mm. ……; Crista ……; Sulcus terminalis

Ventriculus dexter Septum ……, pars membranacea, pars muscularis
Valva …… (valva tricuspidalis)
Cuspis ……, cuspis ……, cuspis ……
Chordae tendineae; M. papillaris ……, m. papillaris ……, m.
papillaris ……; Trabeculae carneae; Trabeculae ……; Conus
arteriosus (infundibulum); Ostium trunci pulmonalis; Valva trunci
pulmonalis; Valvula semilunaris ……, valvula semilunaris ……,
valvula semilunaris ……
Atrium sinistrum Septum interatriale; Ostium venae pulmonalis (ostia venarum
pulmonalium); Auricula sinistra
Mm. pectinati; Ostium …… sinistrum
Ventriculus sinister Septum interventriculare
Valva …… (valva mitralis/valva bicuspidalis)
Cuspis ……, cuspis ……
M. papillaris ……, M. papillaris ……
Trabeculae carneae; Vestibulum ……; Ostium aortae
Valvula aortae
Valvula semilunaris ……, valvula semilunaris ……, valvula
semilunaris ……
Ostium arteria coronaria dextra, Ostium arteria coronaria sinistra
4. Describe and identify the structure in the base of the heart:

Structures in the Parts
base of the heart
Ostium Ostium …… dextrum; Ostium …… sinistrum; Ostium trunci
pulmonalis; Ostium aortae
Skeleton cordis Anulus fibrosus dexter; Anulus fibrosus sinister
…… fibrosum dextrum; …… fibrosum sinistrum
Pars membranacea septum interatriale and interventriculare
Tendo ……
Major blood Truncus pulmonalis; a. pulmonalis dextra and sinistra; Aorta
vessels ascendens, arcus aortae; Truncus brachiocephalicus; a. carotis
communis sinistra; a. subclavia sinistra; vv. pulmonales
v. cava superior; ligamentum arteriosum
5. Explain the conduction system of the heart:

Part of conduction system Location Function
Nodus …… (SA) …… ……
Nodus …… (AV) …… ……
Bundle of His …… ……
Crus dextrum (Right bundle branch) Trabecula septomarginalis ……
Etc. …… ……
6. Describe the identify the vascularization and autonomic innervations of the heart:
a. Describe and identify the right coronary artery (a. coronaria dextra), and trace the
branches and the parts of the heart it vascularizes.
Vessel Course Distribution
A. coronaria dextra …… ……
R. nodi sinuatrial …… ……
R. …… dexter Passes in margo inferior ……
R. …… posterior …… ……
R. nodi atrioventricularis …… Nodus atrioventricularis

b. Describe and identify the left coronary artery (a. coronaria sinistra), and trace the branches
and the parts of the heart it vascularizes.
Vessel Course Distribution
A. coronaria sinistra …… ……
R. …… anterior …… Ventriculus sinister and
dexter
R. circumflexus Passes in sulcus coronarius ……
R. …… sinister Passes in margo sinistra ……
c. Describe and identify the venous system of the heart:

Vein Course Tributaries from
V. cardiaca …… Passes in sulcus ……
interventricularis anterior
V. obliqua atrii sinistri …… Atrium sinistrum
Sinus coronarius Passes in sulcus coronarius ……
V. cardiaca …… …… ……
V. cardiaca …… Passes in margo inferior ……
V. posterior ventriculi sinistri …… Ventriculus sinister
Vv. cardiacae minimae …… ……
d. Describe the autonomic innervations of the heart:

Autonomic nervous Source Effect on the heart Effect on
system coronary arteries
Sympathetic nervous Dromotropic + ……
system Inotropic +, etc.
Parasympathetic N. vagus (CN X) …… ……
nervous system

Date : …………………………

BLOOD VESSEL
Date : …………………………
After attending the third anatomy practical session, students should Instructor
be able to:: …………………………
1. Understand and identify the anatomy of blood vessels.
a. Describe, differentiate, and identify blood
ANATOMY vessels SESSION
PRACTICAL in the body.3
b. Describe and identify the blood supply BLOOD VESSEL
of the body regions.
c. Describe and identify the innervation of blood vessels.
After attending
d. Describe the third
the lymph anatomyof
drainage practical session,
the body students should be able to:
regions.
1. Understand and identify the anatomy of blood vessels.
2. a. artery
Identify the Describe,
anddifferentiate, and identify blood vessels in the body.
vein in cadavers:
b. Describe and identify the blood supply of the body regions.
a. Identify the artery and vein in cadaver. What is the differences between the arteries and
c. Describe and identify the innervation of blood vessels.
the veins?
d. Describe the lymph drainage of the body regions.
b. Identify and describe the branches of the aortic arch (arcus aortae) and their distribution,
the1.main branch
Identify of thoracic
the artery and
and vein abdominal aorta, and aortic bifurcation (bifurcatio aortae)!
in cadavers:
a. Identify the artery and vein in cadaver. What is the differences between the arteries and the
3. Identify and veins?
describe the blood supply (main artery and vein) in the region of the human
b. Identify and describe the branches of the aortic arch (arcus aortae) and their distribution,
body: the main branch of thoracic and abdominal aorta, and aortic bifurcation (bifurcatio aortae)!
THE MAIN
2. BRANCH
Identify andOF THEthe
describe AORTA
blood supply (main artery and vein) in the region of the human body:
THE MAIN BRANCH OF THE AORTA

To the head
……… ………
a. subclavia
To the right ……… ………
dextra To the left upper
upper extremity
extremity
Arcus aortae
a. coronaria
a. coronaria
Aorta ascendens dextra
sinistra
Aorta
rr. esophageales a. ……
………
posterior
descendens,
Pars Thoracica
……… rr. bronchiales
a. subcostalis
To the digestive rr. mediastinales
organ a. …… superior
………
a. …… inferior Aorta
descendens,
Pars Abdominalis
To the kidney a. renalis
To the gonads ……… = continue

aa. lumbales
a. sacralis mediana
= gives branch

THE MAJOR ARTERIES OF THE HEAD
THE MAJOR ARTERIES OF THE HEAD
To the
THEcranial
MAJOR ARTERIES OF THE HEAD
labialis
cavity superi ………
To the cranial
labialis
cavity superi ………
a. maxillaris
Terminal branch of
a. carotis externa a. maxillaris a. auricularis
Terminal branch of posterior
a. carotis externa a. auricularis a. palatina
posterior ascendens
a. occipitalis a. palatina
a. carotis ascendens
a. occipitalis a. …… superior
externa ………
a. carotis and a. ……
a. …… superior
inferior
externa ………
a. lingualis and a. ……
Bifurcatio carotidis inferior
a. a. lingualis
pharyngea
Bifurcatio carotidis ascendens
a. carotis ……… a. pharyngea
ascendens
interna
a. carotis ……… ……… a. laryngea
superior
interna ……… a. laryngea
superior
THE
THE MAJOR
MAJOR ARTERIESOF
ARTERIES OFUPPER
UPPER LIMB
LIMB
a.THE MAJOR ARTERIES………
laryngea OF UPPER LIMB Truncus a. vertebralis
inferior thyrocervicalis
a. laryngea ……… Truncus a. vertebralis
inferior thyrocervicalis
a. axillaris a. subclavia
a. axillaris a. subclavia
rr. mediastinales
a. thoracica a. subscapularis a. circumflexa a. thoracica rr. bronchiales
superior scapulae interna (a. rr.rr.tracheales
mediastinales
a. thoracica a. subscapularis a. circumflexa a. thoracica
mammaria r.rr. bronchiales
mammaria medialis
superior
a. thoracoacromialis a. ……… anterior
scapulae interna
interna)(a. a.rr.intercostalis
tracheales
mammaria r. mammaria medialis
anterior
a. thoracoacromialis a. ……… anterior interna) a. intercostalis
a. thoracica anterior
lateralis
a. thoracica a. ……… posterior
lateralis
a. ……… posterior
………
a. profunda a. brachialis a. musculophrenica
brachii ………
a. profunda a. brachialis a. musculophrenica
brachii
Anastomosis with
……… ……… a. epigastrica
Anastomosis
inferior with
……… ……… a. epigastrica
inferior
Arcus palmaris Arcus palmaris
superficialis profundus
Arcus palmaris Arcus palmaris
superficialis profundus
Anastomosis with
each other
Anastomosis with
each other

THEMAJOR
THE MAJORARTERIES
ARTERIES OF
OF CRANIAL
CRANIAL CAVITY
CAVITY
THE MAJOR ARTERIES OF CRANIAL CAVITY
……… ………
r. communicans
……… anterior ………
r. communicans
anterior
a. cerebri media a. carotis a. carotis a. cerebri media
interna dextra interna sinistra
a. cerebri media a. carotis a. carotis a. cerebri media
r. communicans interna dextra CIRCULUSinterna sinistra r. communicans
posterior ARTERIOSUS posterior
r. communicans of WILLIS
CIRCULUS r. communicans
posterior ARTERIOSUS posterior
……… ………
of WILLIS
……… ………
a. basilaris
……… a. basilaris ………
……… ………
THE MAJOR VENOUS DRAINAGE OF THE DIGESTIVE ORGAN

THE MAJOR VENOUS DRAINAGE OF THE DIGESTIVE ORGAN
THE MAJOR VENOUS DRAINAGE OF THE DIGESTIVE ORGAN ………
………
v. cava inferior v. portae
……… HEPAR
hepatis
v. cava inferior v. portae
……… HEPAR ………
hepatis
………
v. mesenterica
inferior
v. mesenterica
inferior

THE
THE MAIN
MAIN ARTERIES
ARTERIES OFOF PELVIS
PELVIS ANDLOWER
AND LOWERLIMB
LIMB
Anastomosis with ………

a. epigastrica
superior
To the abdomen
periumbilicalis
………
Bifurcatio iliaca
a. iliaca externa
a. iliaca
interna
a. epigastrica
………
superficial
a. profunda a. pudenda a. …… a. sacralis

femoris externa superior lateralis
a. obturatoria
a. poplitea a. glutea
inferior
a. ……
inferior/
a. rectalis a. vaginalis
media
……… ………
a. uterina/
a. …… a. ductus
interna deferentis
a. fibularis a. dorsalis pedis

THE MAJOR
THE MAJOR VENOUS
VENOUS DRAINAGE
DRAINAGE OFOF THE
THE BODY
BODY
……… ………
v. axillaris v. brachiocephalica v. brachiocephalica

dextra sinistra
v. azygos ……… ………
v. brachialis v. lumbalis Atrium v. lumbalis

ascendens Dextra ascendens
dextra sinistra
v. cephalica v. basilica ………
v. iliaca
communis
v. iliaca sinistra
communis
dextra
v. femoralis v. iliaca externa ………
v. glutealis
……… v. pundenta
interna In bold = Deep vein
v. obturaturia In italic = Superficial vein
……… v. sacralis
v. saphena
parva lateralis = give tributaries
v. rectalis media
v. vesicalis
= continue
Rete venosum v. uterina
dorsale pedis v. vaginalis
3.Describe the main lymphatic nodes and lymphatic vessels in the body:
Lnn. axillares; Lnn. cervicales; Truncus jugularis; Truncus bronchomediastinalis
3. Describe Angulus
the mainvenosus dextra;
lymphatic Angulus
nodes andvenosus sinistra;
lymphatic Ductus
vessels in lymphaticus
the body: dextra
Ductus thoracicus; Cisterna chyli; Lnn. inguinales
Lnn. axillares; Lnn. cervicales; Truncus jugularis; Truncus bronchomediastinalis
Angulus venosus dextra; Angulus venosus sinistra; Ductus lymphaticus dextra
Ductus thoracicus; Cisterna chyli; Lnn. inguinales
Which part of the body will drain into ductus lymphaticus dextra? Which part of the body
will drain into ductus thoracicus? What is the cisterna chyli? What is the main function of
the lymphatic system?

Date : …………………………

THE UPPER RESPIRATORY TRACT
After attending the fourth anatomy practical session, students should be able to:
1. Describe and identify the divisions of the respiratory system:
a. Describe and identify the organs that belong to the upper respiratory tract.
b. Describe and identify the organs that belong to the lower respiratory tract.
2. Describe and identify the organs of upper respiratory tract:
a. Describe and identify the external nose.
b. Describe and identify the nasal cavity and its structures.
c. Describe and identify the paranasal sinuses and its function.
d. Describe and identify the part of pharynx that belong to the respiratory tract.
1. Describe and identify the division of the respiratory system:

a. Upper respiratory tract:
Parts of the air passages which lie above the inlet of the larynx: nasus externus, cavitas
nasi, nasopharynx, oropharynx.
b. Lower respiratory tract:
Larynx, trachea, bronchi, and the rest of the respiratory tree and the respiratory surface
of the lungs.
2. Describe and identify the external nose (nasus externus):

a. Identify the part of nasus externus.
b. Describe and identify the nasal cartilages.
Parts
Nasus Externus …… nasi; ….. nasi; …… nasi; …… nasi; Nares anterior/apertura
nasalis anterior; Vestibulum nasi; Vibrissae
Nasal Cartilages Cartilago nasi lateralis; …… crus medial, crus lateral; Cartilago
alaris minor; Cartilago ……
3. Describe and identify the nasal cavity:

a. Describe and identify the entrance and the exit of nasal cavity:
Anterior hole/entrance Posterior hole/continuous with the
nasopharynx
……… ………
b. Describe and identify the nasal septum:

Parts
Septum nasi cartilagineum ………
Septum nasi osseum Os ethmoidale, lamina perpendicularis; Os vomer

c. Describe and identify the boundaries of the of cavitas nasi:
Boundary Part
Lateral wall Concha nasalis superior; Concha nasalis media; Concha nasalis inferior
Medial wall ………
Roof Frontonasal parts (os frontale and os nasale); Os ethmoidale; Os
sphenoidale
Floor ………
d. Describe and identify the division of cavitas nasi:

Region Location Epithelium Function
Vestibulum nasi ……… Stratificatum squamous ………
Regio respiratoria 2/3 inferior Pseudocolumner with cillia ………
Regio olfactoria ……… ……… Olfaction (special
visceral afferent)
e. Describe and identify the structures in the lateral wall of the nasal cavity:
Structure in the Structures Note
lateral wall of
cavitas nasalis
Elevation Limen nasi ………
Agger nasi An elevation superior to the limen nasi,
contains carina nasi, a sneeze receptor
……… An elevation caused by os concha nasalis
inferior
Concha nasalis media ………
Concha nasalis An elevation caused by os ethmoidale
superior
……… An elevation caused by cellulae ethmoidales
mediae
Meatus Meatus nasi inferior The opening of ductus nasolacrimalis
Meatus nasi medius ………
Meatus nasi superior The opening of cellulae ethmoidales
posteriores
……… The opening of sinus sphenoidalis
Hiatus semilunaris ………
Infundibulum The opening of ductus frontonasalis
ethmoidale
f. Describe and identify the vascularization of the nasal cavity:

In the medial wall of the nasal cavity, identify the location of plexus Kiesselbach! What
vessels contribute to plexus Kiesselbach?
Vessels Origin Course

a. ethomidalis anterior a. ophthalmica ………
a. ethomidalis posterior ……… Contribute to the plexus from superior
r. septalis a. labialis superior a. facialis ………
a. palatina major ……… Through the foramen incisivum then
contribute to the plexus from inferior
a. sphenopalatina a. maxillaris ………
g. Describe and identify the venous drainage and the lymphatic drainage of the nasal cavity!

h. Describe the innervations of the nasal cavity:
For the sensory innervations, the nasal cavity is divided into three parts: the first two part
is divided by an imaginary oblique line from the recessus sphenoethmoidalis to apex nasi.
This line divides the nasal cavity into the anterosuperior part and the posteroinferior part.
The third part is the regio olfactoria.
Parts Innervation
Anterosuperior part Branch of …… (CN V1):
n. ethmoidalis anterior and n. ethmoidalis posterior which are the
branches of n. nasociliaris
Posteroinferior part Branch of …… (CN V2):
n. nasopalatinus; n. palatinus major
Regio olfactoria …… (CN I) via the fila olfactoria that passes the foramina cribrosa
Describe the autonomic (sympathetic and parasympathetic) innervations of the nasal cavity!
What is the main effect of the autonomic nervous system to the nasal cavity?
Autonomic Origin Effect to the Effect to nasal

nerve system mucosal glands cavity blood
vessels
Sympathetic ……… Secretoinhibitor ………
Parasympathetic Ganglion ……… Vasodilatation
pterygopalatinum of the
facial nerve (CN VII)
i. Describe and identify the paranasal sinuses:

1. Describe and identify sinus frontalis, sinus ethmoidalis, and sinus sphenoidalis
Paranasal sinuses Location Note
Sinus frontalis Os frontale ………
Sinus ethmoidalis ……… Consists of three parts; cellulae
(cellulae ethmoidales) ethmoidales: anteriores, mediae, and
posteriores.
Sinus sphenoidalis Os sphenoidale ………
2. Sinus Maxillaris:
The paired sinus maxillaris are the largest of the paranasal sinuses. The form of sinus
maxillaris is like a pyramid with an apex pointing to lateral, basis pointing to the medial,
roof, and floor.
Wall of sinus maxillaris Feature
Apex ………
Basis Forms the inferior part of the lateral wall of the nasal cavity
Roof ………
Floor Formed by the alveolar part of os maxilla
3. Describe the vascularization, sensory innervation, and the structure the paranasal
sinuses drain into.
Paranasal sinus Drain into Vascularization Innervation
Sinus frontalis Infundibulum ……… ………
ethmoidale
through
the ductus
frontonasalis

Cellulae ……… a. ethmoidalis ………
ethmoidales anterior (branch
anteriores of a. ophthalmica)
Cellulae ……… ……… n. ethmoidalis anterior and
ethmoidales n. ethmoidalis posterior
mediae (branch of n. nasocilliaris)
Cellulae Meatus nasi ……… ………
ethmoidales superior
posteriores
Sinus sphenoidalis ……… ……… n. ethmoidalis posterior
Sinus maxillaris Meatus nasi ……… Plexus dentalis superior, a
medius nerves network formed by n.
alveolaris superior posterior,
n. alveolaris superior media,
and n. alveolaris superior
anterior (branches of n.
maxillaris)
4. Describe the autonomic (sympathetic and parasympathetic) innervation and the lymphatic
drainage of the paranasal sinuses!
j. Describe and identify the part of the pharynx that belong to the respiratory tract:
1. Describe and identify the division of the pharynx and the structure in each division:
Part of pharynx Skeletopi Structure
Nasopharynx ……… choanae/apertura nasalis posterior; torus ……; torus
……; plica ……; plica ……; recessus pharyngeus;
ostium pharyngeum tubae auditivae
isthmus pharyngeus
……… VCII – isthmus faucium; arcus ……
VCII /at arcus ……; fossa tonsillaris
the level plica glossoepiglottica mediana; plica glossoepiglottica
of os lateralis; vallecula epiglottica
hyoideum
Laryngopharynx ……… recessus piriformis; plica nervi laryngei
2. Describe the division of the pharyngeal muscles:

Muscles
Intrinsic Muscle m. stylopharyngeus; m. palatopharyngeus
m. salphyngopharyngeus
Extrinsic Muscle m. constrictor pharyngis superior; m. constrictor pharyngis media;
m. constrictor pharyngis inferior; raphe pharyngis
3. Describe the vascularization, sensory innervation, motoric innervation, and the lymphatic
drainage of the pharynx!

m. salphyngopharyngeus
Extrinsic Muscle m. constrictor pharyngis superior; m. constrictor pharyngis media; m.
constrictor pharyngis inferior; raphe pharyngis
3. Describe the vascularization, sensory innervation, motoric innervation, and the

lymphatic drainage of the pharynx!
4. 4.Describe
Describethe
thecomponents
components ofofthe
the Waldeyer’s
Waldeyer’s ringring and
and its its main
main function:
function:
Tonsilla
Pharyngea
……… ………
The Waldeyer’s
Ring
Tonsilla Palatina Tonsilla Palatina
………
Describe the location of each tonsil! What is the main function of the Waldeyer’s ring

Date : …………………………

THE LOWER RESPIRATORY TRACT
After attending the fourth anatomy practical session, students should be able to:
1. Describe and identify the larynx, its internal structures, cartilages, muscles, vascularization,
and innervations.
2. Describe and identify the trachea and bronchus.
3. Describe and identify the lungs and the pleura.
1. Describe and identify the larynx:

a. Describe and identify the laryngeal cartilages:
Laryngeal cartilages Notes
Cartilago thyroidea The largest of the laryngeal cartilages, has lamina dextra
and lamina sinistra which are fused anteriorly to form the
…… (Adam’s apple), the superior border of the cartilago
thyroidea attached to os hyoideum by a membrane,
membrana thyrohyoidea
……… Shaped like a signet ring, attaches to the inferior margin of
cartilago thyroidea by lig. cricothyroideum medianum
Cartilago epiglottica Heart shaped cartilage covered with mucous membrane,
situated in the posterior of radix linguae and os hyoideum,
and located anterior to the aditus laryngis
……… (paired) Paired three-sided pyramidal cartilages. It has an apex
superiorly, proc. vocalis anteriorly, and proc. muscularis that
projects medially from its base
Cartilago corniculata Small elastic cartilages located at the apex of the cartilago
(paired) arytenoidea
……… (paired) Variably small cartilages located at plica aryepiglottica
b. Mention the ligaments and membrane of the larynx:

Ligaments/membrane Location Notes
Lig. vocale ……… ………
Lig. vestibulare Superior to plica vocalis and ………
extends from the cartilago
thyroidea to cartilago
arytenoidea
Membrana Between the lateral aspects Parts of fibroelastic
quadrangularis of cartilago arytenoidea and membrane of the larynx
cartilago epiglottica
Conus elasticus ……… ………
c. Describe and identify the border of the entrance of the laryngeal cavity (aditus laryngis):
Posterior border Lateral border Anterior border
……… Plica aryepiglottica Incisura interarytenoidea

d. Describe and identify the structures in the laryngeal cavity (cavitas laryngis):
Division of the cavitas Structures
laryingis
Vestibulum laryngis Plica vestibularis; Rima vestibuli
Membrana quadrangularis
……… Sacculus laryngis; Rima glottidis; Plica vocalis
Cavitas infraglottica ………
e. Describe and identify the external and intrinsic laryngeal muscles:

Laryngeal Muscles Function Innervations
muscles
Intrinsic m. cricothyroideus; m. thyroarytenoideus;
muscles m. cricoarytenoideus posterior; m.
cricoarytenoideus lateralis; m. arytenoideus
obliquus; m. arytenoideus transversus; m.
vocalis
Extrinsic Suprahyoid muscles: m. mylohyoideus;
muscles m. geniohyoideus; m. stylohyoideus; m.
digastricus
Infrahyoid muscles: m. sternohyoideus;
m. omohyoideus; m. sternothyroideus; m.
thyrohyoideus
Describe muscles that relate to vocal fold (rima glottidis) and vocal ligament:
Vocal Fold (rima glottidis) Vocal Ligament
adduction vocal fold abduction vocal fold strengthen weaken
(close) rima glottidis (open) rima glottidis
m. arytaenoideus ……. ……. …….
……. ……. ……. …….
f. Describe the vascularization and innervations of the larynx:

Part of larynx Vascularization Sensory Lymphatic
innervations drainage
Above plica vocalis ……… n. laryngeus superior ………
r. internus
Below plica vocalis a. laryngea inferior ……… Lnn. paratracheales
2. Describe and identify the trachea and the bronchus

a. Describe and identify the component of the trachea!
b. Describe the division of trachea into pars cervicalis and pars thoracica! Describe the
skeletopi of the trachea, describe and identify the two bronchus prinicipalis, what is the
difference between the two bronchus principalis?
c. What is the carina bifurcatio trachea? Where is it located? What is the importance of the
carina bifurcatio trachea?
d. Describe the vascularization, innervations, and lymphatic drainage of the trachea!
3. Describe and identify the pleurae and the lung:

a. Describe and identify the division of the pleura parietalis and describe its vascularization
and innervation:
Parts of the parietal pleura Note
Pleura costalis
Pleura diaphragmatica
Pleura mediastinalis
Cupula pleurae

b. Describe the vascularization, innervation, and lymphatic drainage of the parietal pleura!
c. Describe the projection of the parietal and visceral pleura to the thoracic wall:
Lower part of pleura parietal Lower part of pleura visceralis
Linea parasternalis Cartilago costa 6 ----
Linea ---- -----
midclavicularis
Linea midaxillaris Costa 10 ----
Linea scapularis ------- Costa 10
d. Describe and identify the structures in the hilus of the lung (hilum pulmonis):
Structures
Hilum pulmo dextra a. pulmonalis; vv. pulmonales; Bronchus lobaris superior pulmonis
dextri; Bronchus lobaris inferior pulmonis dextri; Bronchus lobaris
medius pulmonis dextri; Lig. pulmonale
Hilum pulmo a. pulmonalis; vv .pulmonales; Bronchus lobaris superior pulmonis
sinistra sinistri; Bronchus lobaris inferior pulmonis sinistri; Lig. pulmonale
e. Describe and identify the apex, and basis of the pulmo. Describe and identify the margo
and the facies of the pulmo!
Parts
General parts Apex pulmonis; Basis pulmonis
Margo Margo anterior; Margo posterior; Margo inferior
Facies Facies costalis; Facies diaphragmatica; Facies mediastinalis
Fissura Pulmo sinistra: Fissura obliqua; Pulmo dextra: Fissura obliqua; Fissura
horizontalis
Recessus Recessus costodiaphragmaticus; Recessus costomediastinalis
Hillum Dextra: bronchus epiarterialis, arteria pulmonalis, vena pulmonalis
pulmonis Sinistra: arteri pulmonalis, bronchus lobaris, vena pulmonalis
f. Describe and identify the sulcus and impressio of the pulmo:

Parts
Pulmo Dexter Impressio cardiaca; Sulcus vena cava superior; Sulcus vena azygos;
Sulcus esophagei; Sulcus costalis I
Pulmo Sinister Impressio cardiaca; Sulcus aorta ascendens; Sulcus arcus aortae;
Sulcus aorta descendens; Sulcus costalis I; Lingula pulmonis sinistri;
Incisura cardiaca
g. Describe the vascularization, lymphatic drainage, and the autonomic innervations of the lung!
What is the main effect of the sympathetic and parasympathetic stimulation on the lung?
Tissue Vascularization Lymph nodes Autonomic Effect of

innervation innervations
(bronchus, mucosal
glands, vessel)
Lung tissue a. bronchialis lnn. pulmonales n. vagus ………..
(alveolus/
parenchyma)
Bronchial tree ………. lnn. bronchiales ………….. bronchodilatation
bronchocontraction
Bifurcation ……
trachea

h. Describe and identify the segments of the lung:
Pulmo Lobus Segment
Pulmo Dextra Lobus Superior Apical; Posterior; Anterior; Lateral; Media; Superior;
Lobus Medius Basalis anterior; Basalis posterior; Basalis medialis;
Lobus Inferior Basalis lateralis
Pulmo Sinistra Lobus Superior Apical; Posterior; Anterior; Lingulalis superior;
Lingulalis inferior; Superior; Basalis anterior
Lobus Inferior Basalis posterior; Basalis medialis; Basalis lateralis

Date : …………………………
Date : …………………………
ANATOMY PRACTICALOF
INTEGRATED MACROSTRUCTURES SESSION 6
CARDIORESPIRATORY
INTEGRATED MACROSTRUCTURES OF CARDIORESPIRATORY SYSTEM
SYSTEM
In the end of the first anatomy practical session, students should be able to:
1. end
In the Understand,
of the firstdescribe,
anatomyand identify
practical the integrated
session, studentscomponents of the
should be able to: cardiorespiratory
system, including thoracic wall, cardiovascular system (heart and blood vessels),
1. Understand, describe, and identify the integrated components of the cardiorespiratory system,
respiratory tract, and its innervation.
including thoracic wall, cardiovascular system (heart and blood vessels), respiratory tract,
and its innervation.
THORAX
Thoracic Wall Respiratory System Cardiovascular System
Upper Tract Lower Tract Heart Blood Vessels
Vasculature, Lymphatic Drainage & Innervation
Somatic Autonomic
Dermatome
Sympathetic Parasympathetic

2. Describe the framework of the thorax, including the sternum and its parts.
3. Diagram a typical intercostal space, including muscles, nerves, and vessels.
4. Describe the make up and surface projections of the pleural cavity. Identify its recesses.
5. Distinguish between parietal and visceral pleura and between parietal and visceral
pericardium. Identify the various divisions of the parietal pleura.
6. Identify and describe the mediastinum, including its boundaries and subdivisions.
7. Identify the contents of the anterior mediastinum.
8. Describe the pericardium and its parts.
9. Identify the sternocostal projections of the heart, in addition to its borders, surfaces, and sulci.
10. Identify the organs forming the respiratory passageway(s) in descending order until the
alveoli are reached.
11. Describe the location, structure, and function of each of the following: nose, paranasal
sinuses, pharynx, and larynx.
12. Describe the gross structure of the lungs and pleurae.
13. Describe the neural controls of respiration.
14. Describe the size, shape, location, and orientation of the heart in the thorax.
15. Name the coverings of the heart.
16. Describe the structure and function of each of the three layers of the heart wall.
17. Describe the structure and functions of the four heart chambers. Name each chamber and
provide the name and general route of its associated great vessel(s).
18. Name the heart valves and describe their location, function, and mechanism of operation.
19. Trace the pathway of blood through the heart.
20. Name the major branches and describe the distribution of the coronary arteries.
21. Name the components of the conduction system of the heart, and trace the conduction
pathway.

BLOCK A.3
PRACTICAL SESSION OF PHYSIOLOGY
BLOOD PRESSURE REGULATION

SPIROMETRI
HARVARD STEP UP TEST
DEPARTMENT OF PHYSIOLOGY
FACULTY OF MEDICINE, PUBLIC HEALTH, AND NURSING
UNIVERSITAS GADJAH MADA
YOGYAKARTA
2020

General Rules
Laboratory of Physiology
1. Student has to obey the regulation of Medical Faculty Universitas Gadjah Mada
2. Student has to wear shoes and laboratory coat.
3. Student has to sign the attendance form for each practical session.
4. Student must attend the class on time. No one permit to come late more than fifteen minutes.
5. Student must bring the practical guide. No one permit to bring handphone, HSC and the
other things which not related to the practical session.
6. Student will be given pretest and posttest; it will be conducted at the beginning and the end
of each practical session.
7. If student come late before fifteen minutes, but pretest already finished, he/she is not
permitted to perform the pretest and posttest. And as the consequence he/she will lost his/
her score for this session.
8. Student has to participate each practical session completely and be recognized by the
authority of physiology laboratory. Students with absence of three particular circumstances
(being illness, in grieve of family members or in an activity involvement as faculty’s
representative) must obtain the inhall practical session.
9. Each student group has to arrange a laboratory report for each laboratory activity, and the
report has to completed at least one week before block examination.
11. Student is prohibited to use any equipment which does not related to practical session
on that day. If there is any equipment damaged or lost during practical session, the group
responsible to replace it.
12. Certificate of Satisfaction of Physiology Laboratory will be awarded to those:
• Students with full attendance in all practical sessions.
• Students who obtain well-requested marks to minimum mark of 6 ( the mark consist of
pre-test and post-test: 20-40%; report 20% and practical examination: 40- 60%).
• Students who have settled the administration matters at Department of Physiology
regarding practical activities.

BLOOD PRESSURE REGULATION
Objective
After this practical session, students are expected to be able to:
1. Observe the regulation of blood pressure due to change in body position.
2. Explain the physiological control pathways underlying the blood pressure response to
change in body position.
3. Analyze data and draw appropriate conclusions about blood pressure changes.
Introduction
Blood pressure (BP) is the force exerted by blood as it presses against the walls of blood
vessels. When the heart beats faster or harder, BP increases. If some internal or external
stimulus causes blood pressure (controlled condition) to rise, the sequence of events occurs
as negative feedback. Several reflexes in the cardiovascular system help control the arterial
blood pressure and heart rate. Several interconnected negative feedback systems control
blood pressure by adjusting heart rate, stroke volume, systemic vascular resistance, and blood
volume. Some systems allow rapid adjustments to cope with sudden changes, such as the drop
in blood pressure in the brain that occurs when you get out of bed. One of these reflexes is the
baroreceptor reflex, a simple and a rapidly acting control mechanism.1,2
Stretch receptors called baroreceptors are located in the walls of the bifurcation region of
the carotid arteries in the neck, and also in the arch of the aorta in the thorax. This receptors
are stimulated by stretch of the arterial wall. When these become stretched by high pressure,
signals are transmitted to the brain stem. Here these impulses inhibit the vasomotor center
where they inhibit the sympathetic impulses to the heart and blood vessels and excite the
parasympathetics. Lack of these impulses causes diminished pumping activity by the heart and
also dilation of the peripheral blood vessels, allowing increased blood flow through the vessels.
Both of these effects decrease the arterial pressure. This allows the arterial pressure to fall back
toward normal.2,3
The ability of the baroreceptors to maintain relatively constant arterial pressure in the
upper body is important when a person stands up after having been lying down. Immediately on
standing, the arterial pressure in the head and upper part of the body tends to fall, and reduction
of this pressure could cause loss of consciousness. In normal condition, the falling pressure at
the baroreceptors elicits an immediate reflex, resulting in strong sympathetic discharge through
out the body that minimizes the decrease in pressure in the head and upper body.1
Time Allocation
Time Activity Students Instructor
5 minutes Pre-test Answering the questions Lead the pretest Question and
answer sheet -
30 minutes Introduction Listening Explaining & Video, PPT
demonstating
60 minutes Practical Practicing Guiding & Equipment
session discussing
5 minutes Post-test Answering the questions Lead the post test Question and
answer sheet -
Material and Equipment

1. Sphygmomanometer mercury
2. Stethoscope
3. A patient bed

Procedures
If you are the operator, seat yourself in proper proximity to the subject and proceed as follows:
place the arm band around the left arm just above the elbow, locate the brachial artery just
below the band, and gently place the stethoscope bell over the artery.
Observations
1. Pump air into the cuff until a distinct sound is heard in the stethoscope. Slowly increase
the pressure in the cuff until the sound disappears or you cannot feel the pulse anymore.
Than pump again about 30 mmHg above. For example, if the sound disappears at 150
mmHg than pump again until 180 mmHg.
2. Reduce the pressure in the cuff gradually. The first sound you hear is the systolic point
and at this time the systolic pressure, in mmHg, is read from the sphygmomanometer.
The palpatoir systolic should be checked, by means of a second reading.
Reading No 1: ____________ mmHg (palpation)
Reading No 2: ____________ mmHg (auscultation)
3. Measure the blood pressure in three different positions (lying down, sitting down and
standing up), for each position measures it three times. Wait for 3-5 minutes before pump
the cuff for every measurement (9 measurements).
4. Measure the blood pressure with patient lying down, then have the patient stand up
suddenly and measure it again at that time. Repeat this procedure three times (6
measurements).
References
1. Guyton AC. and Hall, J.E. 2016. Guyton and Hall Textbook of Medical Physiology. 13th ed.
Elsevier, Philadelpia. pp. 219-222.
2. Tortora, G.J. & Derrickson, B. 2017. Principles of Anatomy and Physiology. 15th ed. John
Willey & Sons, United States of America. pp. 752-758.
3. Silverthorn, D.U., Michael, J. 2013. Cold test and the
cold pressor test. Adv Physiol Edu. 37:93-96.

SIGNATURE OF LABORATORY PRACTICE PARTICIPANT
Subject 1
Name : ……………………………………………………….
Student Number : ……………………………………………………….
Age : ……………………………………………………….
I have read and understand the manual guide of BLOOD PRESSURE REGULATION laboratory
practice and I volunteer to participate in this laboratory practice as a proband.
Yogyakarta, ……………………
(.………………………)
Subject 2
Name : ……………………………………………………….
Student Number : ……………………………………………………….
Age : ……………………………………………………….
(.………………………)
Subject 3
Name : ……………………………………………………….
Student Number : ……………………………………………………….
Age : ……………………………………………………….
(.………………………)

DATA SHEET
Name : Gender :
Age : Body weight/height :
Baroreceptor
Lying down with arms beside the body

Measurement Subject 1 Subject 2 Subject 3
Reading no 1 (systole/
diastole)
diastole)
diastole)
Mean of result
Sitting down with arms hanging beside the body

diastole)
diastole)
diastole)
Mean of result
Standing up with arms hanging beside the body

diastole)
diastole)
diastole)
Mean of result
Lying down then stand up suddenly

Measurement Lying down (mmHg) Stand up suddenly (mmHg)
Subject 1 Subject 2 Subject 3 Subject 1 Subject 2 Subject 3
Reading no 1
(systole/diastole)
Reading no 2
(systole/diastole)
Reading no 3
(systole/diastole)
Mean (systole/
diastole)

Result
Measurement Subject 1
Subject 2 Subject 3
(Mean)
Lying down (systole/diastole)
Sit down (systole/diastole)
Standing up (systole/diastole)
Stands up after lying down
(sistole/diastole)
Interpretation : ...............................................................................................................
...............................................................................................................
...............................................................................................................
Feedback : ...............................................................................................................
...............................................................................................................
...............................................................................................................
Instructor, Student,
(__________________)
(__________________)

VOLUME AND CAPACITY OF THE LUNG
Objective
1. Understand factors affecting volume and capacity of the lung
2. Calculate volume and capacity of the lung using spirogram.
3. Make an interpretation of findings.
Introduction
The main task of respiratory system is to provide oxygen for tissues and removed
cabondioxyde. To reach the goal, there are 4 step of respiratory cycle that should be passed
(figure 1):
i. Ventilation
ii. Gas exchange between alveoli and pulmonary capillaries
iii. Transport of gas
iv. Gas exchange between systemic capillaries and tissue cells.
Figure 1. Respiratory process 1
Ventilation is process of gas exchange between atmosphere and lung (inspiration and
expiration). To understand about pulmonary ventilation, spirometer is used in this experiment to
measure the volume and capacities of the lung. Spirometry is one of a non-invasive, objective
and reproducible measurement of pulmonary function.
There are many kind of spirometer available, here is some of them:
Hutchinson Spirometer Microlab Spirometer Digital Spirometer

Using spirometer, the following volume and capacities are possible to be measured2:
a. Tidal Volume
Tidal volume is the amount of air moved into and out of the lungs during natural respiration.
b. Inspiratory Reserve Volume (IRV)
IRV is the maximum amount of gas that can be inspired after tidal inspiration.
c. Expiratory Reserve Volume (ERV)
ERV is the maximum volume of air that can be expired after tidal expiration.
d. Inspiratory Capacity (IC)
Inspiratory capacity is the amount of air that can be inspired after normal quite inspiration
(IC= IRV + TV).
e. Vital Capacity (VC).
Vital capacity is defined as the amount of air that can be exhaled forcibly after the most
forceful inspiration.
Figure 2. Spirogram
Time Allocation
Time Activity Students Instructor Material
10 minutes Preparation and answering the Lead the pretest Question and answer
pre test questions sheet
35 minutes introduction listen explain video, Power point
50 minutes practice practicing guiding and Spirometer, paper graph,
discussing nose clip, mouthpiece,
calculator
5 minutes post test answering the Lead the post Question and answer
questions test sheet

1. Spirometer:
Hutchinson Spirometer
2. Hutchinson millimeter block graph paper
3. Nose clips
4. Mouth piece
5. Alcohol 70% solution
Procedure and observations with Hutchinson Spirometer

A. Prior to testing
Although it is safe for most people, some people should avoid this procedure3:
• Excessive tiring (patients who cannot expend the required effort for testing)
• Severe respiratory distress

• Patients not motivated or desiring to take the test
• Children too young
• Recent eye surgery, because of increased pressure inside the eyes during the procedure
• Recent belly or chest surgery
• Chest pain, recent heart attack, or an unstable heart condition
• A bulging blood vessel (aneurysm) in the chest, belly, or brain
• Active tuberculosis (TB) or respiratory infection, such as a cold or the flu
Prior to performing spirometry, records the age, gender, height and weight of the subject.
Check for factors that the patient should be avoided prior to the test (Table 1). Records the
temperature of the room, humidity and the room air pressure.
Table 1. Factors that the patient should be avoided prior to the test4
B. Examination Technique
1. Clean up the mouthpiece of spirometer with alcohol 70% solution or use disposable
mouthpiece and set the pointer at the middle of the graph paper.
2. Connect the spirometer to the electrical power source and turn it on (green lamp is on)
3. Set te paper velocity at the 2,5 mm/second.
4. Hold the nose with nose clip.
5. Put the mouthpiece around the mouth tightly, breathing as usual by your mouth through
this mouthpiece (inhale and exhale), subsequently inhale as deeply as possible and
exhale with maximum effort.
6. Repeat by 3-8 times, until we get at least three similar result (difference of each tidal
volume <5%, vital capacity < 150 ml), then we get a spirogram like picture below2:
7. Calculate each volume and capacity from spirogram (1 mm of amplitude = 30 ml of air).

8. Calculate vital capacity prediction (VCP) According to the Pneumobile Project Indonesia5:

Table 2. Normal Value of FVC of Indonesian Male People

Table 2. Normal Value of FVC of Indonesian Female People
9. Calculate ratio of Vital Capacity/ Vital Capacity Prediction

References
1. Sherwood, L. From Cells to Systems. In: Human Physiology: From Cells to System [Internet].2012.
pp 461–510. Available from: http://journals.sagepub.com/doi/10.1177/1073858411422115
2. Guyton, A.C. and Hall, J.E. Pulmonary Ventilation. In: Textbook of Medical Physiology. 2006.
pp. 471–6.
3. Altman, M.A. Pulmonary function testing [Internet]. Third Edit. Diffuse Lung Disease:
A Practical Approach. 2012. Second Edition. Mosby, Inc. Available from: http://dx.doi.
org/10.1016/B978-0-323-05267-2.00091-1
4. Moore, V.C. Spirometry: step by step Educational aims. Eur Respir J [Internet]. 2012.
8(3):233–40. Available from: http://breathe.ersjournals.com/content/breathe/8/3/232.full.pdf
5. Mangunnegoro, H., Alsagaff, H., Bernstein, R., Johnson, L., et al. Nilai-Normal-Faal-Paru-
Indonesia. 1992. Pneumobile.pdf.

Subject 1
Name : ............................................................................................
Student Number : ............................................................................................
Age : ............................................................................................
I have read and understand the manual guide of VOLUME AND CAPACITY OF THE LUNG
laboratory practice and I volunteer to participate in this laboratory practice as a proband.
Yogyakarta, ............................

(.........................................)
Subject 2
Name : ............................................................................................
Student Number : ............................................................................................
Age : ............................................................................................
I have read and understand the manual guide of VOLUME AND CAPACITY OF THE LUNG
laboratory practice and I volunteer to participate in this laboratory practice as a proband.
Yogyakarta, ............................

(.........................................)

DATA SHEET
VOLUME AND CAPACITY OF THE LUNG
Environment condition
Room air : Temperature .......................... oC
Humidity ........................... %
Air Pressure ........................... mmHg
Identity
Subject 1 Subject 2
Subject’s name
Gender
Age (year)
Height (cm)
Weight (kg)
Position
Result :
Subject 1 Subject 2
Tidal volume (ml) 1. 1.
2. 2.
3. 3.
Average: Average:
Inspiratory reserve volume (ml) 1. 1.
2. 2.
3. 3.
Average: Average:
Inspiratory Capacity (ml) 1. 1.
2. 2.
3. 3.
Average: Average:
Expiratory reserve volume (ml) 1. 1.
2. 2.
3. 3.
Average: Average:
Vital Capacity (ml) 1. 1.
2. 2.
3. 3.
Highest: Highest:
Vital Capacity Prediction (ml)
VC/ VCP ratio (%)
Interpretation : ...............................................................................................................
...............................................................................................................
...............................................................................................................
Feedback : ...............................................................................................................
...............................................................................................................
...............................................................................................................
(__________________) (__________________)

Harvard Step-Up Test
(Fitness Test)
Objective
1. Asses physical fitness index of the subject using Harvard Step Up Test
2. Monitor the capability of the subject’s cardiovascular system.
Introduction
Physical fitness is a set of attributes a person have or achieve, which is linked to the person’s
capability to do physical activity. Fitness is divided into health and skill related components, with
the health component further consists of cardiorespiratory endurance, muscular endurance,
muscular strength, and flexibility Physiological fitness implies the capacity for skillful performance
and rapid recovery. Physiological effort is estimated from the magnitude of the heart rate change
during exercise and front the rapidity of return of the heart rate to normal following the exercise.
Physical fitness implies not only the absence of disabling deformity or disease and the
capacity to perform a sedentary task efficiently but also a sense of physical well-being and the
capacity to deal with emergencies demanding unaccustomed physical effort
The Harvard Step test is a test of aerobic fitness, developed by Brouha et al. (1943) in the
Harvard Fatigue Laboratories. The Harvard step test is a kind of cardiovascular endurance test,
it is a type of cardiac stress test for detecting and diagnosing cardiovascular disease. It also is
a good measurement of fitness and a person’s ability to recover after a strenuous exercise by
checking the recovery rate. The more quickly the heart rate returns to resting, the better shape
the person is in.
Testing and measurement are the means of collecting information upon which subsequent
performance evaluations and decisions are made but in the analysis we need to bear in mind
the factors that may influence the results.
Time Allocation
Time Activity Students Instructor Material
5 minutes Preparation answering the Lead the pretest Question and answer sheet
and pre test questions
30 minutes introduction listen explain Power point
40 minutes practice practicing guiding and Standard gym bench
discussing (Harvard Step) 40 cm high,
Stop watch, Metronome
20 minutes Discussion listen explain
5 minutes post test answering the - Question and answer sheet
questions

To undertake this test we will require:
1. Standard gym bench (Harvard Step) 40 cm high
2. Stop watch
3. Metronome

Procedure
The Harvard Step Test is conducted as follows:
1. The subject sits down for 5 minutes, then count the pulse in one minute by the following
procedure.
a. Compare the rhythm & power pulse of the right and left wrist (radial artery).
b. If equal, count the pulse in 15 seconds then multiplied by 4
c. If different, count the pulse in one minute full.
2. Set the metronome at 120 beats for 30 complete steps every minute. Practice to do the right
each complete step in 4 beats (one: right foot up; two: left foot up, knee straight; three: right
foot down; four: left foot down).
3. After the supervisor gives a sign, the subject start to step up and down on the bench for
maximum 5 minutes. Have someone to help the subject keep to the required pace. Stop
the step at any times if the subject:
a. Cannot maintain the stepping rate for 15 steps
b. Falling down
c. Headache
d. Chest pain
e. Exhausted
4. The subject immediately sits down on completion of the test for one minute, then count the
pulse for 30 seconds (P).
Analysis
Duration (seconds) x 100

Physical Fitness Index (PFI)= ----------------------------------------------------------------------------
5,5 x P (pulses in 30 seconds duration, 1 minute after finish the step)
For an estimation of your fitness level:

IF YOUR SCORE:
>80 Good
50 - 80 Average
<50 Poor
References
o Brouha L, Health CW, Graybiel A. Step test simple method of measuring physical fitness
for hard muscular work in adult men. Rev Canadian Biol, 1943 ;2:86
o Hall, J.E. 2016. Guyton and Hall Textbook of Medical Physiology. 13th ed. Elsevier, Philadelpia.
pp. 219-222.

Subject 1
Name : ............................................................................................
Student Number : ............................................................................................
Age : ............................................................................................
I have read and understand the manual guide of Harvard Step-Up Test laboratory practice and
I volunteer to participate in this laboratory practice as a proband.
Yogyakarta, ...........................

(......................................)
Subject 2
Name : ............................................................................................
Student Number : ............................................................................................
Age : ............................................................................................
I have read and understand the manual guide of Harvard Step-Up Test laboratory practice and
I volunteer to participate in this laboratory practice as a proband.
Yogyakarta, ...........................

(......................................)

HARVARD STEP-UP TEST RESULT SHEET
Identity
Name : ...........................................................................................................
Age : .................................... year
Sex : male/female
Height : .................................... cm
Weight : .................................... kg
Result
1. Man volunteer
Test duration : .................................... seconds
Heart rate before doing test : .................................... bpm
Heart rate after doing test : .................................... for 30 seconds
Fitness score : ....................................
Conclusion : ....................................
2. Woman volunteer
Test duration : .................................... seconds
Heart rate before doing test : .................................... bpm
Heart rate after doing test : .................................... for 30 seconds
Fitness score : ....................................
Conclusion : ....................................
( ) ( )

BLOCK A.3
SYSTEMA CARDIORESPIRATORIUM
PRACTICAL SESSION OF HISTOLOGY
Session 1
Microstructure of Cor, Valva Atrioventricularis, Musculus Papillaris
and Vasa Sanguinea
Session 2
Microstructure of Tractus Respiratorius
Contributors:
Dra. Dewajani Purnomosari, M.Si, Ph.D
Dian Eurike Septyaningtrias, S.Ked, M.Sc, Ph.D
Jajah Fachiroh, SP, M.Si, Ph.D
Drg. Yustina Andwi A S, M.Kes
dr. Rina Susilowati, Ph.D
Dewi Kartikawati Paramita, S.Si, M.Si, Ph.D
Department of Histology
Yogyakarta
2020

General Rules in Histology Laboratory
1. Histology practical work is held online.

2. Students are obliged to follow all sessions on the designated time.
3. Before each practical work, students must study module for practical work and watch the
explanation video through Gadjah Mada Medical E-learning (Gamel)
4. Students must follow all practical work through Gamel, fully study and answer all questions
of the practical work according to the session.
5. Each practical session is held for 100 minutes, 70 minutes for studying the material and
answering questions, while 30 minutes is used for students-instructor group discussion.
6. Before the discussion time, representative of the student group should independently send
link for online discussion media (zoom, webex, google meet, etc) to all group members and
the instructor.
7. Students are obliged to attend the discussion forum with instructors; discussing the practical
material of the day that is poorly understood.
8. Students who are unable to attend practical sessions for allowed reasons must provide a
letter from the institution or parent/ legal guardian. For instance, sick-leave letter must be
issued by GMC or hospital, or when there is death in the family the letter must be provided
by the parent/ legal guardian.
9. Students who are unable to attend the practical session must follow replacement session
(inhal) according to the designated time. They must fill in the practical absence form
(formulir ketidakhadiran praktikum) provided in Gamel and upload the required document.
Replacement session will only be held ONCE for all practical sessions.
10. Instruction for answering questions on practical work and exam:
● Use nomina histologica to answer questions on structure
● Do not use abbreviation
● Answer the question specifically
Assessment
Assessment will be done by the end of the block, that includes:
a. Score on practical works 30%
b. Score on exam 70%
The score contributes to the total block score.
Students with final practical work score below 60 are suggested to follow remediation for the
exam on the designated time and register themselves to Mr. Muryadi by sending an e-mail
(muryadi@ugm.ac.id and d.purnomosari@ugm.ac.id).

SESSION 1:
MICROSTRUCTURE OF COR, VALVA ATRIOVENTRICULARIS, MUS-
CULUS PAPILLARIS AND VASA SANGUINEA
Objective To observe and describe microscopic structure of heart (cor), valva

atrioventricularis, musculus papillaris and vasa sanguinea.
Name of specimen, staining

1. Heart (Cor), Hematoxylin Eosin
2. Valva Atrioventricularis, Hematoxylin Eosin
3. Musculus papillaris, Hematoxylin Eosin
4. Arteria and Vena, Hematoxylin Eosin
5. Aorta, Hematoxylin Eosin
6. Aorta, Hematoxylin Verhoeff
Background Systema cardiovasculare is composed of cor (heart), vasa sanguinea (arteria,

theory vena and vas capillare (capillary)).
Cor is the main organ in systema cardiovasculare, responsible to pump blood
throughout the body. Arteria and vena distribute blood from cor throughout
the body and vice versa, from cells and tissues back to cor. Around 5 liters of
blood circulates in the circulatory system. Vas capillare, which is the smallest
vasa sanguinea, plays role in the exchange of oxygen and nutrients from
blood to tissues, as well as the exchange of metabolic waste and carbon
dioxide from tissues to blood. The structure of cor and vasa sanguinea can be
read in Mescher, A.L. Junquera’s Basic Histology Text and Atlas. 2016. 14th
edition. McGraw Hill Education. New York. Pages 215 - 219.
Valva atrioventricularis is a valve between atrium and ventriculus which

prevents regurgitation of ventricular blood to atrium. There are two types of
valva, valva tricuspidalis and valva mitralis. Valva tricuspidalis is located
between atrium and ventriculus dexter, while valva mitralis is located
between atrium and ventriculus sinister. Histologically, there is no difference
between valva mitralis and valva tricuspidalis.
usculus papillaris, which is located in the ventricular wall, binds to valva
atrioventricularis via chordae tendineae. A tensed chordae tendineae prevents
inversion or prolapse of the valve.
Procedure Open practical work link in Gamel.
Read the instruction, observe the displayed structures, and answer the
questions provided. Make sure that you have sent the answers before the
session is over.
1. Cor (Heart)
Staining : Hematoxylin Eosin
Speciment explanation:
Heart wall consists of 3 layers; endocardium, myocardium and epicardium. Endocardium is
the innermost layer of the heart, consisting of endothelium and stratum subendotheliale.
Endothelium is composed of one layer of endotheliocytus and membrana basalis. Stratum
subendotheliale is a thin textus connectivus laxus composed of fibra elastica, fibra collageni and
a few myocytus levis. Stratum subendocardium lies between endocardium and myocardium.
In stratum subendocardium, myofibra cardiaca conducens (Purkinje fibers) can be found.
Myofibra cardiaca conducens is part of the heart conduction system (can be read in Mescher, A.

L. Junquera’s Basic Histology Text and Atlas. 2016. 14th edition. McGraw Hill Education. New
York. Pages 215 - 219). Myofibra cardiaca conducens is a modification of myofibra cardiaca, and
responsible for transmitting impulses to the entire heart wall. Myofibra cardiaca conducens is
larger than myofibra cardiaca, with nucleus situated in the center of the cell and pale cytoplasma.
Myocardium is the middle layer of the heart wall. This layer is the thickest layer and is
composed of myocytus cardiacus/myofibra cardiaca (heart muscle cells). Myofibra cardiaca
has a short cylindrical shape, interlocked to form an elongated structure. The junction between
myofibra cardiaca is called discus intercalatus. In this specimen, discus intercalatus is difficult
to observe. Myofibra cardiaca has one or two nuclei located in the center of the cell. Among
myofibra cardiaca, textus connectivus rich with vas capillare can be found. Myocardium in the
atrial wall is usually thinner than that in the ventricular wall. Myofibra cardiaca conducens can
also be found in myocardium.
Epicardium is the outer layer of the heart wall, consisting of textus connectivus coated by a
single layer of flat epitheliocytus called the mesothelium. In this specimen adipocytus can be
found in the epicardium.
Discussion:
1. How do you differentiate epicardium from endocardium in the observed specimen?
2. What are the morphological characteristics of myofibra cardiaca conducens?
References:
● Mescher, A.L. Junquera’s Basic Histology Text and Atlas. 2016. 14th edition. McGraw Hill
Education. New York. Page 215 – 219.
● Federative International Committee on Anatomical Terminology (FICAT) 2008. Terminologia
Histologica. International Terms for Human Cytology and Histology. Wolter Kluwer. Lippincott
Williams & Wilkins
STRUCTURES NEED TO BE OBSERVED

Low magnification High magnification
1. Endocardium 1. Endothelium
2. Myocardium 2. Stratum subendotheliale
3. Epicardium 3. Stratum subendocardium
4. Myofibra cardiaca conducens
5. Myofibra cardiaca
6. Mesothelium
7. Adipocytus
2. Valva atrioventricularis
Specimen explanation:
The observed specimen is a longitudinal section of valva atrioventricularis that lies between
atrium and ventriculus. Valva atrioventricularis is composed of textus connectivus compactus
lined by endocardium on both sides (atrium side and ventricular side).
The walls of atrium and ventriculus can be distinguished based on the thickness of the
myocardium. The atrial myocardium is thinner than the ventricular myocardium.
The atrial endocardium is thicker than ventricular endocardium. Textus adiposus can also be
found in epicardium.
Discussion:
1. What is the role of valva atrioventricularis?
2. How can we differentiate atrial wall from ventricular wall?

References:
Education. New York. Page 219.
Williams & Wilkins.

1. Atrial wall 1. Endocardium atrium
2. entricular wall 2. Endocardium ventriculus
3. Valva atrioventricularis 3. Endotheliocytus
4. Myofibra cardiaca
3. Musculus papillaris
Musculus papillaris has a cone-shaped structure, coated by a thin endocardium. The base
of musculus papillaris is part of the wall of ventriculus cordis, and is composed of myofibra
cardiaca. The tip of musculus papillaris continues as chordae tendineae, that is composed of
textus connectivus compactus regularis. The center of the musculus papillaris consists of a
mixture of myofibra cardiaca and textus connectivus compactus.
Discussion:
1. What is/are the function of musculus papillaris and chordae tendineae?
2. When atrium contracts, blood flows into ventriculus as valva atrioventricularis opens.
Conversely, when ventriculus contracts, blood flows to aorta as valva atrioventricularis
closess. From both conditions, when does musculus papillaris contract? Is chordae tendineae
stretched whenmusculus papillaris is contracting?
References:
● Tortora GJ dan Derrickson B. 2012. Principles of Anatomy & Physiology. 13th edition. John
Wiley & Sons, Inc. Page 763 – 767.
Williams & Wilkins.

1. Musculus papillaris 1. Fibra collageni
2. Area containing textus muscularis and textus connectivus 2. Fibroblastus
3. Chordae tendineae 3. Myofibra cardiaca
4. Arteria and Vena

At low magnification, arteria and vena can be distinguished by the thickness of the wall, as well
as by the size and shape of their lumen. Arteria has a narrower, rounded lumen and a relatively
thicker wall than vena. The venous lumen tends to collapse, resulting in an irregular shape.
Arteria and vena’s wall consists of 3 main layers, namely tunica intima (the inner layer facing
the lumen) tunica media, the middle layer and tunica adventitia/externa as the outer layer.

Tunica intima is composed of endothelium, stratum subendotheliale and membrana elastica
interna. Tunica media consists of circular myocytus levis/myocytus non striatus. Tunica
media of vena is thinner than tunica media of arteria.
Tunica adventitia is composed of textus connectivus laxus. Tunica adventitia of vena is thicker
than tunica adventitia of arteria. Tunica adventitia of the large vasa has small blood vessels
known as vasa vasorum. Vasa vasorum serves to supply nutrients to cells and tissues that are
far from the lumen of the vasa.Vena of the inferior extremities has valva which prevents blood
flowing toward gravity. Valva vena is tunica intima protrusion toward the lumen
Discussion:
1. Why does lumen of vena look irregular, while arteria’s lumen looks rounded?
2. What is/are the function of valva vena of the inferior extremities?
References:
● Mescher, A.L. 2016. Junquera’s Basic Histology Text and Atlas. 14th edition. McGraw Hill
Education. New York. Page 223 – 224, 229 – 230.
Williams & Wilkins.

1. Arteria 1. Endotheliocytus
2. Vena 2. Membrana elastica interna
3. Tunica Intima arteria and vena 3. Myocytus levis
4. Tunica media arteria and vena 4. Fibra collageni
5. Tunica adventitia arteria and vena 5. Vasa vasorum
6. Valva vena
5. Aorta
Staining : Hematoxylin Eosin and Verhoeff
The aortic wall has a basic structure similar to arteria and vena, consisting of 3 layers, namely
tunica intima, tunica media, and tunica adventitia. This general structure can be observed
in specimens stained with hematoxylin eosin. Tunica adventitia of aorta is relatively thin and is
composed of textus connectivus laxus. Vasa vasorum is found in this layer and tunica media.
The aortic wall has high levels of elastin, so the aorta is often referred as arteria elastotypica.
Fibra elastica is found in tunica media and forms membrana elastica fenestrata, alternates
with circular myocytus levis. Fibra elastica appears black in specimens stained with Verhoeff,
while nucleus of various cells were not visible.
Discussion:
1. What is the correlation between the e presence of membrana elastica fenestrata and aorta’s
function?
2. Why does vasa vasorum can only be observed in large sized vasa?
Reference:
● Mescher, A.L. 2016. Junquera’s Basic Histology Text and Atlas. 14th edition. McGraw Hill
Education. New York. Page 220 – 222.
Williams & Wilkins.

1. Tunica intima 1. Endotheliocytus
2. Tunica media 2. Fibra elastica
3. Tunica adventitia 3. Myocytus levis
4. Vasa vasorum
5. Fibroblastus

SESSION 2:
MICROSTRUCTURE OF TRACTUS RESPIRATORIUS
Objectives To observe and describe microscopic structure of cavum nasi, epiglottis,

trachea, bronchus, bronchiolus and alveolus.
Specimen name, staining

Cavitas nasi, Hematoxylin Eosin
Epiglottis, Hematoxylin Eosin
Trachea, Hematoxylin Eosin
Pulmo – Bronchus, Hematoxylin Eosin
Pulmo – Bronchiolus – Alveolus, Hematoxylin Eosin
Background Tractus respiratorius is divided into two parts based on its function; pars
theory conductoria (provides a channel for air movement to and from alveoli) and
pars respiratoria ( facilitates the exchange of oxygen and carbon dioxide). Pars
conductoria consists of cavitas nasi, nasopharynx, larynx, trachea, bronchus,
bronchiolus and bronchiolus terminalis. Pars respiratoria consists of bronchiolus
respiratorius, ductus alveolaris and alveolus.
Epiglottis is a flap cartilage on the pharynx, behind lingua and in front of the
larynx. Epiglottis is usually in an upright position, allowing air to pass into the
larynx, trachea and pulmo. During deglutition (swallowing), epiglottis folds
backward to cover the entrance of the larynx. Thus, the swallowed food and
liquid do not enter the trachea and pulmo. Afterward, epiglottis returns to its
original upright position.
Trachea is the continuation of the larynx and ends in a branching structure called
bronchus. Bronchus branches to form smaller structures called bronchiolus.
Each bronchiolus forms five to seven terminal branches called bronchiolus
terminalis. Bronchiolus terminalis branched into two or more bronchiolus
respiratorius.
The wall of tractus respiratorius pars conductoria consists of tunica mucosa,
supported by textus muscularis and cartilago. However, cartilago can only
be found in trachea and bronchus,and no longer in bronchiolus. Epithelium lining
the wall of tractus respiratorius from cavitas nasi until bronchus is epithelium
pseudostratificatum columnare ciliatum, often called as epithelium
respiratorium. Epithelium respiratorium is composed of epitheliocytus columnare
ciliatum, cellula basalis (stem cells, cuboidal) and exocrinocytus caliciformis.
Compared to bronchus, bronchiolus has a smaller diameter. The epithelium lining
bronchiolus gradually changes from epithelium pseudostratificatum columnare
ciliatum in the larger bronchiolus to simplex columnare ciliatum or simplex
cuboideum ciliatum in the smallest bronchiolus terminalis.
Epithelium of bronchiolus terminalis contains exocrine cells called
exocrinocytus bronchiolaris, or Clara cells. Exocrinocytus bronchiolaris is a
non-ciliated epitheliocytus. It plays a role in producing glycoprotein substance
which prevents attachment between apical epitheliocytus when the lumen shrinks
during expiration.
Bronchiolus respiratorius branched into ductus alveolaris and ended in a space
called sacculus alveolaris. The wall of ductus and sacculus alveolaris are
covered by epithelium simplex squamosum and supported by a thin layer of
myocytus levis. In alveoli, epithelium becomessimplex squamosum.
Various structures of tractus respiratorius are summarized in Mescher, A.L.
Junquera’s Basic Histology Text and Atlas. 2016. 14th edition. McGraw Hill
Education. New York. page 356 (tables 17-1 and 17-2).

Procedure Open practical work link in Gamel.
Read the instruction, observe the displayed structures, and answer the
questions provided. Make sure that you have sent the answers before the
session is over
1. Cavitas nasi
Cavitas nasi lie within the skull as two cavernous chambers separated by the septum nasale.
On the right and left side of cavitas nasi lie sinus paranasalis, an air-filled space that surrounds
cavitas nasi. The cavity is formed by textus osseus.
The main constituent of septum nasale is cartilago hyalina, which lies in the middle of septum
nasale. Both surfaces of the septum nasale are covered with epithelium respiratorium.
Textus connectivus laxus containing glandula seromucosa are found in the lamina propria
beneath the epithelium. The glandula seromucosa acts to maintain the moisture of cavitas nasi.
Cluster of lymphocytus (nodulus lymphaticus) and vascular anastomosis called plexus venosus
(Kiesselbach’s plexus) are also found in lamina propria. Plexus venosus serves to warm the
respiratory air.
Cavitas nasi is divided into pars respiratoria and pars olfactoria. Pars respiratoria cavitas
nasi is located at the back of the inferior and medial sides. In this part, cavitas nasi is lined by
epithelium respiratorium with numerous exocrinocytus caliciformis. Plexus cavernosus
nasalis (the venous network) and folliculus lymphaticus can be found in the inferior side.
Pars olfactoria can be found in the superior part of cavitas nasi. This part is lined by epithelium
olfactorium which contains neuron olfactorius that has special receptors to sense odorant. .
The structure and function of pars olfactoria will be discussed in block A.5.
Discussion:
1. Which structure functions to moist the breathing air in cavitas nasi?
2. What is/are the function of folliculus lymphaticus found in the lamina propria of the inferior
part of cavitas nasi?
References:
Education. New York. Page 349 - 351.
Williams & Wilkins.

1. Septum nasale 1. Epithelium pseudostratificatum columnare ciliatum
2. Cartilago hyalina 2. Exocrinocytus caliciformis
3. Nodulus lymphaticus 3. Glandula nasalis
4. Chondrocytus
5. Perichondrium
6. Plexus venosus
7. Fasciculus nervosus

2. Epiglottis
Epiglottis has cartilago elastica, the most prominent structure in the middle of epiglottis.
Cartilago in epiglottis is formed by chondrocytus that reside inside lacunae and surrounded
by matrix cartilaginea. In this specimen, fibra elastica cannot be seen with hematoxylin eosin
staining.
Epiglottis has two surfaces, facies lingualis (surface facing cavum oris) and facies laryngealis
(facing larynx). Both surfaces are lined by different types of epithelium. Facies lingualis and
apical sides of facies laryngealis, (because it is vulnerable to abrasion due to its relation to the
tractus digestivus) are covered by epithelium stratificatum squamosum non-cornificatum.
The rest of the facies laryngealis on the other hand, which is related to the systema respiratoria,
has epithelium respiratorium, i.e. epithelium pseudostratificatum columnare ciliatum with
mucou- secreting exocrinocytus caliciformis. In both surfaces, lamina propria consists of
textus connectivus laxus with scattered lymphocytus, glandula seromucosa called glandula
epiglottica and adipocytus.
Discussions:
1. Why is epiglottis composed of cartilago elastica, and not other types of cartilago?
2. What is/are the function of glandula seromucosa in epiglottis?
3. What is the relationship between the type of epithelium covering the facies lingualis
epiglottis with the function of the epiglottis?
Reference:
Education. New York. Page 353.
Williams & Wilkins.

1. Facies lingualis 1. Epithelium stratificatum squamosum non cornificatum
2. Facies laryngealis 2. Epithelium pseudostratificatum columnare ciliatum
3. Cartilago elastica 3. Exocrinocytus caliciformis
4. Lamina propria
5. Glandula epiglottica
6. Lymphocytus
7. Adipocytus
3. Trachea (with glandula thyroidea and parathyroidea)

Trachea’s wall is composed of 3 layers, tunica mucosa which consists of epithelium and lamina
propria, tela submucosa, and tunica adventitia. A series ofC-shaped cartilago located between
tela submucosa and tunica adventitia serves to prevent trachea from collapse during expiration.
The open ends of these cartilage rings are located on the posterior surface of the trachea.
Tunica mucosa of trachea is covered by epithelium pseudostratificatum columnare ciliatum
which includes epitheliocytus basalis as progenitor cells and exocrinocytus caliciformis.
Lamina propria of trachea is composed by textus connectivus laxus that contains glandula
trachealis. Mucus produced by glandula trachealis and exocrinocytus caliciformis acts as a
dust filter.

In tela submucosa, circular cartilago hyalina resemblinge the shape of the letter C is found. The
open end of the cartilago that facing posteriorly is connected by ligamentum anulare which is
composed of fibra elastica, and myocytus levis called musculus trachealis. The outermost
layer of trachea, the tunica adventitia, is composed of textus connectivus laxus.
On the right and left side of trachea sit glandula thyroidea and glandula parathyroidea. The
functional unit of glandula thyroidea are folliculus thyroideus, a rounded structure lined by
epithelium simplex cuboideum with lumen filled with colloidum (pink colloidal fluid). Folliculus
has varying size and shape of thyrocytus T. Small-sized folliculus is covered by cuboidal to
columnar thyrocytus T, while larger folliculus is covered by cuboidal to squamous thyrocytus
T which indicates low glandular activity. alcitonin-producing cells, called thyrocytus C or C
cells, can be found among folliculus. Thyrocytus C is attached to membrana basalis of folliculus
but some are clustered between folliculus (more easily observed in specimens).
Discussions:
1. What is/are the function of cartilago of the trachea?
2. What is/are then function of cilia on the surface of epitheliocytus columnare ciliatum?
3. What is/are the function of hormones secreted by glandula thyroidea and parathyroidea?
Reference:
Education. New York. Page 354, 429 – 434.
Williams & Wilkins.

1. Tunica mucosa 1. Epithelium pseudostratificatum columnare ciliatum
2. Tela submucosa 2. Exocrinocytus caliciformis
3. Tunica adventitia 3. Lamina propria
4. Cartilago hyalina 4. Glandula trachealis
5. Glandula thyroidea 5. Chondrocytus
6. Glandula parathyroidea 6. Ligamentum anulare
7. Musculus trachealis
8. Folliculus thyroideus
9. Epithelium simplex cuboideum
10. Thyrocytus T
11. Thyrocytus C
4. Pulmo (Bronchus)
The specimen is a proximal part of pulmo; thus bronchus can be found between alveoli.
Bronchus is composed of three layers, namely tunica mucosa, tela submucosa and tunica
adventitia.
Structurally, tunica mucosa bronchus is similar to tunica mucosa trachea, except for the
organization of cartilago and myocytus levis/myocytus non striatus.
Tunica mucosa of bronchus is lined by epithelium respiratorium. Lamina propria beneath
epithelium is composed by spirally arranged myocytus levis, fibra collageni, fibra elastica and
glandula seromucosa. Lymphocytus can be found in lamina propria and extends to tunica
adventitia. Some lymphocytus are clustered to form nodulus lymphaticus which is part of the
bronchus-associated lymphoid tissue (BALT).

Under tunica mucosa, there are cartilago bronchialis (type: cartilago hyalina) and spirally
arranged myocytus levis (musculus spiralis).Compared to cartilaginea tracheales, the shape
of cartilago bronchialis is more irregular. As bronchus diminished in diameter, the structure
progressively changed, cartilago becomes more separated and forms island-like structure.
Tunica adventitia of bronchus is composed by textus connectivus laxus.
DIscussion:
What structure differentiates bronchus from trachea?
References:
Williams & Wilkins.

1. Tunica mucosa 1. Epithelium pseudostratificatum columnare
ciliatum
2. Tunica muscularis 2. Glandula seromucosa
3. Tunica adventitia 3. Nodulus lymphaticus
4. Cartilago bronchialis (type: cartilago 4. Musculus spiralis
hyalina)
5. Pulmo (Bronchiolus and Alveolus)

The specimen is a distal part of pulmo; thus many smaller channels than bronchus, i.e.
bronchiolus and ductus alveolaris are found.
Each bronchiolus branched into five to seven terminals called bronchiolus terminalis.
Compared to bronchus, bronchiolus terminalis has a smaller diameter and the epithelium lining its
lumen changes from epithelium pseudostratificatum columnare ciliatum to simplex columnare
ciliatum or simplex cuboideum ciliatum.
In bronchiolus, cartilago and exocrinocytus caliciformis are no longer found, but myocytus levis
and textus connectivus still can be found.
Bronchiolus terminalis branched into two or more bronchiolus respiratorius. Bronchiolus

respiratorius is lined by epithelium simplex cuboideum ciliatum equipped with exocrinocytus
bronchiolaris. Unfortunately, exocrinocytus bronchiolaris cannot be recognized by routine
staining. Bronchiolus respiratorius branched into ductus alveolaris which ended in a space
called sacculus alveolaris. The walls of the ductus and sacculus alveolaris are covered by
epithelium simplex squamosum and supported by a thin layer of myocytus levis.
Epithelium of bronchiolus respiratorius is directly related to epithelium of ductus alveolaris,
therefore in transversal section it may appear to change from simplex cuboideum to simplex
squamosum.
Structurally, alveoli resemble small pockets open on one side. Septum interalveolare (alveolar
wall) consists of three components; epithelium alveolare, supporting tissue and vas capillare.
Epithelium alveolare provides a continuous lining of each alveolus and consists of two types of
cells. Most of the alveolar surface area is covered by squamous cells called pneumocytus type
I. This cell plays role as a barrier that must be passed by the exchanged gases. Together with
vas capillare on septum interalveolare, pneumocytus type I form a structure known as claustrum

aerosanguineum (blood-air barrier). A second epitheliocytus known as pneumocytus type II,
has large and rounded nuclei. Pneumocytus type II is responsible to secrete surfactants, which
play a role in reducing alveolar surface tension. Large phagocytic cells called macrophagocytus
alveolaris (dust cell) are found in septum interalveolare and in spatium alveolaris.
Discussions:
1. In which part of tractus repiratorius, gas exchange starts to occur?
2. Describe the mechanism of gas exchange in septum interalveolare!
3. What is the function of macrophagocytus alveolaris and pneumocytus type II?
References:
Williams & Wilkins.

1. Bronchiolus terminalis 1. Pneumocytus typus I
2. Bronchiolus respiratorius 2. Pneumocytus typu II
3. Ductus alveolaris 3. Macrophagocytus alveolaris
4. Sacculus alveolaris 4. Vas capillare
5. Alveolus 5. Endotheliocytus
6. Septum interalveolare

BLOCK A.3
PRACTICAL SESSION OF BIOCHEMISTRY
OXYDATIVE PHOSPHORYLATION
Department of Biochemistry
Faculty of Medicine Universitas Gadjah Mada
Yogyakarta
2020

OXIDATIVE PHOSPHORYLATION
The free energy available as a consequence of transferring electrons from NADH or

succinate to molecular oxygen is -57 and -36 kcal/mol, respectively. Oxidative phosphorylation
traps this energy as the high-energy phosphate of ATP. In order for oxidative phosphorylation
to proceed, two principal conditions must be met. First, the inner mitochondrial membrane must
be physically intact so that protons can only reenter the mitochondrion by a process coupled
to ATP synthesis. Second, a high concentration of protons must be developed on the outside
of the inner membrane.
The energy of the proton gradient is known as the chemiosmotic potential, or proton motive
force (PMF). This potential is the sum of the concentration difference of protons across the
membrane and the difference in electrical charge across the membrane. The 2 electrons from
NADH generate a 6-proton gradient. Thus, oxidation of 1 mole of NADH leads to the availability
of a PMF with a free energy of about -31.2 kcal (6 x -5.2 kcal). The energy of the gradient is
used to drive ATP synthesis as the protons are transported back down their thermodynamic
gradient into the mitochondrion.
During the electron tranfers at the three classic sites of phosphorylation (marked I, II,
and III), protons are pumped out of the mitochondria into the cytoplasm. The exact number of
protons pumped at each site is somewhat controversial; however, this proton pumping makes
the interior of the mitochondria alkaline.
ATP synthase is a multiple subunit complex that binds ADP and inorganic phosphate at its
catalytic site inside the mitochondrion, and requires a proton gradient for activity in the forward
direction. ATP synthase is composed of 3 fragments: F0, which is localized in the membrane;
F1, which protrudes from the inside of the inner membrane into the matrix; and oligomycin
sensitivity—conferring protein (OSCP), which connects F0 to F1. In permeable to protons, the
ATP synthase reaction is active in the reverse direction acting as a very efficient ATP hydrolase
or ATPase.
ATP is made by the F 1F 0 ATPase. This enzyme allows the protons back into the
mitochondria. Since the interior is alkaline, the reaction is favorable—favorable enough to
drive the synthesis of ATP by letting protons back into the mitochondria. Exactly how the F1F0
ATPase couples the flow of protons down their concentration gradient to the formation of ATP
is not known in molecular detail. The proton flow through the F1F0 ATPase is required to release
ATP from the active site where it was synthesized from ADP and Pi. The ATP is made in the
interior of the mitochondria and must be exchanged for ADP outside the mitochondria to keep
the cytosol supplied with ATP.
The exchange of mitochondrial ATP for cytoplasmic ADP is catalyzed by the ATP/ADP
translocase. The electron transport chain gets its substrates from the NADH and FADH2
supplied by the tricarboxylic acid (TCA) cycle. Since the TCA cycle and electron transport are
both mitochondrial, the NADH generated by the TCA cycle can feed directly into oxidative
phosphorylation. NADH that is generated outside the mitochondria (for example, in aerobic
glycolysis) is not transported directly into the mitochondria and oxidized—that would be too
easy. There are two shuttles involved in getting the electrons from NADH into mitochondria.
The glycerol-3-phosphate shuttle works most simply. In this shuttle, NADH in the cytoplasm is
used to reduce dihydroxyacetone phosphate (DHAP) to glycerol-3-phosphate. The glycerol-3-
phosphate is actually the molecule transported into the mitochondrion, where it is oxidized back
to DHAP, giving mitochondrial FADH2. The DHAP then leaves the mitochondrion to complete
the shuttle. With this shuttle in operation, there’s a cost. Normally, the oxidation of mitochondrial
NADH gives 3 ATPs. However, the mitochondrial enzyme that oxidizes glycerol-3-phosphate
uses FAD as the oxidizing agent. The FADH2 that results gives only 2 ATP equivalents. Using
this shuttle, the cytoplasmic NADH yields only 2 ATPs.
The rate of oxidative phosphorylation is controlled by the supply of ADP and phosphate.
Assuming that oxygen is available and that there is a supply of NADH- or FADH2-generating
substrates, the activity of oxidative phosphorylation is determined by the availability of ADP. If

ADP is available and there is enough phosphate around (there usually is), the ADP and Pi are
converted to ATP.
Uncouplers allow protons back into the mitochondria without making any ATP stimulate
oxygen consumption. Mitochondria do three things: oxidize substrates, consume oxygen, and
make ATP. Uncouplers prevent the synthesis of ATP but do not inhibit oxygen consumption or
substrate oxidation. Uncouplers work by destroying the pH gradient. The classic uncoupler is
2,4-dinitrophenol (DNP). This phenol is a relatively strong acid and lipophilic (greasy) enough
to cross the mitochondrial membrane, DNP can transport protons across the membrane and
destroy the pH gradient. The DNP crosses from the cytosol into the mitochondrion, carrying its
proton with it. In the more alkaline environment of the mitochondrion, the DNP loses its proton
and the pH falls. The DNP then leaves the mitochondrion and repeats the cycle again until the pH
inside is the same as the pH outside. With no pH gradient, there is no ATP synthesis. However,
there is still oxidation of substrates and consumption of oxygen. With no ATP synthesis, the
ADP concentration is high and the electron transport chain keeps trying to pump out protons.
In fact, uncouplers usually stimulate oxygen and substrate consumption. Long-chain fatty acids
can uncouple mitochondria by the same mechanism.
Inhibitors block the flow of electrons at a specific site and inhibit electron flow and ATP
synthesis. Inhibitors inhibit oxygen consumption and ATP synthesis. Inhibitors actually block
one of the steps of oxidative phosphorylation. For example, antimycin A is a specific inhibitor of
cytochrome b. In the presence of antimycin A, cytochrome b can be reduced but not oxidized.
Cyanide blocks the last step of electron transfer by combining with and inhibiting cytochrome
oxidase. The effect is similar to oxygen deprivation. The less obvious effect is that all the electron
carriers become more reduced than they would be without the inhibitor. The reason is that the
substrates are still pushing reducing equivalents (electrons) down the electron transport chain.
But it’s blocked at the end. The result is that all the carriers before the block become reduced.
For the same reason, inhibiting electron transport also tends to keep the NADH and FADH2
reduced (depending on where the inhibitor acts). Carriers after the block become more oxidized.
Carriers after the block can still transfer their electrons to oxygen. Once they have done this,
though, there are no more reducing equivalents available because of the block, and they are
left in the oxidized state.
Principle of practice
In the presence of substrate, mitochondria respire and form ATP from added ADP and
inorganic phosphate (Pi). If glucose and the enzyme hexokinase are also present, the Pi
incorporated into ATP during oxidative phosphorylation is trapped into the stable compound
glucose-6 phosphate:
Glucose + ATP Mg++ Glucose – 6 – phosphate
Hexokinase
Figure 1: Electrons flow to the mitochondrion membrane through the integral membrane
protein

Overview of the oxidative phosphorylation
If the ‘hexokinase trap’ is omitted, the ATP is broken down by mitochondrial ATP’ases
and low values of Pi uptake are obtained. The Pi content of the medium before and after the
experiment is measured and the respiration demonstrated by the decolorization of methylene
blue. The redox potential of the oxidized and reduced forms of methylene blue is close to that
of the ubiquinone couple.
Reaction : MB + 2H+ + 2C- MBH2

(Blue ) (Colourless)
MB: Methylene Blue
Reaction : Q + 2H+ + 2C- QH2

Q : Ubiquinone
Methylene blue can therefore compete favorably with ubiquinone for reducing equivalents, so
that two pathways of electron flow from glutamate are possible.
Figure 2: The redox potential of the oxidized and reduced forms of methylene blue
During active respiration, the aerobic pathway competes favorably with the methylene blue
branch, so that the dye becomes only partially decolorized until all the oxygen is used up. At
this stage, the methylene blue goes completely colorless because the respiratory chains can
no longer function. If an uncoupling agent such as 2,4-dinitrophenol is present, the respiration
rate is increased and the above color changes occur more rapidly. Cyanide blocks the electron
flow by inhibiting cytochrome oxidase, the terminal component of the chain. In the presence
of cyanide, methylene blue is therefore very rapidly decolorized but does not go completely
colorless because the dye is readily oxidized by molecular oxygen, which is still present.
Materials
1. Rat liver mitochondria.
2. Incubation medium (the following mixture is prepared, adjusted with alkali to pH 7.4 make
up to a fixed volume to give the molarities indicated).
Component mM
Glucose 150
KHZP04 50
EDTA 3
ATP 3

NAD 0.2
Bovine serum albumin 2.5 mg/ml
Crude hexokinase 0.5 mg/ml
ATP is added since this is cheaper than ADP. The ATP is in any case immediately converted
to ADP in the presence of hexokinase. EDTA removes any traces of heavy metals which may
be present as contaminants in the reagents.
NAD is added to supplement any lost during isolation of the mitochondria. Bovine serum
albumin removes uncouples of oxidative phosphorylation such as long chain fatty acids which
can accumulate in isolated mitochondria.
1. 2,4-Dinitophenol (5mM)
2. Methylene blue (25 mg/100ml)
3. Potassium cyanide (50mM)
4. Sucrose (M solution containing 25 mM MgCl2)
5. Trichlor acetic acid (10%)
6. Shaking water bath at 37°C
7. Reagents for the estimation of phosphate
8. Liquid paraffin(gassed out with nitrogen)
9. Nitrogen cylinder
10. Sodium hydrogen glutamate (0,2M)
METHOD:
A. Cellular Respiration
- Prepare 3 test tubes and give number 1, 2, and 3.
- Add reagents into each tube as Table 1.
Table 1. Skema of Respiration Experiment

No Reagents (mL) Tube 1 Tube 2 Tube 3
1 Incubation medium 1.0 1.0 1.0
2 Sodium hydrogen glutamat 0.2 0.2 0.2
3 2,4-Dinitrophenol (5 mM) - 0.1 -
4 Methylene blue (925 mg/100 mL) 0.2 0.2 0.2
5 Potassium cyanide (50 mM) 0.1 - -
6 Water - - 0.1
7 Sucrose (M with 25 mM MgCl2) 0.6 0.6 0.6
8 Mitochondria suspension (Washes twice in 0.5 0.5 0.5
sucrose), and then as soon as added liquid paraffin
9 Liquid paraffin 2.0 2.0 2.0
- Incubate the tubes at 37oC without agitation and observe the change in color with time.
- Interpret these changes, bearing in mind the points made in the introduction to this
experiment.
B. Oxidative Phosphorylation
- Prepare 2 centrifuge tubes and give number 1 and 2.
- Add reagents into each tube as Table 1.

Table 1. Skema of Respiration Experiment.
No Reagents (mL) Tube 1 Tube 2
1 Incubation medium 1.0 1.0
2 Sodium hydrogen glutamat 0.2 0.2
3 2,4-Dinitrophenol (5 mM) - 0.1
4 Water 0.3 0.2
5 Sucrose (M with 25 mM MgCl2) 0.6 0.6
Note: Before add the mitochondria, prepare 2.8 mL of 10% TCA in test tube.
6 Mitochondria suspension (Washes twice in sucrose), 0.5 0.5
and mix thoroughly
- After mix thoroughly, immediately withdraw 0.2 mL of suspension and enter into TCA.
The suspension tube incubate in water bath at 37oC
- Centrifuge the tube with TCA at 3000 rpm for 15 menit.
- Enter 1 mL supernatant into test tube, added 2 drop HNO3 concentrated and 2 mL
ammonium molibdate , then heated until get yellow color and precipitated will be seen.
Repeat this determination of Pi after 15’ incubation of the suspension. Interpret the
results.
References:
1. Gilbert HF. 2000. Basic Concepts In Biochemistry: A Student’s Survival Guide. 2nd Ed.
McGraw-Hill, New York.
2. Murray RK et al, 2016. Harpers Illustrated Biochemistry 30th Ed. Mc Graw Hill Co.Inc, USA

BLOCK A.3
PRACTICAL SESSION OF MEDICAL

EDUCATION
Department of Medical Education

Yogyakarta
2020

MANUAL OF PRACTICAL SESSION
CONSTRUCTIVE FEEDBACK
MANUAL OF PRACTICAL SESSION
CONSTRUCTIVE FEEDBACK
Mora Claramita
Hikmawati
Mora Claramita
Halwan Fuad Bayuangga
Hikmawati
Savitri Shitarukmi
Halwan Fuad Bayuangga
Savitri Shitarukmi
The The feedback

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could happen anytime and anywhere. As part to achieve certain degree of professionalism,
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process could be deliberated into knowledge, skills, and attitude. All of students will follow many
this process could be deliberated into knowledge, skills, and attitude. All of students will follow
activities and gain experience regarding acquisition of certain degree of knowledge, skills, and
many activities and gain experience regarding acquisition of certain degree of knowledge, skills,
attitude.
and attitude.
UNCONSCIOUS CONSCIOUS
feedback
INCOMPETENT INCOMPETENT
UNCONSCIOUS CONSCIOUS
COMPETENT COMPETENT
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understanding of certain knowledge. In that time, transfer of knowledge between you and your
friend will happen.
While skills need practice to be perfect, anonymous said that a skills should be repeated until
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blaming culture and hierarchical milieu. That would make feedback perceived as insult and
However, how feedback delivered sometimes not so beautiful as it is expected. In our context,
it sound more often as criticism, a personal assault which probable caused by cultural aspect
such blaming culture and hierarchical milieu. That would make feedback perceived as insult
and directing receiver to other thought or make the receiver rejecting the truth within delivered
feedback. It is what we called nonconstructive feedback, things that we are not expect.

The constructive feedback
A constructive feedback is a powerful tool to stimulate learning. A feedback should be easy to
digest, received, encourage further thought, and stimulate the student to seek the right answer
or just change the targeted behavior. Therefore, it has several principles as described below:
1. Feedback should be descriptive rather than judgmental or evaluative.

Avoid phrasing feedback in terms of good or bad, right or wrong. Terms such as adjectives
: awful, stupid, brilliant, lazy, wonderful are of little value to the learner.
- “The beginning was awful, you just seemed to ignore her” (don’t)
- “At the beginning of the discussion, I noticed that you were facing in the opposite direction
looking at your notes which prevented eye contact between you” (do)
2. Feedback should be spesific rather than general.
General or vague comments are not very helpful. Feedback should be detailed and spesific.
Focus on concrete descriptions of spesific behaviour you can see and hear.
- “You didn’t seem to be very empathic” (don’t)
- “Looking from the outside, I couldn’t tell what you felt when she told you about her
unhappiness, your facial expression didn’t change from when you were concentrating
on herargument” (do)
3. Feedback on behaviour rather than personality.
Behaviour is easy to alter, personality less so; we are more likely to think we can change
what we “do” than what we are.
- “Loudmouth” (don’t)
- “You seemed to talk quite a lot, the patient tried to interrupt but couldn’t quite get into
the conversation” (do)
4. Feedback should be for the learner’s benefit.
Feedback should be given that serves the needs of the learner, rather than the needs of
the giver.
- “I hope you can change your behaviour because everybody said so” (don’t)
- “I hope you can consider which behaviour will be helpful for you and for others” (do)
5. Feedback on sharing information rather than giving advice.
By sharing information, we leave recipients of feedback free to decide for themselves what is
the most appropriate course of action. The informed and shares decision making is prompt
at this stage.
“Giving feedback should be like talking to your teenage-daughter. You can give her more
information that you already knew as a parent, but leave the decision in her hands.”
(A Canadian doctor dr. Donald Studley who demonstrated Feedback-Giving at Norcini’s

workshops on work-based assessment, APMEC Singapore, 2010)
6. Feedback should be solicited rather than imposed.

Feedback is most usefully heard when the recipient has actively sought feedback and has
asked for help with specific questions.
(Taken from Teaching and Learning Communication Skills in Medicine (Kurtz,1998)).
In order to make a supportive milieu for learning, you will have your own part to become either
as feedbacks’ giver or receiver. We present tips to give and receive feedback below:
As a giver, a feedback could be delivered through dialogue or directive way. In a term of dialogue,
ask tell ask strategy could be implied. It is started by a prompt question by feedbacks’ giver
to receiver. A good question will lead to a discussion between giver and receiver. Within the
process, a honest and critical thought are needed from both parties.

A sandwich method is a common way of directive feedback, most common feedback that you
will receive during practice, as shown in picture 2. It is consist of positive or an appreciation
for your observed behavior, information on things that need to be improved, and a solution. It
is not a stiffed strategy of feedback, there is a chance of discussion that emerge from solution
part of feedback.
Picture 2. sandwich feedback
For example,
Step 1: Inform the positive behavior you like or already good about your friend
“Siti, I think its wonderful that you already summarize all those teaching material for
us. Its really helpful”
Step 2: Inform the behavior that you think still can be improved for example by explaining the
impact of such performance to the patients/ others
“Some of our friends think that some specific terms are not very clear, maybe because
you write in a very tiny font”
Step 3: Discuss alternatives
“ Perhaps you would like to make it into 12 font rather than 10? What do you think?”
As a receiver, accepting a feedback is not easy. It is no easy to hear something that not really
nice about self, more over if it is delivered in crude/harsh way. The key to take the advantage
and see the true massage behind the delivered feedback is on your listening skills. However,
this certain below habits will help you to achieve the massage behind the delivered feedback:
1 Be ever aware of signals from others that answer the question, “What’s it like to be on
the other side of me?
We often judge others by their actions, while we judge ourselves by our intentions. Despite
our good intentions, we often come across in ways that are offensive or unhelpful to others.
When this happens, shouldn’t we want to know it so that we can change it?
2 Demonstrate an eagerness to learn about yourself by inviting feedback.

Some are afraid of what they will hear if they do this. However, managers who not only
conduct appraisals of employees but also ask employee to tell them how they can perform
better enjoy greater respect. Team members who ask co-workers of bosses how they can
improve inspire more cooperation and grace.
3 Realize that even unfairly negative criticism often contains a grain of truth
It would be much more palatable if all feedback were delivery constructively. However, we
sometimes don’t have that luxury. Even then, we may be able to learn from what the person
is saying. Though there may have bees some misperceptions or distortions, ask yourself,
“What can I learn here about how my action are perceived, and how can I improve my
communications or behavior so that I accomplish the goals more effectively?”

4 Fight the tendency to be defensive
This is a tough one. Defensiveness can be expressed in words (e.g., “You don’t understand”,
or “But…”) or in nonverbal signals (e.g., angry facial expression; tight lips; or folded arms,
which, by the way, can mean other things like you’re cold). It’s hard not to show it when you
don’t like or don’t agree with what you hear. Remember, though, that if you keep an open
mindset, which will show up in your behavior, you’re apt to learn something you can use to
continue to grow.
5 Don’t condemn yourself or let other condemn you

It’s one thing to focus on a specific behavior that can be improved. It’s another to feel generally
ineffective or bad assessment a person. In the letter case, you may become discouraged
to the point that you don’t feel like trying. You may feel paralyzed, believing that it’s no use,
that you’re a hopeless case. This is not true! Keep your focus on specific ways that you
can sharpen your skills and improve your habits. Specific, achievable goals are motivating.
In order not make all of this theory only become a concept inside your mind, lets practice!
This practical sessions is aimed to provide experience for students regarding the usefulness of
constructive feedback. Furthermore, to stimulate students to do constructive feedback for their
friends, teachers, simulated patients, and others.
Here some scenarios for practice!
Scenario 1
Student A is late about 30 minutes in tutorial. Student B is friend of him who is assigned to
give feedback for his late. Tutor has to give feedback for how the student B gives feedback. It
is need to be discussed with all the group members about when and where student B should
give feedback.
Scenario 2
Student A is very dominant in tutorial discussion. He explore much argument, but when the
other group members gives their opinion, he doesn’t listen to them, he tends to interrupt the
discussion. Student B is a chair in tutorial discussion who is assigned to give feedback to student
A. Tutor has to give feedback on how the student B gives feedback.
Scenario 3
Student A is joining the anatomy practical session. Student B acts as instructor (lecture assistant).
When the instructor (lecture assistant) is giving explanation, he is busy to reply and send SMS.
The instructor (lecture assistant) is assigned to give feedback to student A.

The tutor is assigned to give feedback to student B on how he is giving feedback. (Whether
the instructor is giving feedback directly at the practical session or the instructor prefer to give
feedback after the practical session is finish. These options need to be discussed with all the
group members).
Scenario 4
Student A is the leader of student union who is very success in conducting international seminar
in Disaster Preparednes. He is success in invite the participants both the doctor and students
from aboard.
Student B is his/her friend who is assigned to give feedback of the student A (it is need to
remember that feedback can be given for his/ her success story, but it is possible if there are
any weaknesses behind the success story), e.g advice on his/ her arrogant, for the maintaining
the GPA, and etc. Tutor is assigned to give feedback on how the student B gives feedback.

LESSON PLAN CONSTRUCTIVE FEEDBACK PRACTICAL SESSION – BLOCK A.3
Minutes Activities Goals Materials Facilitators

SESSION CONSTRUCTIVE To be able to reflect and
I FEEDBACK practice constructive feedback
15’ Reflect on students Existing condition of feedback Reflection Instructor facilitate to discuss on how positive or negative
experiences of given feedback influence student’s learning process (the impact,
receiving feedback *) what students like about it, and what they do not like), then
summary the positive or negative experiences
20’ Present the To understand the roles of 1. Power point Underlined the need for
constructive feedback feedback and how to deliver 2. Tips for Constructive 1. Objectivity,
materials constructive feedback feedback 2. Observation-based,
3. Tips for receiving 3. Safe learning environment
feedback 4. Taking notes
15’ Practical session To practice constructive Scenario: Facilitate the role play:
Feedback feedback Remember the worst • Person 1 become the role of who gave feedback at
Role-Play 1 experience *) previous experience
Person who has *) should be • Person 2 become the role of person 1 in the past
the one who give feedback • Person 3 if needed
• Other persons observed and taking notes
15’ Reflection on Role To reflect on constructive Reflection on the practical Facilitate the reflection:
play 1 feedback session 1. Reflection of Person 1 (Tutors explores the Student B
(FIRST PERSON WHO DID THE PERFORMANCE) on
how he/she gives the feedback. What does he/she like
about doing that and what constraints
2. Reflection of Person 2 (Tutor checks the Student A
(SECOND PERSON WHO GETS IMPACT OF THE
PERFORMANCE)on how he/she accept the feedback.
What does she/he like about it, whatdoes he/she feel, the
benefits, etc
3. Reflection of groups
4. Facilitator’s feedback

15’ Role play 2 To practice constructive Scenario will depend on Instructor observe the session
feedback participants’ choice (see the
scenario in manual book)
15’ Reflection on Role- To reflect on constructive Reflection on the practical Facilitate the reflection:
play 2 feedback session 1. Reflection of Person 1 (Tutors explores the Student B
(FIRST PERSON WHO DID THE PERFORMANCE) on
how he/she gives the feedback. What does he/she like
about doing that and what constraints
2. Reflection of Person 2 (Tutor checks the Student A
(SECOND PERSON WHO GETS IMPACT OF THE
PERFORMANCE)on how he/she accept the feedback.
What does she/he like about it, whatdoes he/she feel, the
benefits, etc
3. Reflection of groups
4. Facilitator’s feedback
5’ Reflection of the day Overall reflection - Facilitator summarize the sessions and participants give
feedback to facilitators

Biography
Boehler, M.L; Rogers, D.A; Schwind C.J, et.al, 2006, An invesigation on medical student reaction
to feedback: A randomized conrolled trial, Medical education:40:746-749, Blackwell Pub,
Oxon
Kurtz SM, Silverman JD (1998),Teaching and Learning Communication Skills in Medicine.
Oxford: Radcliff Medical Press
Maguire P, Fairbairn S, Flecther C (1986a), Consultation skills of young doctors 1.Benefits of
feedback training in interviewing as students persist. BMJ, 292: 1573- 6.
Norcini, J. Work based Assessment Workshop. Asian Pacific Medical Education Conference,
Singapore, 2010
Ovando, M.N, 1994, Constructive Feedback : A Key to Succesful Teaching and Learning.
International Journal of Educational Management. 8(11) : 19-22.
Patrick, J, 1992, Training: Research and Practice. London: Academic Press
Vickery, A; Lake, F. Teaching on the Run Tips 10 : Giving Feedback. The Medical Journal of
Australia 2005; 183(5): 267-268.

LESSON PLAN AND ASSIGNMENT DETAILS
ACADEMIC WRITING 2: PHARAPHRASING
BLOCK A.3 CARDIORESPIRATORY SYSTEM
YEAR 2019/2020
FACULTY OF MEDICINE, PUBLIC HEALTH AND NURSING
MODULE COORDINATORS
1. dr. Siti Rokhmah Projosasmito, MEd(L,P&C)
2. dr. Prattama Santoso Utomo, MHPEd
Any questions occurred about this module should be addressed to the Department of Medical-
Health Professions Education and Bioethics through mobile 081229481668 (WA/SMS) or email
medicaleducation@ugm.ac.id.
LEARNING OBJECTIVE
1. Discuss techniques to avoid plagiarism
2. Explain principles of academic writing both in Bahasa Indonesia and English
3. Perform appropriate and legitimate paraphrasing
4. Write a plagiarism-free paper or report
LEARNING ACTIVITY
The design of the academic writing course learning process employs a flipped classroom method.
A flipped classroom technique combines synchronous and asynchronous learning session.
Students learn independently about the topics of avoiding plagiarism before the synchronous
session in the e-learning environment through Gamel. This session is called as asynchronous
session. Students are requested to conduct this asynchronous session seriously since the
successful of synchronous session and the achievement of course’s learning objective will be
depend on the result of students’ learning during asynchronous session. Students prepare the
pre-session assignment during this asynchronous session and upload it to Gamel before the
session. Students also ask to download one of other students work and give feedback and
prepare both documents for synchronous session. The on-line learning environment also provide
an on-line discussion forum that can be used as students-to-students and students-to-lecturers
interaction platform in an asynchronous way.
During the synchronous session, students will meet face-to-face virtually with an instructor
and discuss the hindering factors that students face while writing the pre-session assignment.
Instructor then, will discuss on the paraphrasing and quoting technique. In addition, instructor
will also refresh student’s ability on the citing and referencing technique, based on the academic
writing 1 results.

e-LEARNING MAP
e-LEARNING MAP
On-line learning Face-to-face
Pre-session
assignment
Introductory to Course
Learning resources: How to avoid plagiarism

video
Discuss on pre-session
assignment
Principles of academic
writing both in English and Exposure to paraphrasing
Writing a paragraph Bahasa Indonesia and summarising technique
according to an
assigned topic Technique to avoid Re-write the pre-session
plagiarism assignment
Appropriate and legitimate Conclusion

paraphrasing
Post-session
On-line discussion
assignment
Assignment
PRE-SESSION ASSIGNMENT
PRE-SESSION ASSIGNMENT
1. This is an individual assignment.
2.1. Read
This is the ‘Academic
an individual Writing 2’ module available in Gamel.
assignment.
3.2. Perform a literature
Read the ‘Academic search
Writing to answer
2’ module the following
available in Gamel. question:
3. a.
Perform a literature search to answer the
For students who have odd student ID/numberfollowing question: (e.g., 21411, 21435, etc):
a. For students who have odd student ID/number
How are the structure and function of the lungs (e.g., 21411, 21435, the
to support etc):respiratory system?
How are the structure and function of the lungs to support the respiratory system?
b. For students who have even student ID/number (e.g., 21422, 21444, etc):
b. For students who have even student ID/number (e.g., 21422, 21444, etc):
How are the structure and function of the heart to support the circulatory system?
How are the structure and function of the heart to support the circulatory system?
4.4. Write
Write aa short
shortpassage
passagethatthat contains
contains two (2)two (2) paragraphs
paragraphs at a total at a total of
of 200-250 200-250
words lengthwords length
(excluding
(excluding references) to answer the respective question using the correct
references) to answer the respective question using the correct techniques to avoid plagiarism. techniques to
5. avoid
Uploadplagiarism.
your paragraph into Gamel under the file name: your name_NIM_pre (for example: Budi
5. Upload your paragraph into Gamel under the file name: your name_NIM_pre (for example:
Sudidi_20001_pre)
Budi Sudidi_20001_pre)
6. The pre-session assignment is due by 4 January 2021 at 5:00 PM for both Regular and
International class.
7.Department
Choose and of download
Medical-Health Professions
the work of one ofEducation,
your friends FMPHN UGM (2020)
in Gamel: 2
a. If you have odd student number/ID, please choose one work of your friend who has
even student number.
b. If you have even student number/ID, please choose one work of your friend who has
an odd student number.
8. Try to analyse your friend’s work and try to identify if there are some points need to be improve,
such as the writing technique or quality, in-text citation technique, or referencing technique.
9. Bring your pre-session assignment and your analysis result to the scheduled Academic
Writing practical session

ON-SESSION PRACTICE
2. Bring your pre-session assignment file and your analysis result.
3. Prepare some questions that you still have on academic writing technique.
4. Prepare one assignment for each group to be presented and discussed during the session.
Lesson Plan of The Session

Time Topic Activity Tools
5 INTRODUCTION Video TED: DPI video
5 How to avoid plagiarism: slides
paraphrasing and summarizing
technique
- Learning objective of the
session
- Introduction
5 CONTENT Type of paraphrasing slides
5 Paraphrasing technique slides
5 Summarising technique slides
5 General tips on academic slides
writing
25 EXERCISE Review the pre-session work discussion
25 Analysis of need to be discussion
improved
5 ASSIGNMENT Explanation on post-session slides
assignment
5 CLOSING Paraphrasing is not equal to slide
translating
POST-SESSION ASSIGNMENTS
Post-session assignment 1
2. Upload your revised pre-session assignment into the Gamel with the the file name: your
name_NIM_on (for example: Budi Sudidi_20001_on).
3. Post-session assignment 1 is due by the end of the week of the Academic Writing Practical
Session, Sunday, 10th January 2021 at 5:00 PM, both for Regular and International class.
Post-session assignment 2
2. Choose and download the work of one of your friends in Gamel:
a. If you have odd student number/ID, please choose one work of your friend who has
even student number.
b. If you have even student number/ID, please choose one work of your friend who has
an odd student number.
3. Based on the principles of constructive feedback that you have learnt during the Constructive
Feedback practical session, provide a written constructive feedback to your friend’s work
according to the academic writing techniques have given to you (citing, referencing,
paraphrasing and summarising).
4. Write your feedback in the same file as your friend’s work.
5. Upload your feedback in the Gamel with the file name: your name_NIM_post (for example:
Budi Sudidi_20001_post)
6. Post-session assignment 2 is due by Friday, 15th January 2021 at 23:59 PM for both Regular
and International class.

ASSIGNMENT MARKING CRITERIA AND RUBRIC
1. The assignments will be your requirement to get the pass card from learning skills practical
sessions
2. The assignments will contribute approximately 4% to the final mark of Block A.3
3. The assignments will be marked based on the following criteria/rubric:
Criteria/
No. Incompetent Sufficient Proficient
Component
1 Paraphrasing and 0 - 0,5 1-2 2,5 - 3
summarising The work The work The work
reflects a somewhat is evident
poor-sloppy reflects of a robust
paraphrasing principles of paraphrasing
and paraphrasing and
summarising and summarising
quality summarising quality
quality
2 Citing and 0 0,5 1
referencing • Cited only 1 • Cited 2 references • Cited at least 3
reference • Cited some high references
• Did not cite high quality literature (e.g., • Cited high quality
quality literature journal, book) literature (e.g., journal,
(e.g., journal, book) • Minor incorrect and book)
• Major incorrect and inaccurate citation and • Correct and
inaccurate citation referencing using the accurate citation and
and referencing, did Harvard method referencing using the
not use the Harvard Harvard method
method
3 Plagiarism degree 0 0,5 - 1 1,5 - 2
Plagiarism Plagiarism Plagiarism scan
scan results in scan results in results in <20%
>50% (using 20-50% (using (using Novus
Novus Scan®) Novus Scan®) Scan®)
4 Constructive 0 – 0,5 1-2 2,5 - 3
feedback • Incorrect sequence • Correct sequence • Correct sequence
and structure of the and structure of the and structure of the
feedback feedback feedback
• Addressed • Addressed unspecific • Addressed specific
unspecific problems problems problems
• Provided unspecific • Provided unspecific • Provided specific yet
yet irrational but rational rational suggestions
suggestion suggestions
5 Compliance 0 0,5 1
• Word count is >10% • Word count is up to • Adheres to the word
above or below the 10% above or below limits (200-250 words)
limit the limit • Adheres to the due
• Late submission • Late submission (up date
(more than 24 hours to 24 hours after the
after the due date) due date)

BASIC CLINICAL COMPETENCE MATERIAL BOOK
GENERAL PHYSICAL EXAMINATION
YEAR 1
THORAX EXAMINATION
BLOCK A.3

Skills Laboratory
Yogyakarta
2020

THORAX EXAMINATION
Coordinator:
Bambang Djarwoto
Internist – Consultant of Renal Hypertension, Department of Internal Medicine
CONTRIBUTORS
Rizka Humardewayanti Asdie Santosa Budihardjo

Staff of Internal Medicine Staff of Anatomy and Embryology
Faculty of Medicine UGM Faculty of Medicine UGM
Efrayim Suryadi I Dewa Putu Pramantara
Staff of Anatomy and Embryology Staff of Internal Medicine
Hasanah Mumpuni Putrika Prastuti Ratna Gharini
Internist Internist
Staff of Department of Cardiology Staff of Department of Cardiology
CO-CONTRIBUTORS
Arum Tri Wahyuningsih

Assistant of Material Development Team
for Skills Training
Faculty of Medicine UGM
Educational design reviewed by
dr. Ery Kus Dwianingsih,Sp.PA.,P.hD

The First Year Coordinator for Clinical Skills Training
Acknowledgement
Wasilah Rohmah
Internist – Consultant of Geriatrics Department of Internal Medicine
Faculty of Medicine
Adistara Swatindra Shiska Novalia

Assistant of Curriculum Team Assistant of Curriculum Team

The general rule in Skills Laboratory
1. Students must follow every practical session.

2. Students must arrive in practical session on time.
3. The time for each practical session is 100 minutes as written in the lesson plan in the student
book.
4. If a student arrives after the session starts, he/she has to sign a yellow card which can be
taken in the skills lab office (2rd floor) as a requirement to join the practical session. The yellow
card will be submitted to the skills lab and affects the corresponding student’s professional
behaviour.
5. Eating, drinking and use of phone or electronic devices not associated with lab materials is
prohibited during lab sessions. Rule breakers has to sign a yellow card which can be taken
in the skills lab office (2rd floor). The yellow card will be submitted to the skills lab and affects
the corresponding student’s professional behaviour.
6. Students are not allowed to leave the classroom without permission.
7. If the instructor is late, students must use the time to read the material which corresponds
to the session topic.
8. Students are allowed to borrow a mannequin or other tools by showing your student card.
Students should check if the tool is complete or not by referring to the tools mentioned in
the manual. If they find a damaged mannequin or broken tools, they should be immediately
reported. If the mannequin or tools are damaged because of the student’s mistakes, they
should replace the mannequin or tools.
9. Students must submit their work plan to the instructor. Work plan should be written by hand
on foolscap paper. The work plan consists of the student name, number, group, topics,
objectives, clinical correlation, step procedures, tools used, and relevant questions you
want to ask to the instructor.
10. Students who cannot attend the practical sessions with a very important reason should
submit a letter asking for a permission and take a follow-up class before the next block.
11. If there are special cases, for example:
a. In case the instructor could not attend the lab sessions, skills laboratory will refer the students
to the companying instructor.
b. If the lab session was delayed by an instructor who is responsible, practical sessions must
be rescheduled within the week. If it is not rescheduled within the week, the instructor in
charge will be substituted by the companying instructor.
12. Any skills lab announcement regarding assignments will be posted via Gamel and skills lab
bulletin board.
*Yellow card will be submitted to the skills lab office and will affect the student’s professional
behaviour.

TABLE OF CONTENTS
PREFACE........................................................................................................................ 111
GENERAL OBJECTIVES OF SKILLS TRAINING YEAR 1............................................. 113
RESPIRATORY TRACTS ANATOMY.............................................................................. 116
HISTOLOGY OF RESPIRATORY TRACTS.................................................................... 118
PHYSIOLOGY OF PULMONARY SYSTEM................................................................... 118
STRUCTURE AND PHYSIOLOGY................................................................................. 119
PHYSICAL EXAMINATION............................................................................................. 122
Evaluate Posterior Chest Excursion................................................................................ 124
The Principals of Percussion........................................................................................... 124
Auscultation..................................................................................................................... 127
PHYSICAL CARDIOVASCULAR EXAMINATION........................................................... 132
INSPECTION................................................................................................................... 133
PALPATION..................................................................................................................... 133
PERCUSSION................................................................................................................. 134
AUSCULTATION.............................................................................................................. 136
GENERAL ASSESSMENT OF CARDIOVASCULAR EXAMINATION............................ 138
Estimating central venous pressure................................................................................ 140
PHYSICAL EXAMINATION PROCEDURE (Heart – Lungs)........................................... 142

PREFACE
Students of medical school need to learn and practice some clinical skills as they prepare
to enter clinical rotation before they become real doctors. Medical school is nowadays convinced
that students should master the skills before they make contact with real patients. Therefore,
an early skills training is needed. Skills laboratory allows students to learn and practice their
clinical skills.
The topic in this manual book is one of the topics under the main topic: General Physical
Examination which will be studied continuously within blocks during undergraduate studies. The
skill included in this book is based on Competency-Based-Curriculum 2007. The topics included
under General Physical Examination in Year 1 are listed as follows:
No. Skills Training Topic Block

1. Basic Principles of Physical Examination A.1
(Locomotor System)
2. Basic Locomotor Examination A.1

(Locomotor System)
3. Vital Signs A.2

(Digestive System &
Metabolism)
4. Examination of the Abdomen A.2

(Digestive System &
Metabolism)
5. Examination of the Thorax A.3

(Cardiorespiratory System)
6. Genitourinary Examination A.4

(Genito-urinary System)
It is important for students to be aware that all topics included are related to each other.
Therefore, students are hoped to be able to group those topics under their main topic so that
the continuity of the topics is obtained. We hope this skills training manual book will be useful
for the students to improve their skills especially in physical examination and for instructors who
are involved in the skills training.
Yogyakarta, November 2020
Contributors

The following is the division of competence levels according to the Miller Pyramid:
• Competence Level 1: Understanding and Explaining

The graduates of medical school possess theoretical knowledge concerning these skills,
so that they are able to explain concepts, theories, principles or indications, performing
procedures, emerging complications and others to their colleagues.
• Competence Level 2: Having seen or Having been demonstrated
The graduates of medical school possess theoretical knowledge concerning this skill
(concepts, theories, principles or indications, performing procedures, complications and
others). Besides, during their study, they had seen this skill or this skill had been demonstrated
to them.
• Competence Level 3: Having done or Having applied under Supervision
to them or they had applied it several times under supervision.
• Competence level 4: Able to perform independently
to them and they had applied several times under supervision; in addition, they possess
experience to use and apply this skill in the context of doctor practices independently.
Physical Examination Level of expected ability
General Survey
measurement of jugular venous pressure 1 2 3 4
palpation of lymph nodes 1 2 3 4
Thorax
inspection at rest 1 2 3 4
inspection during respiration 1 2 3 4
palpation of respiratory expansion 1 2 3 4
palpation of tactile fremitus 1 2 3 4
palpation of apex beat 1 2 3 4
percussion of lungs, lung bases, cardiac size 1 2 3 4
auscultation of lungs 1 2 3 4
auscultation of heart 1 2 3 4
Extremities
inspection of skin, nails, muscle tone 1 2 3 4
inspection of joints 1 2 3 4
assessments of capillary pulse 1 2 3 4
assessments of capillary refill 1 2 3 4
palpation of arterial pulses 1 2 3 4
detection of bruits 1 2 3 4
palpation of skin, tendons, joints 1 2 3 4
examination of monitor system 1 2 3 4

PULMONARY CHEST PHYSICAL EXAMINATION
GENERAL OBJECTIVES OF SKILLS TRAINING YEAR 1

1. Students are able to perform basic skill procedures (communication, physical, procedural,
supporting examinations) and convey the results to the patient;
2. Students are able to consider the clinical reasoning aspect of communication and its
procedure (communication, physical, procedural, supporting examinations).
Scenario
You are a medical student at the Medical Faculty Universitas Gadjah Mada. You work as a first
aid team volunteer in a Healthy Heart Competition (Lomba Senam Jantung Sehat). Soon after the
contest, a participant enters the first aid room requesting for his heart and lungs to be examined.
Questions
1. What equipment should be prepared to examine the lungs and heart?
2. Is there any difference between examining the lungs and heart before exercise compared
to after exercise?
Learning Objectives
1. Understanding the steps in basic pulmonary and cardiovascular examination.
2. Understanding the methods and procedures in using equipment needed for pulmonary and
cardiovascular examination.
3. Being capable of reporting the results of pulmonary and cardiovascular examination.
Intended Learning Outcomes

Students are expected to be competent in vital signs, pulmonary, and cardiovascular
examinations.
1. After performing pulmonary examination techniques, students will be capable of doing:
a. Inspection: grade muscle retraction, lymph node enlargement, skin anomalies, organ
enlargement, and chest expansion during respiration.
b. Palpation: pain, mass, tactile fremitus, lung expansion.
c. Percussion: differentiate percussion on the right, left, upper and lower areas of the chest.
d. Auscultation: know the difference of tracheal and vesicular sounds.
2. After performing cardiovascular examination techniques, students will be capable of doing:
a. Inspection: examine the ictus cordis, chest wall anomalies.
b. Palpation: examine the ictus cordis.
c. Percussion: locate the right, left, upper, lower boarder of the heart. As well as the contour
of the heart.
d. Auscultation: understand the basic heart sounds (S1 and S2).
3. Students are capable of reporting the results of pulmonary and cardiovascular examination.
Relation with Other Skills

To be capable of the skills in Block A.3, competence on the basic techniques in physical
examinations in both block A.1 and A.2 are required, as well as an understanding in pulmonary
and cardiovascular anatomy and physiology. Block A.3. pulmonary and cardiovascular
examinations are basic skills for integrated skills and encounters with simulated patients, (nearly
conducted in every block), Block B.1. Chest problem, and Block D.1. Emergency.
Assessment
This skills will be assessed both during formative assessment session and OSCE. Students
are hoped to achieve score up to > 70

Independent Learning
The goal of independent learning is to improve the examination procedure score up to
≥ 70.
Study Program
Table 4. Study Program

Individuals
No. Contents Remarks
Involved
1. Opening:
• Conducting a prayer. - Instructor 15 minutes
• Presentation and preparation of - Student
materials. - Student Equipments:
• Scenario and pretest. - Instructor • Alcohol
• Learning objectives. - Student • Stethoscope (teaching
• Role play by student (done by a stethoscope and single
student who has been prepared him/ stethoscope)
herself or chosen by the instructor). - Instructor • Sphygmomanometer
• Comments from instructor and students • Thermometer
2. Main Activity:
• Practice Session. Each group consists
of ± 3-4 students, acting as a patient,
doctor, and evaluator (each student
must join the role playing). Roles
of doctor, patient and evaluator are
switched.
• If there are only two students in
one group, they must take turns in
becoming the patient.
Student 80 minutes
• If there are more than 3 students,
Supervisors Checklist
2 students act as patients and the
others act as doctors and evaluators
for the first round. Then, the third
student acts as a patient in the second
round, but the patient in the first round
acts as a doctor.
• Perform heart and lungs examination.
• Direct feedback from students.
• Discussion: All questions in the work
plan are directed by the instructor.
3. Closing:
• Reflection, results of the exercise are Instructor 25 minutes
compared with checklist.
• Explanation of tasks to improve skills
by Independent Learning.
• Remind students of the importance
of these skills as the basis of physical
examination that will be taught in the
future blocks.
• Reflection by students on the practice
session (for Skills Lab)
• Pray.

Instruments and Equipment
Acquired instruments and equipment for thoracic lung and heart examination are listed
in Table 2.
Table 5. Instruments used for vital sign, thorax, lungs, and cardiac examination
Oral, axilla, rectal
Mercury Thermometer Electrical thermometer
Digital
Infra-red thermometer
Sphygmomanometer -Mercury
-Needle
-Digital
-Bed side monitor
Pulse -Manual (wristwatch with second
pendulum)
-Electrical/digital
Examination sites Desk, equipment desk, and bed
Stethoscope
Pen flashlight
Pencil and paper
weight/height measurer
Examination robe
covering cloth
disposable gloves

RESPIRATORY TRACTS ANATOMY
Figure 8 shows pulmonary system starting from nose cavities, nasal cavity, nasopharynx,
oropharynx, larynx and its parts, trachea, bronchus, bronchioles and bronchiolus terminalis
with alveolus.
Figure 8. Respiratory Tract Anatomy

Published by Clinical Reference System. A Division of HBO & Company
Copyright © 2000 HBO & Company. All rights reserved.
While inspiration, upper respiratory tracts warm, filter and humidify air, after flowing
through cartilage cricoids larynx, it flows through a flexible pipe system called trachea. At fourth
or fifth thoracic vertebra, trachea divides into left and right bronchus. Right bronchus is shorter,
wider and flatter than left bronchus. The bronchus keeps splitting into smaller ones that later
becomes bronchioles inside the lungs. Each bronchiolus respiratorius ends at an alveolar-
duct that splits into many alveolar-saccus. Bronchiolus terminalis’ diameter is less than 1 mm,
without cartilage, but it has plain muscle layers. Respiratory tract ends at acinus that consists
of bronchiolus respiratorius, and alveolaris ductus that are bordered by alveolus and saccus
alveolaris terminalis. Saccus are single layered pouch-like cells. It is estimated that there are
more than 500 million alveoli in the lungs with total surface area as wide as a tennis field. This
wide area is required to enable proper gas exchange. Lungs, therefore, are an aerogenic organ,
meaning that it can float on water. Each alveolus wall contains elastic fibers that allow the saccus
to expand during inspiration and to contract during expiration with elastic recoil mechanism.

Figure 9. Bronchus
Source: http://en.wikibooks.org/wiki/Human_Physiology/The_respiratory_system
Lungs are divided into several lobes: upper, middle and lower part at right lung and upper
and lower part at left lung. Lungs tissue consists of abundant capillary artery. Blood that flows
back from major circulation has to circulate through the lungs for gas exchange before flowing
back into major circulation. Lung is wrapped by a thin pouch-like organ called pleura. Pleura
visceralis is located right above lung parenchyma, and the pleura parietals covers the chest
wall. Both layers are attached with the vacuum pleura chamber filled with thin layer of liquid to
facilitate lung contraction. The chamber is called the cavum pleura.
Figure 10. Lungs

Source: http://www.shoppingtrolley.net/cardio-respiratory-system.shtml

HISTOLOGY OF RESPIRATORY TRACTS
Wall of bronchus consists of 3 layers (figure):
1. Mucus, located across lumen covered by cuboids cells with cilia. Among those epithelium
cells are goblet cells that produce mucus. If mucus irritation occurs, its secretion will increase.
Bronchial mucus epithelium contains cilia for secretion discharge and trapped materials (dust,
uncommon matters) to the direction of the pharynx. At chronic bronchus, cilia disappear or
atrophy resulting in obstructed secretion discharge. Sub mucus is located below the mucus.
2. Muscular layer, consists of plain muscles that form circles. Those muscles arrange bronchus
lumen dimension. Bronchus muscles contraction causes bronchus constriction.
3. Layers of cartilage can be found at large bronchus, smaller bronchus (closer to distal) contains
smaller amount of cartilage. There is no cartilage at bronchiolus terminalis.
Figure 11. Wall of Bronchus

Source: Junqueira and Carneiro, Basic Histology, a text and atlas, p. 355, Figure 17-8.
The air inside alveoli is separated from capillaries by a layer of endothelium alveoli and
capillary endothelium. Alveolar duct and alveoli stay open, not collapsed, although its wall only
consists of a single cell layer, due to substances with high surface tension that cover the internal
surface, called surfactant. At certain occasion (such as HMD at neonates), surfactant production
is insufficient resulting in collapsed alveoli.
The pulmonary blood circulation begins from the pulmonary artery then enters the heart’s
right chamber through the hillus. From the hillus it enters the lung to provide nutrition and oxygen
and carry carbon dioxide out of the lungs. Oxygen from lumen alveoli diffuses into capillary
blood vessels because of different pressure. Normally 75% of vein blood hemoglobin binds with
oxygen (25% at reduced condition) while artery blood saturates 97% of oxygen.
Students should remember pulmonary lymph flow to understand various pulmonary
diseases. Lymph liquid from pulmonary interstitial tissue flows through lymph vessels into regional
lymph glands. Most important regional lymph glands are hillus, paratracheal and supraclavicular.
Lymph liquid also flows into axilla and abdomen. Lungs’ abnormality (inflammation or tumor)
involves lymph circulation system. X-Ray image shows PKTB as primary focus, lymphangitis,
enlarged hillus, and paratracheal shadow (chimney-like shape or Schoorsteen figure)
PHYSIOLOGY OF PULMONARY SYSTEM

Respiration is alternating episodes of inspiration (breathe in) and expiration (breathe out)
regularly and automatically controlled by respiration center through respiration reflex. Lung
contraction happens at exact time following chest chamber, in parallel with respiration muscles
activities, inspiration muscles and expiration muscles at diaphragm and chest wall. In respiration
diseases, such as asthma, additional respiration muscles are also active.

When inspiration muscles are active, the chest chamber expands:
1. In abdominal respiration, diaphragm muscles contraction results in its concave-shape change
into wide and flat form causing chest chamber volume to expand.
2. In costal respiration, intercostals respiration muscles contraction will lift costae to cranial
lateral. This contraction rests on costae-vertebralis causing expansion of chest chamber
volume. Neonates’ respiration is abdominal; growth of chest wall muscles functions costal
respiration so that infant respiration becomes costo-abdominal.
During expiration, inspiration muscles relax and expiration muscles contract. Expiration
muscles activities facilitate inspiration muscles to get back into previous position, so that chest
wall collapses into minimal volume.
At normal respiration, similar amount of air flows in and out human respiratory tract alternatingly
and regularly. Air volume is called tidal volume. At the end of normal expiration, a certain amount
of air stays inside lungs, called functional residue capacity. Strengthening expiration will let little air
out, but certain amount of residue remains inside bronchus and its splitting. The remaining air is
called residue volume. When at maximum expiration someone breathes in as hard as they can,
the amount of air input is a maximum amount of air that can flow in and out the lungs. This is called
vital capacity. Air fractions are important to assess lung function. At restrictive and obstructive lung
abnormality, tidal volume decreases. However, at obstructive abnormality, functional residue capacity
increases because some blocked air is unable to flow out.
STRUCTURE AND PHYSIOLOGY

In order to describe the physical signs within the chest accurately, the examiner must
understand the topographic landmarks of the chest wall. The landmarks of clinical importance
are as follows: sternum, clavicula, incisura suprasternalis, angulus sternomanubrialis, linea
midsternalis, linea para sternalis, linea midclavicularis, linea axillaris anterior, linea axillaries
media, linea axillaris posterior, linea scapularis, and linea midspinalis.
Figure 12 shows the anterior thorax, Figure 13 shows lateral views, and Figure 14 shows
the posterior thorax.
Figure 12. Oblique view of Anterior Thorax

Source: Bickley L.S. and Szilagyi P.G. Bates’ Guide to Physical Examination and History
Taking. 9th edition. Lippicott Williams & Wilkins. 2007.
Figure 13. Oblique view of Lateral Thorax

Figure 14. Oblique view of Posterior Thorax
The incisura suprasternalis is located at the tip of the sternum and can be felt as a
depression at the base of the neck. The angulus sternomanubrialis is often referred to as the
Louis angle. This bony ridge lies approximately 5 cm below the incisura suprasternalis. When
you move your fingers off the ridge laterally, the adjacent rib that you feel is the second rib.
The interspace below the second rib is the second intercostal space. Using this as a reference
point, you should be able to identify the ribs and the anterior part of the intercostal space. Try
it on yourself.
To mark the areas on the surface of the chest, several imaginary lines are plotted on the
anterior and posterior areas of the chest, which are the midsternal line, the midclavicular line
(figure 12), the anterior axillary line, the medial axillary line, the posterior axillary line (figure
13), the scapular line and the midspinal line/ vertebra line (figure 14).
The fissura interlobaris, shown in Figure 15 and 16, are situated between the lobes of the
lungs. Both the right and the left lungs have an fissura obliqua, which begins on the anterior chest
at the level of the sixth rib at the linea midclavicularis and extends laterally upward to the fifth
rib in the linea axillaries media, ending at the posterior chest at the prosesus spinosus vertebra
thoracalis 3 (T3). The right lower lobe is located below the right oblique fissure; the right upper
and middle lobes are superior to the right oblique fissure. The left lower lobe is below the left
oblique fissure; the left upper lobe is superior to the left oblique fissure. The fissura horizontalis
is present only on the right and divides the right upper lobe from the right middle lobe. It extends
from the fifth rib at the sternal border to the fifth rib at the lineamidaxillaris.
Figure 15. Surface topography and fissura interlobar beneath, anterior and posterior

Figure 16. Surface topography and fissura interlobar beneath, right and left lateral
view
The lungs extend superiorly about 3-4 cm above the medial end of the clavicula. The
inferior margins of the lungs extend to the sixth rib at the midclavcular line, the eighth rib at the
midaxillary line, and in the posterior between the 9th thoracic vertebra (T9) and 12th thoracic
vertebra (T12). This variation is related to respiration. The bifurcation of the trachea, the carina,
is located behind the angulus of Louis at approximately the same height of the 4th thoracic
vertebra (T4) on the posterior chest. The right hemidiaphragm at the end of the expiration is
located at the level of the fifth rib anteriorly and the 9th thoracic vertebra (T9) posteriorly. The
presence of the liver on the right side makes the right hemidiaphragm slightly higher than the
left. During quiet breathing, muscle contraction occurs only during inspiration. Expiration is
passive, resulting from elastic recoil of the lungs and chest.

PHYSICAL EXAMINATION
The equipment necessary for the examination

of the chest is a stethoscope.
After a general assessment of the patient, the examination of the posterior chest is
performed while patient is still seated. The patient’s arms should be folded in his or her lap.
After the examination of the posterior chest is completed, the patient is asked to lie down; the
examiner should try to imagine the underlying lung areas.
If the patient is a man, his gown should be removed to his waist. If the patient is a woman,
the gown should be positioned to prevent unnecessary or embarrassing exposure of the breasts.
The examiner should stand facing the patient.
The examination of the anterior and posterior aspects of the chest includes the following:
• Inspection
• Palpation
• Percussion
• Auscultation
General Assessment
Inspect the Patient’s Facial Expression
Is the patient in acute distress? Is there nasal flaring or pursed lip breathing? Nasal flaring
is the outward motion of the nares during inhalation. This is seen in any condition that causes
an increase in the work of breathing. Are there audible signs of breathing, such as stridor and
wheezing? These are related to obstruction of airflow. Is cyanosis present?
Inspect the Patient’s Posture

Patients with airway obstructive disease tend to prefer a position in which they can support
their arms and fix the muscles of the shoulder and neck to aid in respiration. A common technique
used by patients with bronchial obstruction is to clasp the sides of the bed and use the latissimus
dorsi muscles to help overcome the increased resistance to outflow during expiration. Patients
with orthopnea remain seated or lie on several pillows.
Inspect the Neck

Is the patient’s breathing aided by the action of the accessory muscles? Use of the
accessory muscles is one of the earliest signs of airway obstruction. In respiratory distress, the
trapezius and sternocleidomatoid muscles contract during inspiration. The accessory muscles
assist in ventilation; they raise the clavicle and anterior chest to increase the lung volume and
produce an increased negative intrathoracic pressure. This results in retraction of the fossae
supraclavicular and intercostales muscles. An upward motion of the clavicle of more than 5 mm
during respiration has been associated with severe obstructive lung disease.
Inspect the Configuration of the Chest

A variety of conditions may interfere with adequate ventilation, and the configuration of
the chest may indicate lung disease.
Figure 17. Chest Configuration commonly found

Source: Swartz M.H. Buku Ajar Diagnostik Fisik. EGC. 1995

Assess the Respiratory Rate and Pattern
The normal adult takes about 16-24 breaths a minute. Bradypnea is an abnormal slowing
of respiration (less than 14 breaths a minute); tachypnea is an abnormal increase (more than
24 breaths a minute). Apnea is temporary cessation of breathing. Hyperpnea is an increased
depth of breathing, usually associated with metabolic acidosis. It is also known as Kussmaul’s
breathing. There are many types of abnormal breathing patterns. Figure 7 illustrates and lists
the more common types of abnormal breathing.
Figure 18. Respiratory Types

Source: Bickley L.S. and Szilagyi P.G. Bates’ Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
Types of breathing
In healthy women, generally the thoracic breathing is more dominant thus is called the
thoraco-abdominal type. While in healthy men, the abdominal breathing is more dominant and
is called the abdomino-thoracal type.
Inspect the Hands

Is clubbing present? The earliest finding of clubbing is loss of the angle between the
nail and the terminal phalanx. Look at the Figure 19 in which a normal index finger is compared
with a severely clubbed index finger of a patient with bronchogenic carcinoma.
Figure 19. Clubbing finger

Source: Swartz M.H. Textbook of Physical Diagnosis, History and Examination. 5th edition.
Philadelphia.
WB Saunders Company. 2007.

Posterior Chest
Now move to the back of the patient to examine the posterior chest.
Inspection
• During inspiration observe: the lateral movements of the ribs, widening of the epigastric
angle, and the size increase of the anteroposterior portion of the chest.
• During expiration observe: the retraction of the ribs, the tightening of the epigastric angle,
and the decrease of the chest’s anteroposterior size.
• Also, observe the use of additional breathing muscles.
Palpation
Palpation is used to assess the following:
• Areas of tenderness
• Symmetry of chest excursion
• Tactile fremitus
Palpate for Tenderness

Palpate firmly with your fingers any chest areas where tenderness is experienced by the
patient. Softly knock the patient’s back with your fist. A complaint of “chest pain” may be related
only to local musculoskeletal disease and not to disease of the heart or lungs. Be thorough in
assessing for areas of tenderness.
Evaluate Posterior Chest Excursion

The degree of symmetry of chest excursion can be determined by placing the hands
flat against the patient’s back with the thumbs parallel to the midline at approximately the level
of tenth ribs and pulling the underlying skin slightly toward the midline. The patient is asked
to inhale deeply, and the movement of the hands is noted. The hand movement should be
symmetrical. Localized pulmonary disease may cause one side to move less than opposite
side. The placement of the hands is shown in Figure 20.
Figure 20. Hands position on chest examination
The Principals of Tactile Fremitus

The words spoken can cause vibrations that can be heard if an examiner uses a
stethoscope on the chest to listen to the lungs. This is called vocal fremitus. If an examiner
palpates the chest wall when a patient is talking, vibrations can be felt. This is called tactile
fremitus. Sound is transferred from the larynx through a branch of the bronchus to the lungs
parenchyma and chest wall. Tactile fremitus gives vital information on the density of the lungs
tissues and the underlying chest cavities. A condition that increases the density of the lungs
and causes it to be thicker such as consolidation increases the conduction of tactile fremitus.
Clinical conditions that cause the decrease of sound conduction will decrease the tactile fremitus.
If there are large amounts of fatty tissues in the chest, air or liquid in the chest cavity or if the
lungs over expands, tactile fremitus will decrease.
Evaluate Tactile Fremitus

Tactile fremitus can be evaluated in two ways. In the first technique, the examiner places
the ulnar side of the right hand against the patient’s chest wall, as shown in Figure 10 and asks

the patient to say “ninety-nine.” Tactile fremitus is evaluated, and the examiner’s hand is moved
to the corresponding position on the other side. Tactile fremitus on the opposite side is then
evaluated and compared. By moving the hand from side to side and from top to bottom, the
examiner can detect differences in the transmission of the sound to the chest wall. If the patient
speaks either louder or deeper, the tactile sensation is enhanced. Tactile fremitus should be
evaluated in the six locations shown in Figure 22.
The other method of evaluating tactile fremitus is to use the fingertips instead of the ulnar
side of the hand. The same side-to-side and top-to-bottom positions shown in Figure 21 are
used. The evaluation of tactile fremitus should be performed using only one of these techniques.
The examiner should try both methods initially to determine which one is preferable.
Figure 21. Examination Technique for fremitus tactile

Philadelphia.
WB Saunders Company. 2007
Figure 22. Location for tactile fremitus examination

Philadelphia.
The Principals of Percussion

Percussion refers to tapping on a surface to determine the underlying structure. It is similar
to a radar or echo detection system. Tapping between the ribs on the chest wall is transmitted
to the underlying tissue, reflected back, and picked up by the examiner’s tactile and auditory
senses. The sound heard and the tactile sensation felt are dependent on the air-tissue ratio.
The vibrations initiated by percussion of the chest enable the examiner to evaluate the lung
tissue to a depth 5-6 cm, but percussion is valuable because many changes in the air-tissue
ratio are readily apparent.
Percussion over a solid organ, such as the liver, produces dull, low amplitude, short-
duration note without resonance. Percussion over a structure containing air within a tissue,
such as the lung, produces a resonant, higher-amplitude, lower-pitched note. Percussion over
a hollow air-containing structure, such as the stomach, produces a tympanic, high-pitched,
hollow-quality note. Percussion over a large muscle mass, such as the thigh, produces a flat,
high-pitched note.

Normally, in the chest, dullness over the heart and resonance over the lung fields are
heard and felt. As the lungs fill with fluid and become denser, as in pneumonia, resonance is
replaced by dullness. The term hyperresonance has been applied to the percussion note obtained
from a lung with decreased intensity, such as that found in emphysema. Hyperresonance is a
low-pitched, hollow-quality, sustained resonant note bordering on tympany.
Table 6. Sound Characteristics based on percussion and location.

Relative Relative Relative
Sound Quality Location
intensity pitch duration
(flatness) Soft High Short Flat Muscle
(dullness) Thud-like Liver, full bladder,
Soft to mild High intermediate
pregnant uterus
(resonance) Mild to loud Low Long Hollow Normal lungs
(hyperresonance) Echoic Hyperinflated lungs
Very loud Very low Long
like in emphysema
Tympanic Drum like Air in the stomach,
Loud High Intermediate
air in the intestine
Source: Lynn Bickley, Bates’ A Guide to Physical Examination and History Taking 9th edition.
2007. JB Lippicott Company. Philadelphia.
The technique of percussion

The technique of percussion is diagrammed in Figure 23. Try doing percussion on
yourself. Percuss over your right lung (resonant), stomach (tympanic), liver (dull), and thigh (flat).
Figure 23. Percuss technique
Percussion on the Posterior Chest

The sites on the posterior chest for percussion are above, between, and below the
scapulae in the intercostals spaces, as shown in Figure 24. The bony scapulae are not
percussed. The examiner should start at the top and work downward, proceeding from side to
side, comparing one side with the other.
Figure 24. Posterior Percussion and auscultation sites


Percussion is also used to detect diaphragmatic movement. The patient is asked to
take a deep breath and hold it. Percussion at the right lung base determines the lowest area
of resonance, which represents the lowest area of diaphragm. Below this level is dullness from
the liver. The patient is then instructed to exhale as much as possible, and the percussion is
repeated. With expiration, the lung contracts, the liver moves up, and the same area become
dull that is, the level of dullness moves upward. The difference between the inspiration and
expiration levels represents diaphragmatic movement, which is normally 4-5 cm. In patient with
emphysema, the motion is reduced. In patient with phrenic nerve palsy, diaphragmatic motion
is absent. This test is illustrated in Figure 25.a and 25.b
Figure 25.a. Examination technique of diaphragm movement. During respiration, in left

picture, percussion over the 7th right spatium intercostalis posteriorly on midscapular
line will sonor due to the existence of the lungs below. During Expiration, in right
picture, the pulmonary and diaphragm elevate. Percussion over the same area will
result in a dull sound due to the existence of the pulmonary below.
Philadelphia.
Figure 25.b. Examination technique of diaphragm movement or the lung resonance

Taking. 9th edition.
Lippicott Williams & Wilkins. 2007
Auscultation
Auscultation is the technique of listening for sounds produced in the body. Auscultation
of the chest is used to identify lung sounds. The stethoscope usually has two heads: the bell
and the diaphragm. The bell is used to detect low-pitched sounds, and the diaphragm is better
at detecting higher pitched sounds. The bell must be applied loosely to the skin; if it is pressed
too tightly, the skin will act as a diaphragm, and the lower-pitched sounds will be filtered out. In
contrast, the diaphragm is applied firmly to the skin. In very cachectic individuals, the bell may
be more useful because the protruding ribs in these patients make placement of the diaphragm
difficult. When using a stethoscope, never listen through the patient’s clothes. The diaphragm
or bell of the stethoscope should always be in contact with the patient’s skin.

Figure 26. How to place the stethoscope head A. How to place the diaphragm
properly. Note to place the stethoscope head firmly to the skin. B. How to place the
bell. Note to place the bell lightly on the skin.
Types of Breathing Sounds

Breath sounds are heard over most of the lung fields. They consist of an inspiratory
phase followed by an expiratory phase. There are four types of normal breath sounds:
• Tracheal
• Bronchial
• Bronchovesicular
• Vesicular
Tracheal breath sounds are harsh, loud, high pitched sounds heard over the extra-thoracic
portion of the trachea. The inspiratory and expiratory components are approximately equal in
length. Although these sounds are always heard when one listens over the trachea, they are
rarely evaluated because they do not represent any clinical lung problems.
Bronchial breath sounds are loud and high pitched and sound like air rushing through a
tube. The expiratory component is louder and longer than the inspiratory component. These
sounds are normally heard when one listens over the manubrium. A definite pause is heard
between the two phases.
Bronchovesicular breath sounds are a mixture of bronchial and vesicular sounds. The
inspiratory and expiratory components are equal in length. They are normally heard only in the
first and second interspaces anteriorly and between the scapulae posteriorly. This is the area
overlying the carina and main-stem bronchi.
Vesicular breath sounds are the soft, low-pitched sounds heard over most of the lung fields.
The inspiratory component is much longer than the expiratory component, which is also much
softer and frequently inaudible. The four types of breath sounds are shown and summarized
in Table 7.
Table 7. Characteristics of Breathing

Pitch of Locations Where
Duration of Intensity of
Ratio Expiratory Heard Normally
Sounds Expiratory
Sound Sound
Vesicular* Inspiratory 3:1 Soft Relatively Over most of both
sounds last low lungs
longer than
expiratory
ones.
Bronchovesicular Inspiratory 1:1 Intermediate Intermediate Often in the 1st and
and expiratory 2nd interspaces
sounds are anteriorly and
about equal. between the
scapulae

Bronchial Expiratory 1:3 Loud Relatively Over the
sounds last high manubrium, if heard
longer than at all
inspiratory
ones.
Tracheal Inspiratory 1:1 Very loud Relatively Over the trachea in
and expiratory high the neck
sounds are
about equal.
The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch
Taking.
9th edition. Lippicott Williams & Wilkins. 2007
Auscultate the Posterior Chest

Auscultation should be performed in a quiet environment. The patient is asked to breath
in and out through the mouth. The examiner should first concentrate on the length of inspiration
and then on expiration. Very soft breath sounds are referred to as distant. Distant breath sounds
are commonly found in patient with hyperinflated lungs, as in emphysema. The examination
should proceed from side to side and from top to bottom, one side being compared with the
other. The positions are illustrated in Figure 24. Because most breath sounds are high pitched,
the diaphragm is used to evaluate lung sounds.
Anterior Chest
The examiner should now move to the front of patient. The first part of the examination
of the anterior chest is performed with the patient seated, after which the patient is asked to
lie down.
Evaluate the Position of the Trachea

The position of the trachea can be determined by placing the right index finger in the
suprasternal notch and moving slightly lateral to feel the location of the trachea. This technique
is repeated, moving the finger from the suprasternal notch to the other side. The space between
the trachea and the clavicle should be equal. A shift of the mediastinum can displace the trachea
to one side. This technique is shown in Figure 27.
Figure 27. Technique of finding the trachea position
Look at the patient shown in Figure 28. Notice that the trachea is markedly displaced
to the right in this very cachectic woman. The diagnosis of a mass either pushing or pulling the
trachea to the right is suggested.
Now ask the patient to lie on his or her back for the rest of the examination of the anterior
chest. The patient’s arms are at the sides. If the patient is a woman, either have her elevated her
breasts or displace them yourself as necessary during palpation, percussion, and auscultation.
These examinations should not be performed over breast tissue.

Figure 28. Trachea deviation
Philadelphia.
Chest Inspection
There are several points that should be observed in chest examination. During inspiration
observe the lateral movements of the ribs, widening of the epigastric angle, and the size increase
of the anteroposterior portion of the chest. During expiration observe: the retraction of the ribs,
the tightening of the epigastric angle, and the decrease of the chest’s anteroposterior size. Also,
observe the use of additional breathing muscles.
Examine the Chest Movements

Examine the symmetry of the chest movements by placing both hands along the lateral
rib margin seen in Figure 29. Ask the patient to breathe in while the examiner moves their hands.
Figure 29. Examination technique of chest movement
Evaluate Tactile Fremitus

Tactile fremitus is assessed in the supraclavicular fossae and in alternate anterior
interspaces, beginning at the clavicle. The techniques for evaluating tactile fremitus have already
been discussed. Proceed from the supraclavicular fossae downward, comparing one side with
the other (Figure 30).
Figure 30. Examination of chest tactile fremitus

Philadelphia.

Percuss the Anterior Chest
Percussion of the anterior chest includes the supraclavicular fossae, the axilla, and
the anterior interspaces, as shown in Figure 31. The percussion note on one side is always
compared with that elicited in the corresponding position on the other side. Dullness may be
noted in the third to fifth intercostals spaces to the left of the sternum, which is related to the
presence of the heart. Percuss high in the axilla because the upper lobes are best evaluated at
these positions. Axillary percussion is sometimes easier to perform while the patient is sitting.
Figure 31. Percussion site and chest auscultation

Taking.
9th edition. Lippicott Williams & Wilkins. 2007
Figure 32. The site of chest percussion

Source: Wasilah et al. Block 2, Basic Techniques of Physical Examination.
Skills Laboratory. 2005
Auscultate the Anterior Chest

Auscultation of the anterior chest is performed in the supraclavicular fossae, the axilla,
and the anterior chest interspaces, as illustrated in Figure 32. The techniques of auscultation
have already been discussed. The breath sounds of one side are compared with the breath
sounds heard in the corresponding position on the other side.

PHYSICAL CARDIOVASCULAR EXAMINATION
PROJECTION OF THE HEART AND LARGE BLOOD VESSELS ON THE CHEST

Generally, the heart is examined from the chest. Most of the anterior surface of the heart
consists of the right ventricle. This ventricle with the pulmonary artery is in a shape of an axe
which is located behind and to the left of the sternum. The bottom border of the right ventricle
is located as high as the border between the sternum and the xiphoideus process. Then the
right ventricle shortens when it rises and connects to the pulmonary artery at the 3rd left rib
cartilage near the sternum (figure 33).
The left ventricle forms a small part of the anterior portion of the heart, located to the
left and behind the right ventricle. Still, the left ventricle is clinically important because it is the
left border of the heart which plots the ictus cordis.
The ictus cordis is a systolic pulse which can be seen in the 5th intercostal space, 7-9
cm from the midsternal line (figure 33).
The right border of the heart is formed by the right atrium. The left atrium cannot be
examined directly. Even though, a small portion of this atrium forms part of the left border of
the the left heart with the pulmonary artery and the left ventricle.
Figure 33. Heart projection over chest wall

Above the heart are the large arteries. The pulmonary artery branches out to become
the right and left branch. The aorta curves above the left ventricle in the sternal angel area then
curves behind and to the bottom. To the right the superior vena cava enters the right atrium
(Figure 34).
Even though it is not pictured above, the inferior vena cava also enters the right atrium.
The superior and inferior vena cava supplies venous blood to the superior and inferior areas
of the body.
Four classic auscultation areas are plotted according to where precordial occurrences
originate from each heart valve which can be heard most clearly. These areas do not need to
be involved in the anatomic position of the valves and all sounds which can be heard in this
area also cannot be directly produced by the specific valve named in the area.
The following areas are:
• Aorta : second costal interspace, edge of right sternum (2nd intercostalis space – right
parasternalis space)
• Pulmonal : second costal interspace, edge of right sternum (2nd intercostalis space – left
parasternal line)
• Tricuspid : bottom left of the sternum
• Mitral : heart apex (5th intercostalis space – left midclavicular line)

Figure 34. Vein projection over chest wall
Figure 35. Auscultation area of the heart valves

Taking.
9 edition. Lippicott Williams & Wilkins. 2007
th
INSPECTION
Specifically for inspection of the heart, observe the pulse at the apex, tricuspid, pulmonal
and aortic areas.
Figure 36.a. Ictus cordis palpation using palms
PALPATION
Using the tip of the fingers or the palm of the hands, depending on the sensitivity, feel
the apex, tricuspidal, pulmonal and aortic areas.

• Pulsation
• Thrill which is the vibration felt on the hands of the examiner. This can be felt because
there is a minimal third degree murmur. A systolic thrill or diastolic thrill can be
differentiated based on which phase is present.
• Heaving which is a feeling of wave on the hands of the examiner. This is due to an
overload of the left ventricle, such as in mitral insufficiency.
• Lift which is the feeling of pressure on the hands of the examiner. This is caused by an
increase of pressure in the ventricle, such as in mitral stenosis.
• Ictus cordis which is pulsation in the apex. The diameter is measured, where it is
normally 2 cm and the location is evaluated which is located 2 fingers medial from the
left midclavicular line.
Figure 36b. Ictus cordis palpation using finger tip
PERCUSSION
Technique
Percussion may provide an estimate of a patient’s heart size. Initially, the area of
decreased resonance or relative dullness is heard just at the right sternal border; this comprises
the right border of the heart. At the left sternal border, dullness becomes absolute; this area is
where the heart is closest to the chest wall. The absolute heart dullness extends approximately
3 to 4 cm to the left from the left sternal border. Percussion in the left parasternal line estimates
the superior heart border. The relative dullness starts at the third intercostal space, and the
absolute dullness occurs at the fourth intercostal space. The left heart border is percussed at
the fifth intercostal space starting from the axillar line. The relative dullness begins at the left
midclavicular line and becomes absolute 2 to 3 cm medially.
The inferior heart border is not amenable to precise percussion. Limitations of estimating
heart size with cardiac percussion are due to constitutional factors (e.g., obesity, large muscles
or breast tissue) and lung disease. Coincidentally, the same is true for the echocardiography.
Figure 37. Heart borders


Right Heart Border
Initially the medial point of the right midclavicular line is plotted. The fingers of the right
hand are placed parallel to the ribs. Then percussion is done starting from the medial point from
a cranial towards caudal direction. The normal sound heard is a sonor sound that originates
from the lungs. The percussion continues until a dull sound appears, usually in the 6th right
intercostal space. This dull sound originates from the border between the lungs and the tip of
the liver. The tip of the liver is covered by the diaphragm and there is still pulmonary tissue
on the tip of the liver, thus there is a combination of solid mass and small amounts of air from
the lungs. After the point of sonor-dull is established measure two fingers towards the cranial
position. In this new point, place the palms of the hands and the fingers positioned parallel to the
ribs. Then perform percussion medially to search for sound alterations from sonor to dull which
is the relative right border of the heart and normally the right line of the sternum. Percussion
is performed on this border point until a stony dull sound is heard which is the absolute right
border of the heart, usually the midsternal line.
Left Heart Border

Initially plot the left anterior axillar line. If there is heart enlargement to the left the
percussion can start from the medial axillar line. Then the middle finger is placed on the highest
point of the anterior axillar line with the fingers parallel to the ribs. Percussion is performed from
cranial to caudal searching for changes in sounds from sonor to tympanic which is the border of
the lungs and stomach, usually located in the 7th left intercostal space. From this point measure
two fingers towards a cranial direction. From this new point perform percussion again towards
the medial area with the left fingers parallel to the ribs until there is a sound alteration from sonor
to redup which is the relative left border of the heart and is usually located two fingers from the
left midclavicular line. The percussion is continued to the medial area until the sound changes
from dull to stony dull which is the absolute border of the left heart. When there is emphysema
of the lungs the absolute borders of the heart will shrink.
If the patient has had much to eat, the tympanic sound which is the border of the lungs
will not appear, thus another technique is performed to obtain the border of the left heart. Initially
the border of the lungs and liver is determined, then 2 fingers are measured (or around 4 cm)
towards the cranial direction. From this point a straight line is pulled parallel the ribs through
the left anterior axillar line. From this point percussion is performed parallel the ribs towards
the medial direction to search for the point where the sound changes from sonor to dull which
is the border of the left heart.
Upper Border of the Heart

Initially define the left sterna lines. From the highest point perform percussion parallel to
the ribs towards the caudal direction until the sound changes from sonor to redup. The normal
sounds originate from the 2nd left intercostal space.
Border of the heart

Firstly define the left parasternal line. Then perform percussion towards the caudal
direction starting from the upper point of the line, with the middle finger parallel to the ribs. Search
for a change of percussion sounds. The normal border is located in the 3rd let intercostal space.
If the board point is in the 2nd intercostal space, then the border of the heart will disappear. This
happens due to enlargement to the left atrium such as in mitral vitium.
Heart Contour
The purpose is to draw the shape of the heart, to confirm the size of the heart and to
the presence of the shape of the heart. Starting from the 1st right intercostal space percussion
is performed from the lateral to medial direction with the middle finger parallel to the ribs until
there is sounds changes from sonor to dull. Then percussion is performed from the 2nd right
intercostals space with the same method and continued towards the caudal direction. The
border points are plotted and then a line is pulled thus obtaining the border of the right heart.

This also does on the left side of the heart with the same method. Finally a picture of the right
and left heart border line is obtained.
AUSCULTATION
With auscultation heart sounds can be heard and also murmurs if there are anomalies
in the heart using a stethoscope. The first investigator to study the heart sounds was Laennec.
To obtain the best auscultation results, the following points must be noticed: examined
in a calm room, focus to listen to faint sounds, synchronize the pulse to obtain the 1st heart
sound and then outline the systolic and diastolic phase as well as heart sounds and murmurs.
The examination location for auscultation can be seen in Figure 24.
Table 5. Auscultatory sounds

Heart Sounds Guides to Auscultation
S1 Note its intensity and any apparent splitting. Normal splitting is detectable
along the lower left sternal border.
S2 Note its intensity.
Split S2 Listen for splitting of this sound in the 2nd and 3rd left interspaces. Ask the
patient to breathe quietly, and then slightly more deeply than normal. Does
S2 split into its two components, as it normally does? If not, ask the patient
to (1) breathe a little more deeply, or (2) sit up. Listen again. A thick chest
wall may make the pulmonic component of S1 inaudible.
Width of split. How wide is the split? It is normally quite narrow.
Timing of split. When in the respiratory cycle do you hear the split? It is
normally heard late inspiration. Does the split disappear as it should, during
exhalation? If not, listen again with the patient sitting up.
Intensity of A2 and P2. Compare the intensity of the two components, A2
and P2. A2 is usually louder.
To evaluate the heart sounds quickly, the examiner should determine the times of
important incidents of the heart cycle. The most dependable method to recognize the the S1
and S2 is to determine the time when the sounds occur by palpating the carotid artery (Figure
28.). While the right hand of the examiner changes the stethoscope’s position, the left hand is
placed on the patient’s carotid artery. The most important aspect is to use the carotid artery,
not the radial. The lateness of the S1 until the radial pulse is significant, thus error can occur
in determining the time.
Figure 38. S2 split during expiration

th
Taking. 9 edition. Lippicott Williams & Wilkins. 2007
Figure 39. Heart Auscultation and carotic artery palpation

Four classic auscultation areas are plotted according to where precordial occurrences
originate from each heart valve which can be heard most clearly. These areas do not need to
be involved in the anatomic position of the valves and all sounds which can be heard in this
area also cannot be directly produced by the specific valve named in the area.
The following areas are:
• Aorta: second costal interspace, edge of right sternum (2nd intercostalis space – right
parasternalis space)
• Pulmonal: second costal interspace, edge of right sternum (2nd intercostalis space – left
parasternal line)
• Tricuspid: bottom left of the sternum
• Mitral: heart apex (5th intercostalis space – left midclavicular line)
Building a good interpersonal relationship.

• creating good environment and communication including common courtesy.
• explaining the procedures and the consequences
• pay attention to the patient’s reaction during physical examination
I. Inspection
Are the right – left chest walls symmetrical? Is there any left-behind movement? Are there
any skin anomalies or change in skin color? Is the patient respiration assisted by the additional
muscles movement? Can you see Ictus cordis?
II. Palpation
Palpating the chest wall can be performed in a static or dynamic condition.
1. Static condition palpation
- Examine the lymph nodes. The expansion of lymph nodes in the area of supraclavicula,
submandibula, and both axillas
- The examination to determine the position of mediastinum.
- Further palpation examination over the posterior chest area using fingers to define
the existence of chest wall abnormalities such as tumor, pressure pain over chest
wall, crepitation due to subcutic emphysema, ictus cordis etc.
2. Dynamic condition palpation
In this condition the examination can be performed to assess the lung expansion as well
as the fremitus vocal examination.
− Lung Expansion examination
− The decrease of tactil fremitus. This exam is performed by putting both palms on
the surface of chest wall, and requests the patient to pronounce the numbers of 77
or 88 or 99, so that the sound vibration yielded will be clearer. Thoroughly feel the
sound vibration.
− This examination is known as tactil fremitus. Compare it gradually starting from the
upper up to the lower lungs both anteriorly and posteriorly. Cross both palms when
performing the examination.
III. Percussion
Based on its pathogenesis, the tips of the sound can be various; the students should
be able to differentiate the sounds produced by the percussion as follows.
a. Sonor (resonant)
b. Hypersonor (hyperresonant)
c. Dull
d. Flat (stony dull)
In the normal condition, sonor sound will be produced in both lungs. Other examination
performed on anterior pulmonary is the percussion to define the pulmonary lung and limb
pulmonary border. Axilla areas can be percussed by requesting the patient to raise the arms

over the head. The Examiner puts the fingers as high as possible over the patient’s axilla to be
percussed. Find the borders of right, left, upper, apex and contour of the heart.
IV. Auscultation
Perform systematic auscultation. Find the basic vesicular respiratory sound. Compare
with the tracheal and bronchial sounds. Perform Heart S1 and S2 Examinations.
GENERAL ASSESSMENT OF CARDIOVASCULAR EXAMINATION

Jugular Venous Pulse and Pressure

Jugular veins
Inspect the neck for jugular vein distension. When the client is supine, the neck veins
normally protrude; when the client stands, they normally lie flat. When the client sits at a 45
degree angle in semi Flowler’s position, the jugular vein will appear distended only if the client
has right heart dysfunction. To check for jugular vein distention, place the client in semi-Flowler’s
position with the head turned slightly away from the side being examined. Use tangential lighting
(lighting from the side) to cast small shadows along the neck, which allow you to see pulse
wave movement better.
If distension is present, characterize it as mild, moderate, or severe. Determine the level
of distension in fingerbreadths above the clavicle or in relation to the jaw or clavicle. Also, note
the amount of distension in relation to the head elevation.
Examination of the jugular veins and their pulsations allows quite accurate estimation of the
central venous pressure, and therefore gives important information about cardiac compensation.
The internal jugular pulsations, although somewhat harder to see than the external jugulars,
give a more accurate reading. In children under 12 years of age, however, the jugular veins
and pulses are difficult to see and are therefore of little use in evaluating the cardiovascular
system in this age group.
Position the patient so as to promote comfort, with the head slightly elevated on a pillow
and the sternomastoid muscles relaxed. Start with the head of the bed of table elevated about
30o; then adjust it so as to maximize the jugular venous pulsations and make them visible in
the lower half of the neck.
Unilateral distension, especially of and external jugular vein may be deceptive: it can be
caused by local factors in the neck.
Identify the external jugular vein on each side. Then find the pulsations of the internal jugular
vein. Since this vein lies deep to muscle, you will not see the vein itself. Watch instead for the
pulsations transmitted through the surrounding soft tissues. Look for them in the supersternal
notch, between the attachments of the sternomastoid on the sternum and clavicle, or just
posterior to the sternomastoid. Distinguish these pulsations from those of the adjacent carotid
artery by the following points.
INTERNAL JUGULAR PULSATIONS CAROTID PULSATIONS

Rarely palpable Palpable
Soft undulating quality, usually with two A more vigorous thrust with a single outward
elevations and two troughs component
Pulsations eliminated but light pressure on Pulsation not eliminated by this pressure
the vein(s) just above the sternal end of the
clavicle
Level of the pulsations usually descends with Level of the pulsation not affected by
inspiration inspiration
Level of the pulsations changes with position, Level of the pulsation unchanged by position
dropping as patient becomes more upright.

Identify the highest point at which pulsations of the internal jugular vein can be seen.
With a centimeter ruler measure the vertical distance between this point and the sternal angle.
Establishing true vertical and horizontal lines is difficult – much like the problem of hanging a
puncture straight when you are close to it. Place your ruler on the sternal angle and line it up
with something in the room that you know to be vertical. Any long rectangle, such as a packaged
tongue blade, makes a good horizontal line. If its short edge is parallel to the vertical ruler, its
long edge should be truly horizontal. A second observer at some distance from you can often
see a slanting line better that you can and help you to correct it.
The highest point of venous pulsations may lie below the level of the sternal angle. Under
these circumstances venous pressure is not elevated and seldom needs to be measured.
If you are unable to visualize pulsations in the internal jugular veins, look for them in the
external jugulars, although they are not usually visible here. If you see none, identify the point
above which the external jugular veins appear to be collapsed. Make this observation on each
side of the neck. Measure the vertical distance of this point from the sternal angle.
By either technique round your measurement off to the nearest centimeter and record it.
The angle at which the patient was lying should also be included because of its possible effects
on the measurement. Thus, “The internal jugular venous pulse is 6 cm above the sternal angle,
with the head of the bed elevated to 45o”. Venous pressure greater than 3 cm or 4 cm above
the sternal angle is considered elevated.

How to examine the JVP
Use the right internal jugular vein (IJV).
Patient should be at a 45° angle.
Head turned slightly to the left.
If possible have a tangential light source that shines obliquely from the left.
Locate the surface markings of the IJV - runs from medial end of clavicle to the ear lobe
under medial aspect of the sternocleidomastoid.
Locate the JVP - look for the double waveform pulsation (palpating the contra lateral
carotid pulse will help).
Measure the level of the JVP by measuring the vertical distance between the sternal angle
and the top of the JVP. Measure the height - usually less than 3 cm.
If congestive heart failure is suspected, whether or not the jugular venous pressure
appears elevated, check for an abdominojugular (hepatojugular) reflux. Adjust the position of
the patient so that the highest level of pulsation is readily identifiable in the lower half of the
neck. Place the palm of your hand on the center of the abdomen and slowly press it inward,
exerting firm and sustained pressure for 30 to 60 seconds. Your hand must be warm, and the
patient should remain relaxed and breathing easily. If your hand is pressing on a tender area,
move it elsewhere on the abdomen. Watch for an increase in the jugular venous pressure. A
transient rise is normal.
Evaluate central venous pressure. The jugular vein demonstrates right heart pressure
just as the mercury in the sphygmomanometer columns demonstrate blood pressure. Because
of their relationship, jugular vein distension can provide a rough estimate of central venous
pressure.
Estimating central venous pressure.

The doctor can estimate a client’s central venous pressure indirectly by determining the
height from the right atrium to the highest level of visible pulsation in the jugular vein. To begin,
place the client at a 45-degree angle and use tangential lighting to observe the internal jugular
vein. Note the highest level of visible pulsation.
Next, locate the angle of Louis, or sternal notch. To do this, palpate the clavicles where
they join the sternum (the suprasternal notch). Place two of your fingers on the suprasternal
notch and slide them down the sternum until they reach a bony protuberance. This is the angle
of Louis. The right atrium lies about 2” (5 cm) below this point.
To estimate central venous pressure, measure the vertical distance between the highest
level of visible pulsation and the angle of Louis. Normally, this distance is less than 1 ⅛” (3 cm).
Add 2” (5 cm) to this figure to estimate the total distance between the highest level of pulsation
and the right atrium. A total that exceeds 4” (10 cm) may indicate elevated central venous
pressure and right ventricular failure.

REFERENCES
Bickley L.S. and Szilagyi P.G. Chapter 7, The Thorax and Lungs. In: Bickley L.S. dan Szilagyi
P.G. Bates’ Guide to Physical Examination and History Taking. 9th edition. Lippincott
Williams & Wilkins. 2007
Rumende C.M. Pemeriksaan Fisis Dada dan Paru. Dalam: Sudoyo A.W. Dasar-dasar Ilmu
Penyakit Dalam. Edisi keempat. Jakarta. Pusat Penerbitan, Departemen Ilmu Penyakit
Dalam Fakultas Kedokteran Universitas Indonesia. 2006
Kaplan N.M. Chapter 2, Measurement of Blood Pressure. In: Kaplan N.M. Kaplan’s Clinical
Hypertension. Ninth edition. Lippincott Williams & Wilkins.

PHYSICAL EXAMINATION PROCEDURE
(Heart – Lungs)
Name: …………………………… Student’s Number: …………………
DIRECTION: Working procedure and all of the examinations results are reported narratively
No Evaluated Aspects Feedback
1 Wash the hands with alcohol according to the procedure before
examining the patient.
2 Ensure that you incorporate appropriate greeting processes,
creating conducive environment by using common courtesy
and check the patient’s condition.
3 Ask the patient’s permission to perform the examination, allow
him /her to go to the examination place and describe what will
be performed.
4 Ask the patient to open up the clothes in his/her posterior area,
and communicate with the patient in a way, which reduces
anxiety, provides necessary information, earns their trust and
ensures safe practice. (Say : sorry, mention the name, thank
you)
5 POSTERIOR CHEST INSPECTION:
Ask the patient to sit in an upright position on the examination
bed, both hands on his /her lap or folded over the chest
6 Perform inspection. Ask the patient to breathe regularly. Report:
body posture, chest topography and configuration.
7 POSTERIOR CHEST PALPATION:
Warm both hands. Systematically examine the palpation: is
there any pressure pain?
8 Put both palms on the right and left chest of the patient to
compare the chest wall movement. Report: symmetrical?
9 Ask the patient to say “seventy seven” or “ninety nine”. Compare
right and left fremitus tactile (using 2 procedures).
10 POSTERIOR CHEST PERCUSSION:
Perform percussion systematically, compare the right and left,
upper and lower (percussion ways, sequentially)
11 Perform Lungs expansion examination (during the inspiration
the diaphraghm will be lower 4 -5 cm).
12 POSTERIOR CHEST AUSCULTATION:
Ask the patient to breath deeply through open mouth to identify
breath sounds. Perform it systematically (how to hold the
stethoscope, sequentially, notifying basic + additional sounds).
13 ANTERIOR CHEST INSPECTION:
Moving to anterior chest, inspect, palpate as before, assessing
expansion and fremitus.
14 Examine the head and neck first, then ask the patient to be in a
supine position with head slightly elevated and examining from
the right – INSPECT and PALPATE for apical impulse.
15 ANTERIOR CHEST PALPATION:
Perform evaluation over trachea position at suprasternal
incisura using right hand forefinger.
16 Put both palms on right and left chest wall to compare the chest
wall movement.
Ask the patient to breath deeply. Report: Symmetrical?
17 Comparing right and left fremitus tactile (using 2 procedures).

18 Feel the ictus cordis using 4 right hand fingers on RIK 4 and 5,
linea midclavicula.
After found, place the forefinger on the ictus cordis. Report
whether it is felt, its location, diameter, “Thrill”, amplitude.
19 ANTERIOR CHEST PERCUSSION:
Perform systematic percussion to compare the right and left
upper and lower (percussion way, sequentially).
20 Ask patient to raise hands to percuss the lateral area starting
from the armpit.
21 Ask patient to straighten both hands on the sides of the body.
Percuss to determine the borders of of pulmonary – lungs on
the linea mid clavicula and give mark.
22 Percuss to determine the borders of heart (upper – right – left)
23 ANTERIOR CHEST AUSCULTATION:
Ask patient to breathe deeply through the nose over the mouth
slowly.
24 Perform pulmonary auscultation systematically sequentially.
25 Listen to the inspiration and expiration on every examined site.
26 Perform auscultation over right and left lateral chest.
27 Perform systematic heart auscultation (4 valves location; S1,
S2).
28 Inform the patient that the examination on posterior and chest
have been done; report the resume of the result and thank the
patient.
Global Rating Scale for Professional Behavior

Scale
Scientific basis and
No. Skills 1
2 3 4
5
explanation Unexpected
Below Meet Exceeding
Excellent
expectation expectation expectation
1 Demonstrate Dealing with one-
confidence self:
during (student able
performing to behave
skills in front of professionally
patient without showing his/
her anxiety, sadness
and worries)
Global Rating Scale for Doctor-Patient Interaction

Scale
Scientific basis
No. Skills 1
2 3 4
5
and explanation Unexpected
Below Meet Exceeding
Excellent
expectation expectation expectation
1 Building and Ability to build a
maintaining good relationship
adequate (through active
relationship with listening, response
patients during properly, empathy,
the whole interpersonal
consultation communication and
putting patient at
ease)

Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observer’s expectation (demonstrate minimal respect and norms + 60%-80%
error)
Scale 3: Meet observer’s expectation (demonstrate minimal respect and norms + 40%-60%
error)
Scale 4: Exceed observer’s expectation (demonstrate minimal respect and norms + 20%-40%
error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, ……………………………..
Observer
……………………………………………………

BASIC CLINICAL COMPETENCE TRAINING
MATERIAL BOOK
ELECTROCARDIOGRAPHY 1
BLOCK A.3

Skills Laboratory
Yogyakarta
2020

ELECTROCARDIOGRAPHY 1
BLOCK A.3
Contributor:
dr. Hasanah Mumpuni, Sp.PD-KKV, Sp.JP(K) Dr.med.dr. Putrika PR Gharini, Sp.JP(K)

Department of Cardiovascular Department of Cardiovascular
RSUP DR.Sardjito RSUP DR.Sardjito
Faculty of Medicine GMU Faculty of Medicine GMU
Dr. dr. Denny Agustiningsih, M.Kes, AIFM dr. Dyah Adhi Kusumastuti, Sp.JP
Department of Physiology Department of Cardiovascular
Faculty of Medicine GMU RSUP DR.Sardjito
Faculty of Medicine GMU
dr. Rahmaningsih Mara Sabirin, M.Sc dr. Dyah Samti Mayasari, Ph.D, Sp.JP
Department of Physiology Department of Cardiovascular
Faculty of Medicine GMU Faculty of Medicine GMU
dr. Ahmad Djunaidi, SU., AIFM dr. Santosa Budiharjo, M.Kes, PA

Department of Physiology Department of Anatomy, Embryology, &
Faculty of Medicine GMU Anthropology
dr. R. Jajar Setiawan, M.Sc., Ph.D

Department of Physiology

CO-Contributor:
dr. Yulia Wardhani, Sp.PD-KGH

Skills Lab Content Team Assistant
Faculty of Medicine, GMU
Indra Sari Kusuma Harahap,Sp.S Noviarina Kurniawati, MS.c

Skills Lab Content Team Assistant Skills Lab Learning Resource Coordinator
Staff of Neurology Department Faculty of Medicine, Public Health and
Nursing Universitas Gajah Mada
Universitas Gajah Mada
dr.Prattama Santosa, MHPEd Istiani Dewi, S.Kep.Ns

Departemen of Medical Education and Undergraduate Study program
Bioetichs Clinical Skills Laboratory
Skills Lab Learning Resource Coordinator Faculty of Medicine, Public Health and
Nursing Universitas Gajah Mada
Universitas Gajah Mada
Education Program Design Supervised by:
dr. Ery Kus Dwianingsih,Sp.PA.,P.hD (K)

The First Year Coordinator for Clinical Skills Training
Faculty of Medicine


book.
behaviour.
a. In case the instructor could not attend the lab sessions, skills laboratory will refer the
students to the companying instructor.
be rescheduled within the week. If it is not rescheduled within the week, the instructor
in charge will be substituted by the companying instructor.
bulletin board.
behaviour.

TABLE OF CONTENTS
PREFACE.......................................................................................................................
FOREWORD.................................................................................................................. 150
A. General Objective of Electrocardiography I.............................................................. 151
B. Level of Competency............................................................................................... 151
C. Activity...................................................................................................................... 151
ELECTROCARDIOGRAPHY I....................................................................................... 152
Anatomy and Electrophysiology of the Heart................................................................. 152
Conduction System of the Heart.................................................................................... 153
Conduction..................................................................................................................... 154
Primary and Ectopic Pacemaker.................................................................................... 155
Normal Activation of the Atrium...................................................................................... 155
Normal AV node Conduction.......................................................................................... 155
Normal Activation of the Ventricle................................................................................... 155
Activation Wave and Repolarization............................................................................... 155
ELECTROCARDIOGRAM ............................................................................................. 155
A. Electrode............................................................................................................. 156
B. From Electrode to Paper..................................................................................... 156
C. Leads and Einthoven Triangle............................................................................ 157
D. Curve and Hill..................................................................................................... 158
E. Cells controlling Cardiac Muscle Cell................................................................. 158
F. Repolarization and Depolarization...................................................................... 158
ECG RECORDING......................................................................................................... 159
A. Devices............................................................................................................... 159
B. ECG Recording................................................................................................... 161
C. Steps in ECG recording...................................................................................... 161
FEEDBACK FORM ELECTROCARDIOGRAPHY RECORDING.................................. 164
ATTACHMENT ............................................................................................................... 159
KEYBOARD................................................................................................................... 160

FOREWORD
Students of faculty of medicine are required to study and train on several skills as a
preparation before entering clinical rotation and later becoming an independent and competent
doctor. Nowadays, medical education should ensure students to become competent in various
skills before facing a real patient. Therefore, exercise and training in clinical skill is done as early
as possible. Skills laboratorium gives chances for students to learn and train on their clinical skills.
In this block, the skills to record the activity of the heart using electrocardiography (ECG)
will be studied. In the next several blocks, interpretation of normal and later on abnormal ECG
recording will be studied further.
No. Skills Training Topic Block

1. Electrocardiography I A.3
(Cardio-Respiratory System)
2. Electrocardiography II B.1
(Chest Problem)
It is important for students to realize that the topics stated above are correlated to one
another. Therefore, students should be able to group those topics into the main topic so as the
learning continuity are seamless. We hope that through this manual, students can improve on
their clinical skills and could even benefit the instructor as well.
Skills Lab Content Development Team

Faculty of Medicine

ELECTROCARDIOGRAPHY I
A. General Objective of Electrocardiography I

1. Students able to understand the anatomy and function of electrical activity of the
heart
2. Students able to utilize the ECG device
3. Students able to make a recording using ECG properly
4. The student should be able to interpret the normal ECG result
B. Level of Competency
Clinical Skills Level of Competency:
Level of Competency according to Miller Pyramid are as follow:

• Competency 1: Understand and Give Explanation
Medical graduates are able to master the theory of the clinical skill and therefore are able
to explain the concept, principle or indication, procedure, and complication that may arise.
• Competency 2: Seen the Demonstration
Medical graduates are able to master the theory of the clinical skill (able to explain the
concept, principle or indication, procedure, and complication that may arise). Besides that,
during their education, they’ve seen this skill being performed in front of them.
• Competency 3: Performed with Supervision and Guidance
during their education, they’ve seen this skill being performed in front of them or they’ve
done it several times under supervision and guidance.
• Competency 4: Perform Independently
during their education, they’ve seen this skill being performed in front of them or they’ve
done it several times independently under supervision. They’ve also have the experience
to conduct this clinical skill in the context of independent practice.
Target for Level of

Diagnostic Procedure
Competency
Electrocardiography (ECG) 1 2 3 4
Exercise Test ECG 1 2 3 4
C. Activity
Time Activity Student Instructor Device

10 Introduction Submit workplan
Facilitate discussion -
minutes to the instructor
from questions in the
workplan
50 Exercise recording Students try to Guide the exercise ECG device
minutes with 12 lead ECG record using ECG while giving ECG recording
feedback paper
50 Practice the normal Practicing Discussing Electrocardiogram
minutes ECG interpretation
10 Evaluation and Ask and give Give feedback -
minutes Conclusion constructive and motivate for
feedback independent study

ELECTROCARDIOGRAPHY I
Anatomy and Electrophysiology of the Heart

Myocardium is a cross striation muscle that makes up the muscle of the heart with the
length around 100µ and width around 15µ. This cell is has a semi-permeable cell wall that is called
sarcolemma. Myocardium cell has a nucleus at its centre surrounded by myofibril located inside
the sarcoplasm. Between these myofibril, mitochondria are located. Energy for the contraction of
sarcomere are obtain from oxydative phosporylation reaction happening inside the mitochondria
that produce high energy phosphate bond in the form of adenosine triphosphate (ATP). These
myofibril are divided inside each sarcomere, the basic element of contraction. Sarcomere is
a unit from one myofibril seperated by two Z-discs and has a normal length of 2,2µ (figure 1).
This unit is bordered by Z-disc at each of its end. From both of these Z-discs, a thin filament
called actin run across the central part located between two bigger filaments called myosin.
A band, as seen in figure 2, consists of actin and myosin, while I band only consists
actin, and H band only consists myosin (figure 1). Cardiac muscle contraction is a mechanical
force stimulated by action potential through a unified process of excitation contraction coupling.
When the muscle contracts, there’s a shortening from H zone (myosin), making thick and thin
filaments slide to shortens the sarcomere spreading throughout the muscle. The strength of
contraction comes from the bridges made up of calcium ion that connects myosin and actin. This
interaction requires ATP as the source of energy. Calcium ion starts the process of contraction by
temporarily binds and disable troponin, the protein that prevents the myosin and actin interaction
to create a contraction. During relaxation, the interaction of myosin and actin is prevented by
the troponin that is not bind to calcium ion.
Figure 1. Sarcomere
(Source : Irawan B. 2008. Interpretasi Elektrokardiografi Secara Praktis. Medika FK. UGM.
Yogyakarta)

Figure 2. Sarcomere
(Source : Irawan B. 2008. Interpretasi Elektrokardiografi Secara Praktis. Medika FK. UGM.
Yogyakarta)
Conduction System of the Heart

The heart consists of 4 chambers, with 2 chambers function to receive blood from the
lung circulation (left atrium) and the general circulation (right atrium), while the other 2 chambers
function to pump blood to the general circulation (left ventricle) and to the lung circulation (right
ventricle). The atrium and ventricle is seperated between one another with a fibrous structure of
atrioventricular (AV) valve called AV ring. Impulse normally activated by the sino auricular node
(SAN) located in the right atrium are conducted throughout both atrium and later conducted to
both the left and right ventricle.
Impulse from the atrium to the ventricle required to enter a specific pathway called
atrioventricular node (AVN) since the border between atrium and ventricle has a non-conductable
structure, the AV ring. Inside the AVN, the impulse undergoes a speed reduce as a safety measure
especially when too many impulses come from the atrium as in the case of atrial flutter or atrial
fibrillation. In those abnormal cases, not all impulse will pass through to the ventricle thus the
stimulation of ventricle is slower than the atrium. This safety mechanism can prevent from the
incidence of heart failure or even sudden death. Impulse is then conducted to both ventricles
through the bundle of His that penetrates the AV ring. This conduction system is possible because
of the presence of cells that is different in terms of histology and electrophysiology from cardiac
muscle to make a rapid conduction. The conduction impulse that are able to conduct impulse
however, has a lower contractility components compared to cardiac muscle. The conduction
system can be seen in figure 3.

Figure 3. Conduction System of the Heart (Source : Irawan B. 2008. Interpretasi
Elektrokardiografi Secara Praktis. Medika FK. UGM. Yogyakarta)
Normal excitation of the heart comes from SAN, a 15 mm x 5 mm x 2 mm eliptical structure

located at sub endocardial in the right atrium near the entrance of superior vena cava, while the
AV node is a 6 mm x 3 mm x 1 mm structure located in the subendocardial of the right atrium
near the inter-atrial septum just above the fibrous component of the AV ring. Distally, it continues
as bundle of His, a fibre with width of around 2 - 3 mm and length around 10 - 20 mm (figure 4).
Figure 4. AV junction as seen from the right side (diagrammatic representation). (1)
Penetrated part, (2) unbranched part dan (3) branched part of bundle of His. VS :
Ventricular Septum, LBB : Left Bundle Branch, RBB : Right Bundle Branch. (Souce :
Irawan B. 2008. Interpretasi Elektrokardiografi Secara Praktis. Medika FK. UGM. Yogyakarta)
Bundle of His penetrates the fibrous tissue which then branched into right and left parts.
The left branch runs along subendocardial of inter-ventricular septum and further branches into
the anterior and posterior part. These fibers will end as the Purkinje fiber which is also a one
unit of conduction system.
Conduction
Cardiac muscle cells has the ability to conduct impulse from one cell to another. Normally,
action potential from the the proximal cells stimulates the more distal cells. A reverse conduction
will not be response by the more proximal cell (refractory period) that has been activated. The
speed of conduction is different in areas of the heart, from 0.2 m/sec at the AVN to 0.4 - 0.7 m/
sec at the atrial muscle and 2 - 5 m/sec at the bundle of His and Purkinje fibers.

Primary and Ectopic Pacemaker
Pacemaker is a group of cells able to generate an impulse or activate the heart. Primary
pacemaker is the pacemaker that sets the rhytm of the heart. In normal circumstances it is the
SAN since the speed of its impulse generation is the fastest compared to the other. Meanwhile
an ectopic pacemaker is a pacemaker that are able to replace the primary pacemaker should
it fails to function. In pathological circumstances, all pacemakers are able to increase its speed
to generate impulse and be the rhytm controller of the heart.
Normal Activation of the Atrium

Impulse generated from SAN are spread to all over atrium and stops right at then junction
of atrium and ventricle (fibrous tissue of AV ring). The impulse then enters the AV node located
at the inferior part of the right atrium. In the atrium, there are no parts that are able to conduct
impulse efficiently, thus the conduction distance is higher compared (60 - 80 mm) compared with
the ventricle (6 - 15 mm). In addition with the short refractory period of the atrium, the incidence
of atrial fibrillation is higher compared to ventricular fibrillation.
Normal AV node Conduction

There’s a reduce of conduction speed in the superior part of AVN around 0.1 second
continued to the inferior part albeit at a lower rate. The conduction speed will increase sharply as
the impulse enters the bundle of His. The reduction of conduction speed in AVN is enough for the
atrium contract and transfer the blood to the ventricle just before ventricular contraction starts.
Normal Activation of the Ventricle

After passing through the AVN, the conduction speed increases up to 2 - 5 m/sec
and spread rapidly to the branches of His bundle as well as the Purkinje. The first part of the
ventricle that gets activated is the septum that receives the impulse mostly from left branch of
the anterior and posterir part of His bundle and some from the right branch. The impulse then
activates the free ventricular wall that receives its impulse from the Purkinje fiber located at the
inside one third of the wall and spreads from the endocardium to the surface of epicardium. The
high speed of impulse in this Purkinje fiber causes the ventricle contraction to be coordinated
and synchronized.
Activation Wave and Repolarization

Throughout impulse conduction, there’s a clear difference between myocard that has
not been activated. This border zone is an activation wave of one part of the heart to the other
until all parts of the heart are activated. In repolarization, there’s a border zone between areas
that have been fully repolarized and the other areas that are still activated
ELECTROCARDIOGRAM
Electrocardiogram or ECG is widely use around the world because of its ease of use to
make a diagnosis and map the condition of the heart. ECG is a recording of weak electrical
current generated by the activity of the heart.

Figure 5. Electrocardiogram recording of electrical wave
Source: Sjarif R., 2002. Electrokardiografi. Skills Lab Jilid 5 . Fakultas
Kedokteran,
Universitas Gadjah Mada, Yogyakarta.
The effort to record electrical current of the heart has been tried for hundreds of
years, but the basic function of the ECG as we know todat has only been developed at early
20th century by the Dutch scientis Willem Einthoven. In 1924, Einthoven received a Nobel
award in Physiology or Medicine for his development in the study of of ECG.
A. Electrode
One of the biggest challenge during the early development of ECG is to make a
sensitive electrode. At the end of 1880s, experiment to record electrical activity of a frog
was conducted. This experiment was only succesful when the electrode touches directly
with the heart. Scientists want to record the electrical activity of the heart without inputing
any devices inside the body. Problem arise as the electrical current is weak since it has
to travel body tissues and bones before reaching the electrode that touches the skin. This
problem was solved several decades later by Willem Einthoven as he managed to increase
the sensitivity of ECG with Galvanometer String.
There are many terminologies developed by Einthoven that are still use until today. His
findings act as the basic foundation of the study of electrophysiology.
B. From Electrode to Paper
Figure 6. Sensitive electrodes are place on certain locations at the body

Source: www.hsd.nhsggc.org.uk

Electrical wave in the heart are recorded in milivolt with electrocardiograph. Those
waves are recorded by the electrodes that are in contact with the skin. Each electrodes
control an inked needle that graph the waves on a paper grid. As the intensity of electrical
wave increases, so too the upward movement of the needle. The paper moves at a certain
speed under the needle that produces specific curve.
Electrical activity in the heart produces a weak electrical current that spreads all over the
body that acts as a conductor. This current produces different electrical potential depending
on the location of the body and the heart activity itself.
Electrocardiograph has 2 different electrodes, whic are exploring and indifferent
electrode. Recording needle of the electrocardiograph moves when the electrical potential
of the exploring electrode is higher than indifferent electrode, with recording happening
from the isoelectric line and vice versa. If both has the same electrical potential, so as the
isoelectric path.
Electrocardiograph has 12 leads. Leads are points on the body that are use to place
the electrode while recording. The places are (see below: Einthoven Triangle):
(1) Bipolar standard limb (extremity) leads or frontal plane bipolar leads
Bipolar leads are recorded by connecting the two points below:
 Lead I : to record electrical potential between the right and left arm, exploring
electrode is placed on the left arm and indifferent electode is on the right arm
 Lead II : to record electrical potential between the left leg and right arm, exploring
electrode is placed on the left leg and indifferent electode is on the right arm
 Lead III : to record electrical potential between the left leg and left arm, exploring
electrode is placed on the left leg and indifferent electode is on the left arm
(2) Augmented unipolar limb (extremity) leads or frontal plane unipolar leads
Unipolar leads are connected to the central terminal (three electrodes which are right
arm, left arm, and left leg) that has zero potential on the right arm (aVR), left arm (aVL)
and left leg (aVL).
 Lead aVR is to record different potential between the right arm with left arm and the
left leg. Exploring electrode is placed at the right arm and indifferent electrode at left
arm and left leg.
 Lead aVL is to record different potential between the left arm with right arm and the
left leg. Exploring electrode is placed at the left arm and indifferent electrode at right
arm and left leg.
 Lead aVF is to record different potential between the left leg with right and left arm.
Exploring electrode is placed at the left leg and indifferent electrode at right and left arm
(3) Unipolar chest (precordial) leads or horizontal plane unipolar leads.

Different potential at indifferent electrode is zero and exploring electrode is place at the
anterior chest wall.
 Lead V1: 4th intercostal space at linea sternalis dextra (through the margin of right
sternocostal cartilage)
 Lead V2: 4th intercostal space at linea sternalis sinistra
 Lead V3: between V2 and V4
 Lead V4: 5th intercostal space, linea midclavikula sinistra
 Lead V5: 5th intercostal space, linea axilla anterior sinistra, or if the linea axilla anterior
sinistra is ambiguous, midway between V4 and V6
 Lead V6: 5th intercostal space, linea axilla media sinistra
C. Leads and Einthoven Triangle

Generally there are 12 electrodes. The plane between two electrodes of the extremities
are called lead. Einthoven stated the leads between three extremities electrodes as “standard
lead I, II, and III” that refer to electrodes located on both armes and left leg. He studied the

connection between those electrodes that formed a triangle which in terms of electrical point
of view is null point at the center of the triangle. Connection between standard leads are
called Einthoven Triangle that is use to determine the axis of heart electrical activity.
Figure 7. Standard / Limb lead (above) Augmented Limb lead (below)

reflects the exremities electrodes (left arm, right arm, left leg) use to record the
heart axis at frontal plane
Source: www.nobel.se/medicine/educational/ecg/ecg-readmore.html
D. Curve and Hill

ECG curves have different characteristics depending on the location of the recording
electrode. Curves below the base line are negative deflection and curves above the base
line are positive deflection. Negative deflection shows that the recorded wave shifts away
from the electrode and positive deflection shows the recorded wave coming towards the
electrode.
Figure 8. ECG curve showing the perspective from the recording electrode
Source: www.nobel.se/medicine/educational/ecg/ecg-readmore.html
E. Cells controlling Cardiac Muscle Cell

When the cardiac muscle is relax, pacemaker cells are filled with negative current and
when the cardiac muscle contracts it is filled with positive current. When positive wave are
are recorded by positive electrode, ECG curve will deflect upwards and vice versa.
F. Repolarization and Depolarization

Cells change their electrical potential with depolarization and repolarization.
Depolarization happens when negative ions flow outside of the cell through cell membrane
and positive ions flow inside the cell.


ECG
ECG Recording
Recording
A. Devices
A. Device
1. Devicesneeded is ECG Recorder (in this skills laboratory is using Cardimax1 FCP-
1. Device
8100, Fukudaneeded is ECG
Denshi). This Recorder (in this
device could skills
record ECGlaboratory is 3using
with 1 or Cardimax1
channels that hasFCP-
the
8100, Fukuda Denshi). This device could record ECG with 1 or 3 channels that has
following features:
the following features:
a. Light and and
a. Light compact
compact
b. Built-in rechargeable
b. Built-in battery
rechargeable battery
c. Touch screen colour LCD
c. Touch screen colour LCD withwith
6/12 lead
6/12 ECG
lead ECG display
display
d. Simple
d. Simple operation
operation withwith
oneone touch
touch
e. Options
e. Options of automatic
of automatic or manual
or manual recording
recording
f. Printing recording format can
f. Printing recording format can be adjust be adjust with integrated
with integrated high thermal
high quality quality printer
thermal
printer
g. Has an ECG memory to duplicate result
g. Has an ECG memory to duplicate result
2. The preview
2. The of the
preview ECG
of the areare
ECG as follow:
as follow:
Patient identity Type of examination : 12-lead Filter: on Menu to change

the setting
Heart
rate
Auto or manual mode of printing Electrode placement status Report : ON
15
Button Explanation Button Explanation
To input the 1mV scale
To on/off the machine into the graph in manual
recording
To change the leads in To re-print the last

monitor recording graph
To change the graph

To start and stop printing
scale (amplitude) the ECG result
To reset the graph
3. Electrodes to be attach to the patient

a. There are 10 electrodes for the patient. These electrodes are attached to the patient’s
cable socket on the right side of ECG instrument
b. Four electrodes for the extremities attaching the extremities to the instrument. All of the
electrodes colour are grey. The small electrodes for upper extremities, and the bigger
electrodes for lower extremities. The cables attached to the electrodes with the colour
as follow:
1) For right arm : red (R)
2) For left arm : yellow (L)
3) For right leg : black (N)
4) For left leg : green (F)
c. Six precordial electrode suction placed on the anteriot chest
1) C1 electrode at 4th intercostal space right sternal border line
2) C2 electrode at 4th intercostal space left sternal border line
3) C4 electrode at 5th intercostal space left midclavicular line
4) C3 electrode between C2 and C4 at approximately the same distance
5) C6 electrode at left midaxillary line at the same level as C4
6) C5 electrode between C4 and C6 at approximately the same distance
4. Connection cable to the patient

Quality of ECG recording depends on the preparation done and whether or not there are
obstacles between the electrode and patient’s skin. To ensure a quality ECG recording is
obtain and minimalize obstacles between the skin and the electrode, take notice on the
following points:
a. Make sure the patient is in a calm and relax state
b. Scrub the electrode area before cleaning
c. Clean all electrode area with alcohol
d. Make sure the electrode is in contact with gel covered skin
5. Standard Lead
Lead Cable Color
N Black
R Red
C1 Red
C2 Yellow
C3 Green
C4 Brown
C5 Black

C6 Violet
L Yellow
F Green
B. ECG Recording
1. Recording can be done automatically or manually
B.
B.
2.ECGAutomatic recording
B. ECG
B. ECG
ECG a.
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Choose autobe(Auto inautomatically
bold character)
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manually
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b. Press the can be done automatically
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2.
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recording
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recording
2.
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Choose
lead
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Choose autoauto
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in bold
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a.
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Press
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Press “start/stop”
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have
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b. the The printing result will have 12
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Choose
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with thethe adjusted
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graphinamplitude automatically
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lead with adjusted graph automatically
3.
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: Menu >inSetting > 12-lead exam > choose the manual setting that
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c.b. Adjust
Choose
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Menu Setting
by pressing the12-lead
“sens.”exambutton.choose the
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mm/mV,
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c.c. Adjust
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x½ for
the sensitivity 5
sensitivity by by
by
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pressing the the
the “sens.”
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sensitivity
the “sens.” button.
button.
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20Sensitivity
mm/mV
button. Sensitivity x1
x1
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for
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10
for 10 mm/mV,
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c.
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the “start/stop”
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buttonand
mm/mV, and sensitivity
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to print
and x2
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the result.
sensitivity for
for20
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mm/mV
mm/mV
sensitivity x½ for mm/mV, and sensitivity x2 for 20 mm/mV
d.
d. Press
Press the
“start/stop” button
button
e.d. End
d. the
Press
Press recording
the
“start/stop” using theto
button
button
to
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to
print
print
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the
result.
button once again.
result.
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e.
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End
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recording
recordingusing
using
usingthe
the
the“start/stop”
“start/stop”
“start/stop”button
button
buttononce
once
onceagain.
again.
again.
e. End the recording using the “start/stop” button once again.
C.
C.
C. Steps in ECG recording
C. Steps
C.
Steps
Stepsin
Steps
in
inECG
in
ECG
ECGrecording
ECG
recording
recording
recording
1. Prepare all devices needed
1.
1.
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Prepare
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devices
devicesneeded
needed
needed
1. Prepare all devices needed
111
11
2.
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2. Check Check and
and
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and connect
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turn on.
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that the
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2. Check and connect the ECG to power source, then turn it on. Make sure that the
machinemachine
machine
is is
isworking.
working.
machine is working.
working.
machine is working.
3.
3. Ask
Ask
3.theAsk the
the
thepatient
patient
patient to
to
toremove
remove
remove the
the top
top
topclothes
theclothes clothes
clothes and
and all
all
allaccessories
accessories
andaccessories
accessories that
that
thatcontains
contains
contains metal
metal
metal
3. Ask3. patient
Ask the to remove
patient to the top
remove the top and and
clothes all all accessories thatthat contains metal
contains metal
222 222 222

22 22 22
4.
4.
4. Clean
4. Clean Clean
the the
the
thepatient's
patient's
patient’s
Clean skin
skin
skinsurface
skin surface
patient's surface (wrist,
(wrist,
(wrist,
surface ankle,
(wrist, ankle,
ankle,
andand
ankle, and
andanterior
anterior
anterior chest)
chest)
chest)
anterior with
with
chest) with alcohol
alcohol
alcohol
with swab
swab
swab
alcohol swab
4. Clean the patient's skin surface (wrist, ankle, and anterior chest) with alcohol swab
444 444 444

44 44 44
5.
5.
5. Clean
Clean
Cleanthe
the
theelectrode
electrode
electrodeusing
using
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alcohol
alcoholswab
swab
swab
5. Clean the electrode using alcohol swab
17
17
17
17
5. Clean the electrode using alcohol swab
555 555
6.6. Give
6. Give
Givelubricant
lubricant
lubricant ororgel
or gel on patient's
gelpatient’s
on
onpatient's
patient's skin (wrist, ankle, and anterior chest)
6. Give
7. lubricant
Place the or gel on
electrodes at their skinskin
skin(wrist,
(wrist,
(wrist,
appropriate
ankle,
ankle,
ankle,
places andand
andanterior
anterior
anterior chest)
chest)
chest)
7. 7.
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theelectrodes
electrodes atattheir
their
appropriate
appropriate
Place the electrodes at their appropriate places places
places
666 777 777
666
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8.8. Make
8. Make
8. Make
Make sure
suresure
sure printout
printout paper
printout
printout paper
paper
paper are
areare
in
are inincorrect
in correct
correctcorrect place
place
place
place before
before starting
starting
before
before the
thethe
starting
starting recording
recording
the recording
recording
9.
9. The The
9.9. The
12 12
Thelead
12 lead
12lead
lead
ECG ECG
ECG
ECG will
will will be displayed
willdisplayed
be be
bedisplayed
displayed in the
ininthe
in the monitor.
themonitor.
monitor.
monitor.
10.
10. Use
10.Use sens
Usesens
sens button
button
button totoadjust
to adjust
adjust the sensitivity ofofthe
the graph.
10. Use sens button to adjust thethe
thesensitivity
sensitivity
sensitivity of
of the thegraph.
graph.
graph.
11.
11.
11. Press
Press
Press start
start
startto
to
to record
record
record and
and
and print
print
print the
the
the ECG.
ECG.
ECG. Pictures
Pictures
Pictures below
below
below shows
shows
shows how
how
how automatic
automatic
automatic
11. Press start to is
recording record
done and print the ECG. Pictures below shows how automatic
recording
recordingisisdone
done
recording is done

18
18
18
8 9 10
88 99 10
10
8 9 10
11 11
11
11 11
11
11 11
12. Cut the paper, write patient information on the printout.

13. Remove
13. Removeall electrodes
all electrodes andand
cables andand
cables put them at their
put them place
at their place
12.
12.Cut
14. CleanCut the
thethe paper,
gelpaper,
from write
writepatient
patient
patient’s bodyinformation
information
and ask on
onthe
him theher
or printout.
printout.
to put on their clothes
14. Clean the gel from patient's body and ask him or her to put on their clothes
13.
13.Remove
15. CleanRemove
the gelall
allelectrodes
fromelectrodes
the and
and cables
electrodes cablesand
and put
putthem
them at
attheir
theirplace
place
15. Clean the gel from the electrodes
14.
14.Clean
Cleanthethegelgelfrom
frompatient's
patient'sbody
bodyand
andask
askhim
himororher
hertotoput
putonontheir
theirclothes
clothes
13. Remove all electrodes and cables and put them at their place
15.
15.Clean
12 Cleanthethegelgelfrom
fromthetheelectrodes
electrodes
13 14
14. Clean the gel from patient's body and ask him or her to put on their clothes
15.
12Clean the gel from the electrodes
12 13
13 14
14
12 13 14
19
19
19
School of Medicine UGM
19 163
FEEDBACK FORM
ELECTROCARDIOGRAPHY RECORDING
Name : ……………………………………………………………
Student No. : ……………………………………………………………
No. Assessment Feedback

1 Introduction, ask the patient’s identity and
informed consent
2 Patient (if conscious) is ask to lie on a
supine position in a relax way
3 Patient is ask to remove the top clothes and
all accessories that contains metal
4 Connect the electrocardiograph to a power
source, turn it on, and start a trial
5 Clean all parts of electrode with alcohol
6 Clean the electrode with alcohol
7 Place the electrode on skin that’s covered
with gel
8 Connect to the respective cables
9 Make sure the printout paper is located at
the start of ECG recording
10 Record the ECG
11 Record patient’s information on the printout
12 Remove all cables and electrodes and put
them back to their respective place
13 Clean the gel from patient’s body and ask
them to wear their clothes
14 Explain the result of interpretation
Global Rating Scale for Professional Behavior

Scale
Skills Scientific Basis and 1 2 3 4
No. 5
Explanation Not as Below According to Exceeds
Perfect
expected expectation expectation expectation
1 Display self Dealing with self (when
confidence students are able to
in performing act professionally
examination in without showing his/
front of patient her current condition,
for example in distress)
2 Ethics (respect Dealing with patient
the patient in (when students
terms of local are able to act
norms) professionally without
making assumptions to
the patient)
3 Minimal mistake Dealing with self,
patient, and duties
(when students
are able to act
professionally in
relation with people
involved and perform
duties without mistake)

Global Rating Scale for Doctor-Patient Relationship
Scale
Scientific Basis and 1 2
3
4
No. Skills According 5
Explanation Not as Below
to
Exceeds
Perfect
expected expectation expectation
expectation
1 GREET Kemampuan membina
Develop and hubungan baik
maintain good (melalui kemampuan
relationship mendengarkan,
during kemampuan merespon
consultation dengan baik,
empati, komunikasi
interpersonal dan
membuat pasien
nyaman)
2 Explore the Ability to develop
patient’s problem good relationship
and conclude a and explore patient’s
problem problem then make a
conclusion (through
exploration, data
collection, history
taking, alloanamnesis,
summary, and
conclusion)
3 DISCUSS Ability to develop good
Patient education relationship, explore
and counseling patient’s problem,
make a conclusion,
and develop plans
while negotiating with
the patient and family
(through education and
counseling)
Explanation:
Scale 1: Not showing respect and norms + more than 80% mistakes
Scale 2: Showing respect and norms minimally + 60 - 80% mistakes
Scale 3: Showing respect and norms minimally + 40 - 60% mistakes
Scale 4: Showing respect and norms minimally + 20 – 40 % mistakes
Scale 5: Showing respect and norms fully + less than 20% mistakes
Yogyakarta, …………………..
Instructor,
( )

REFERENCE
1. Bates, B., 1987. A Guide to Physical Examination and History Taking, Fourth Edition J/B.
Lippincott Company, Philadelphia.
2. Schiller, 1995.ECG Recorder Cardiovit AT-1. SHILLER America Inc., 3002 Dow Ave., 138
Tustin CA 92680, USA.
3. Sjarif R., 2002. Electrokardiografi. Skills Lab Jilid 5 . Fakultas Kedokteran, Universitas
Gadjah Mada, Yogyakarta.
4. Suhandiman 2002. Elektrokardiologi dan Diagnosis penyakit Jantung. Skills Lab Jilid 5.
Fakultas Kedokteran, Universitas Gadjah Mada, Yogyakarta.
5. 2004. Anatomy and function of the heart’s electrical system. (www.stanfordhospital.com/
healthLib/atoz/cardiac/electric.html)
6. 2004. Electrocardiogram. (www.nobel.se/medicine/educational/ecg/ecg-readmore.html)
7. Bellet S. 1971. Clinical Disorders of the Heart Beat. 3rd ed., Lea & Febiger Topan Company
Ltd, Philadelphia, Tokyo, Japan.
8. Chung EK. 1978. Electrocardiography: Practical Applications with Vectorial Principles. 2nd
ed. Harper & Raw Publishers.
9. Goldman MJ. 1973. Principle of Clinical Electrocardiography. 8th ed. Lange Medical
Publication.
10. Irawan B. 1999. Pelatihan Dasar Elektrocardiogram untuk Dokter. Naskah Lengkap Pelatihan
Dasar EKG RS Dr Sardjito Yogyakarta
11. Irawan B. 2000. Pelatihan EKG Tingkat Lanjut untuk Dokter. Naskah Lengkap Pelatihan
EKG Lanjut.
12. Irawan B. 2008. Interpretasi Elektrocardiografi Secara Praktis. Medika FK. UGM. Yogyakarta.
13. Joel WH. 1987. Cardiology for the House Officer. 2nd ed., Williams & Wilkins
Johnson R, Swarzt MH. 1986. A Simplified Approach to Electrocardiography. W.B. Saunders
Company
14. Karim S, dan Kabo P. 1996. EKG dan Penanggulangan Beberapa Penyakit Jantung untuk
Dokter Umum. FK-UI Jakarta
15. Panitia Pelantikan Dokter FK UI 1998. Kapita Selekta Kardiologi. Bagian Kardiologi FK UI
– RS Jantung Harapan Kita, Jakarta
16. Sandu E, Sigurd B. 1991. Arrhythmia Diagnose and Management. A Clinical Electrocardiographic
Guide. Wiesbadener Graphische Betriebe GmbH Greifstraße 6 D-6200 Wiesbaden.
17. Schamroth L. 1976. An Introduction Electrocardiography. 5th ed. Blackwell Scientific
Publications.
18. Yanowitz, FG., 2005, The Alan Lindsay : ECG Learning Center in Cyberspace, http://medstat.
med.utah.edu/kw/ecg/
19. Kligfield, P., Gettes, LS., Bailey, JJ., Childers, R., Deal, BJ., Hancock, EW., Herpen Gv.,
Kors, JA., Macfarlane, P., Mirvis, DM., Pahlm, O., Rautaharju, P., Wagner, GS. 2007.
Recommendations for the Standardization and Interpretation of the Electrocardiogram Part
I: The Electrocardiogram and Its Technology A Scientific Statement From the American
Heart Association Electrocardiography and Arrhytmias Committee, Council on Clinical
Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society.
Circulation;115:1306-1324.

INTERPRETATION OF NORMAL ELECTROCARDIOGRAM
The characteristic of normal electrocardiogram (ECG) is not absolute, and as a
consequence the boundaries of normal ECG can be very wide. ECG recording will be useful if
it is related to the clinical condition of a patient.
Figure 9 illustrates a normal electrocardiogram (ECG) reading. It shows the presences of
P wave, QRS complex and T wave.
Figure1. Illustration of Electrocardiogram
A. Standardization
Before reading the ECG recording, the reader must always pay attention to the standard
of recording that is applied. Standardization that is generally used in electrocardiogram
recording is the 1 milli-Volt = 10 mm (10 small boxes). This standardization must be seen
as a tracing at the beginning or end of ECG recording.
B. Calculating the heart rate

In routine ECG, the speed of paper is 25 mm/second. Therefore the relationship is as follows:
1 small box = 1 mm = 0.04 second
1 medium box = 5 mm = 0.20 second
5 medium box = 25 mm = 1.00 second (1 large box)
C. Several ways to calculate the heart rate

1. Count the number of QRS complex cycles in 6 medium boxes, and then times it by 50.
This method is used to calculate when the heart rate is fast and the heart beat is regular
(figure 2).
Figure 2. Calculating the Heart Rate
2. Count the number of medium boxes between 2 QRS complexes, and then divide 300
by the result. This method is used when the heart rate is slow and the heart beat is
regular (Figure 3).

Figure 3. Heart rate calculation
Bear in mind that 300, 150,100, 75, 60, and 50 consecutively represent the heart rate
in the medium box
3. 1500 is divided by the number of small boxes between 2 QRS complexes

4. Count the number of QRS complex in 6 large box, and then times it by 10. This methode
is used to calculate when the heart beat is irregular.
Frequency of the normal heart rate is 60-100x/minute. If under 60x/minute it is then called
bradycardia. If above 100x/minute it is called tachycardia.
D. Axis and Position

Because electricity possesses volume and direction, it is therefore considered as a
vector. A vector can be illustrated with an arrow. The direction of the arrow indicates the
direction of the vector and the length of the arrow indicates the vector. Within one heart
cycle there electricity during the de-polarization of atrium, ventricle and re-polarization of
ventricle in the recording and respectively called the P wave, QRS wave and T wave. The
P, QRS and T waves are vector spaces that continually change volume and direction and
are respectively termed as vector P, vector QRS and vector T. The pivot system is generally
used to analyze vectors, and the space pivot system is used to analyze the vector spaces
which comprise of three spaces that are perpendicular to each other. In order to analyze
the electrical vectors of the heart then three fields are selected, the horizontal, frontal and
sagital. In conventional electrocardiography only two fields are used, the horizontal and
frontal field. From the conventional lead, it is found that lead in the frontal and horizontal
field are located as follows:
1. In the frontal field: I, II, III, aVR, aVL, and aVF
2. In the horizontal field: V1, V2, V3, V4, V5, and V6
E. Pivot System in the Frontal Field

In compliance to the names of the leads, the pivots in the frontal field are called pivot I,
II, III, aVR, aVL and aVF. Research shows that the location of pivots as follows:

Figure 4. Pivot System in the Frontal Field
In theory, each and every lead that is located in the frontal field can be used to determine
the axis.
F. Pivot System in the Horizontal Field

In compliance to the names of the lead, the pivots in the horizontal field are named
pivot V1, V2, V3, V4, V5, and V6. Research shows that the location of pivots is as follows:
Figure 5. Pivot System in the Horizontal Field
G. Electrical Pivot from the P wave

Electrical pivot from the P wave is used to determine whether it is a rhythm sinus or not.
If the axis of P wave is located outside of the 00-900, then there is high possibility the heart
beat is not from the rhythm sinus.
H. Electrical Pivot from the Vector QRS

The de-polarization of ventricle or vector from the frontal QRS is used to determine the
axis and position of the heart’s electricity. Ways to determine the QRS pivot in the frontal
field are as follows:
1. Select 2 lead. The simplest method is to select two that are perpendicular to each other,
for example I and aVF. Determine the algebra based on the size of the area below the
deflection in each lead and illustrate it as vector in each pivot. The result illustrates the
QRS pivot from these two vectors.

Figure 6. Determining the Electrical Pivot in the Frontal Field
by Using Lead I and aVF. V as QRS Pivot
2. Select one lead that has an algebra value of zero deflection (positive deflection = negative
deflection). The QRS pivot is perpendicular in this lead. To determine the direction of the
following QRS pivot, see one of the other lead to select one of two directions.
Or in other words, it is the size of the area below the deflection and not the height of
the deflection that is measured.
Figure 7. Area Size Below the Deflection

Source : Irawan B. 2008. Interpretasi Elektrocardiografi Secara Praktis.
Medika FK. UGM. Yogyakarta
A normal axis QRS complex is located between -300 to +1100. An axis that is located
less (or more negative) than -300 is called a left axis deviation (LAD), on the other hand
an axis that is located higher or more positive than + 1100 is called a right axis deviation
(RAD). It needs to be noted that an axis tends to experience deviation to the left as the
person grows older. For babies and children right axis deviation is normal. For young adults
(20-30 years old) sometimes there is still axis +1050 (± 2%). A normal axis for persons
aged less than 40 years old is 00 until +1050, whereas for those aged more than 40 years
old the axis tends to be between -300 to +900. QRS Pivot that is between +1800 to -900 is
called superior/extreme pivot (figure 8). All muscle pathologic condition or heart conduction
system can change the distribution of the excitation process, and therefore causing change
in the intensity and direction of the heart’s main vector, which can then lead to deviation of
the axis. For example, in the broadening of the right ventricle, the flow of the de-polarization
in the right ventricle becomes relatively larger causing the axis to shift to the right.

Figure 8. Axis of the QRS pivot
Source : Irawan B. 2008. Interpretasi Elektrocardiografi Secara Praktis.
Medika FK. UGM. Yogyakarta
I. Transition Zone
Basically, determining the pivot of QRS in the horizontal field is similar to when
determining the pivot of QRS in the frontal field. The method most generally used is finding
the lead and algebra with a deflection of zero. From this, we can determine which vector
is perpendicular to this lead, and the QRS pivot at the horizontal field is not to be stated in
degree but simply by determining in which lead there is algebra with a zero deflection. This
lead is called the transitional zone (field/zone transition). Normally, the transition zone is
located in V3-V4 (figure 9).
Because the heart can rotate and follow the longitudinal pivot in two directions, either
clockwise or counter clockwise, therefore determining the transition zone is very important.
In other words, this zone shows change of the QRS complex from being negative in V1,
V2, and V3 into positive in V4, V5, and V6. If the transitional zone moves to the V1 direction
this means the heart rotates counter clock wise (counter clock wise rotation), and if it moves
to the V6 direction this means that it is a clock wise rotation (figure 10).
Figure 9. Transitional zone/area

Figure 10. Transitional Zone that shifts to the V5, indicates a clock wise rotation
J. P Wave
Figure11. P Wave
P wave is a small wave that is recorded when the atrium undergoes de-polarization.
Because the SA node is located in the right atrium, then the right atrium will start and end
the de-polarization process. Therefore the first half of the P wave represents de-polarization
in the right atrium whereas the second half of the P wave represents re-polarization in the
left atrium. After both atriums undergo de-polarization, there will be bioelectrical activity in
the heart. The ECG recording will then show a straight line called the iso-electric line that is
followed by a QRS complex that illustrates de-polarization in the ventricle. The P wave will
be pictured as a smooth half circle having width and height not going more than 2.5 box.
Because 1 small box is equivalent to 0.04 second then the width (during de-polarization in
the atrium) cannot be more or equivalent to 0.10 second. In the rhythm sinus (under normal
condition) the atrium electrical activity will commence from the center of the impulse in the
SA node and will be distributed to all of the atrium muscle both in the right and left side,
and because the flow of the stimulus goes between the muscles in the atrium, then it will
show a wide distance.
In the rhythm sinus (pacemaker is in the SA node) either one, two or three of the
inferior lead (II, III, aVF) must have a positive P wave (going upwards). Whereas in the
junctional rhythm (pacemaker is in the AV node), inferior lead (II, III and aVF) P wave will be
illustrated by half a circle going downwards (negative) because the electrical activity during
de-polarization in the atrium has a vector going upwards. In the rhythm sinus, the P wave
will always be followed by a complex wave QRS (de-polarization ventricle).

Criteria of a normal P wave
1. Illustrate the activation order of left and right atrial
2. Normal P wave is positive in lead I, II, aVF, and V4 – V6
3. Normal P wave is negative in lead aVR
4. Other leads can be varied
5. Duration < 0.12 second
6. Amplitude < 2.5 mm
7. Axis on the frontal field is 0o to 75o
K. PR Interval
Figure 12. PR Interval
PR Interval is the distance passed by the stimulus since the starting of atrium de-
polarization until just before starting of the ventricle de-polarization. This means the distance
from when the stimulus starts to enter from the bundle of Purkinje into the ventricle muscles,
or distance from the beginning of the P wave until the beginning of the QRS complex. The
duration required is between 0.12 second until 0.22 second. Any disturbance in the conduction
throughout this passageway will cause change in the interval PR. This means that if the
interval PR is less than normal then there is a quickening or there is a bypass network
from the top AV node to the bundle of His [LGL syndrome] or from the atrium directly to the
ventricle without going through the AV node [WPW syndrome]. The interval PR is also short
in the junctional rhythm, atrial extra systole and supra-ventricular tachycardia. In a middle
junctional rhythm there is no interval PR because there is no P wave. This is the same for
in the lower junctional where the P wave is located behind the QRS wave. A lengthening of
the interval PR is mostly caused by a conduction disturbance in the AV node.
Criteria of normal interval PR

1. The time required to transmitimpulse from SA node to the AV node.
2. Normal 0.12 – 0.22 second ( 3-5.5 small box)
3. Shortening of interval PR, consider the pre-exitasi syndrome, rhythm nodule of
atrioventricular/junctional
Lengthening of interval PR, consider obstacle in atrioventricular (AV block).
L. PR segment
PR segment is part of the PR interval, starting from the end of the P wave through
to the beginning of the QRS complex wave. Normally the PR segment is iso-electric. If it is
not iso-electric then there is possibility it is an infarct atrial or acute pericarditis.

M. QRS Complex
Figure 13. QRS Complex, ST segment and T wave
This complex is a de-polarization in the right and left ventricle that starts and ends at the
same time. Its shape is normally sharp edged with a distance of less than 0.12 second. This
can be illustrated as complete QRS complex, qR, Rs, R, QS and several of their variations
(figure 22). There has been a general agreement as to the terminology for the QRS complex.
Positive deflection that follows the R wave is called R’, whereas the negative deflection
that follows the S wave is called S’ etc. The q, R and s wave each have its own large and
small deflection variation. In order to clearly differentiate them, the wave q is written down
with a large letter (Q) if the width of the wave q is more than or the same as 0.04 second.
The R wave is written down with a small letter (r) if the height is less than 5 small boxes in
the ECG recording. The wave s is written with a large letter (S) if the depth is the same as
or larger than 5 small box. Under a normal condition, the R wave has a positive deflection
on all lead extremity except for aVR leads. In the pre-cordial lead there is the term R-wave
progressionwhich is a positive deflection in the R that becomes larger as it passes from lead
V1 to V6. In the rhythm sinus, QRS complex is always preceded by a P wave.
Figure 14. The various forms of QRS complex and their nomenclature
When analyzing the QRS complex, there are 5 important factors that must be considered :
1. Duration of QRS complex (interval/duration of QRS)
The QRS interval illustrates the duration of the de-polarization activity in the ventricle
via bundle of His and Purkinje fibers. It is calculated starting from the beginning of the
wave q till the end of the wave s. The normal duration for adults is between 0.06 – 0.11
second, whereas in new born babies it is between 0.04 – 0.05 second.

Interval QRS that has a duration of 0.12 second or more indicates a disturbance in
the intraventricular conduction. This disturbance may be caused by bundle branch block,
escape rhythm that is located below the AV node or ventricular aritmia.
2. Amplitude
Amplitude of the QRS complex that is measured by the ECG electrode represents
the volume of voltage in the ventricle de-polarization. The volume is obtained by
calculating the positive and negative deflection in the QRS complex. The QRS voltage
is influenced by several factors such as age and shape of chest. Persons of young age
and thin-chested will have a higher voltage compared to person of older age or fat-
chested. Persons suffering from lung disease or myocardial damage with diffuse will
usually have an ECG with small amplitude.
It has been widely approved that amplitude less than 5 mm in the three standard
extremity lead (standard limb lead) is called low voltage. This condition is usually found
in persons suffering from coronary artery disease with diffuse, heart failure, pericardial
effusion, mixedema, and diffuse myocardial damage.
Despite being no agreements on the maximum value of amplitude in a QRS
complex, amplitude of 25-30 mm in pre-cordial lead is usually considered as the maximum
limit. This large amplitude in QRS complex can either be caused by rhythm ventricular,
hypertrophy or dilates ventricle, excess systolic load (systolic overload) either in the left
ventricle such as in the aortic valve stenosis, coarctatio aortae and hypertension, or in the
right ventricle such as in the lung emboli, pulmonal stenosis, and pulmonal hypertension
as well as excess diastolic load (diastolic overload) in the left ventricle such as in the
regurgitation mitral/aorta, patent ductus arteriosus and ventricular septal defect, and in
the right ventricle such as the atrial septal defect and tricuspid regurgitation.
The loss or absence of R wave in lead V1-V3 (R<2mm) is called Poor r wave
progression, andcan be found in normal varian (if the other ECG is normal), Left
Ventricular Hypertrophy (check whether it fulfills the voltage criteria and ST-T changes
from LV strain), Left anterior fascicular block, Anterior or Anteroseptal infarct, Emphysema
or COPD and WPW syndrome.
3. Homogeneity of QRS complex
In a normal ECG recording, the morphology of each and every QRS complex in
the same lead will be constant.
4. The presence of Q wave
Under a normal condition, there will be a Q wave in the form of QS or QR in aVR
lead, and also wave q in lead I, aVL, and pre-cordial lateral lead (V5, V6). The wave Q
that needs to be carefully observed in an ECG recording is the pathologicQ waves,
which illustrates the presence of a transmural myocardial infarction. Signs of pathologic
Q waves are as follows: has a width of more than 0,04 second and the depth is a third
lower than the R wave in the same QRS complex and is accompanied by a reversed T
wave. Specifically for pre-cordial lead, it will be impossible to determine the pathologic
Q waves if there is a blockage in the Left Bundle Branch (LBBB). Because lead with
pathologic Q wave shows the location of myocardial infarction, then in order to diagnose
the myocardial infarction the Q wave must at the very least be seen in the two leads.
5. Calculating the axis of bioelectrical heart in the frontal field and transition zone of the
pre-cordial lead.
Criteria of QRS complex

1. Illustrates the activation of left and right ventricle
2. The duration is 0,05 – 0,10 second (<2,5 small box). The measurement is usually in
the limb lead.
3. If the amplitude is less than 10 mm in all leads then it is called the low voltage.
4. An abnormal QRS complex can be seen from a disturbance in the conduction
5. Axis is located between 90o to -30o
6. Nomenclature of QRS complex

a. The first negative deflection is called the Q wave
b. the first positive deflection is called R wave
c. negative deflection after the R wave is called S wave
d. all R wave are above the baseline
e. all Q and S wave are below the baseline
f. small amplitude from the R wave is written using the “r”; similar to the wave Q
g. if the second complex occurs, it is written using (‘), (rSR’)
N. Q Wave
1. Wave q can normally be found in lead I, aVL, and V5-6. This illustrates the activation
of septum from left to right
2. Wave q in V1-2 illustrates an abnormality
3. Is called the pathologic Q wave if it is larger than 0,04 second and/or higher 1/3 than
the height of QRS complex
O. ST Segment
ST segment is an R wave re-polarization from the ventricle. It is normally shaped as
a horizontal straight line that unites with the iso-electric line. Sometimes it curves at the top
between the J point (J = junctional point, a point where the S wave ends) and the beginning
of the ST segment. Because the location of the J point determines the ST segment, whilst
the ST segment is a very important part of the ECG complex used to diagnose the presence
of heart abnormality, it is therefore very crucial to determine the location of the normal J
point. The normal J point is located in the iso-electric line or sometimes will tend to deviate
to the positive or negative (not more than 1 mm) from the iso-electric line (Figure 15). The
ST segment line can either be above the iso-electric line called the elevation or below the
iso-electric line called the depression (figure 16-17).
Under a normal condition, the ST segment is located in the iso-electric line or may
perhaps deviate to the positive section (1-2mm) in the bipolar extremity leads (standard limb
lead). On the other hand, ST segment that is 0.5 mm lower than the iso-electric line must
be considered as abnormal. An abnormal ST segment will only give diagnostic meaning if
it is accompanied by clinical symptoms or accompanied by an abnormal form of other ECG
complexes.
Criteria of a normal ST segment
1. It is usually iso-electric if there is elevation < 1 mm in the normal lead extremity
2. The depression is not more than 0.5 mm
3. The point where the QRS complex ends is called the J point
4. A change in the primary ST segment is indicated by the movement of the ST segment
upward or downward and is related to ischemia or inflammation. A change in the secondary
ST segment is related to a conductive disturbance, hypertrophy ventricle, side effects
from medications or electrolyte.
5. The most frequent result from elevation of the ST segment is myocardial infarction and
pericarditis.
6. Elevation of the ST segment in J point is possibly a normal Varian, especially in children,
young adults or black males. This Varian is called early re-polarization or Juvenile ST
segment abnormality.

Figure15. J Point Figure16. Elevation of ST segment
Figure17. Depression of ST segmenti Segmen ST
P. T wave
The T wave is also re-polarization of ventricle with a shape similar to that of an
unsymmetrical pyramid wherein the front part is wider than the back part. Two things that
must be observed in the T wave are as follows:
i. Direction of the Deflection
The flow of re-polarization will create deflection similar to that of a de-polarization
flow in the same ECG lead. This condition is called the T-concordance. Under a normal
condition the T wave is found positive in lead I, II, and lead pre-cordial located above
the left ventricle (V3-V6) (this does not apply to babies and children), negative in aVR
lead, whilst the direction is varied in other leads. The re-polarization phase of the heart
is very sensitive towards physiological as well pathology changes of the body. Under
a normal condition, the height of T wave in the same lead may change from time to
time. The normal minimum height of the T wave is 1 mm and if it is less than 1 mm the
T wave will not be considered present (flat T) and the maximum height of the T wave
in pre-cordial lead and lead extremities cannot be more than 10 mm (1mV). Outside of
these measurements, the T will be considered abnormal.
ii. Shape of the T wave

A normal T wave is shaped somewhat asymmetrical, wherein the positive
deflection ascends slowly until it reaches the peak and then descends steeply.

A pathological T wave is a T wave that is shaped symmetrical, very high, flat or inverted
(T inverted) or discordance. If there is a wide and deep inverted T wave in the lead I, II or
lead V4-V6 then we can assume there is a transmural myocardial ischemia or aneurysm.
In a strain pattern (stretched muscle) from the left ventricle there will be a nonsymmetrical
inverted T wave located in the V5 and V6, or sometimes start from the V4. In the right
ventricle the same thing can be seen from the V1 and going to the V3 or V4 . In ischemia,
there is a symmetric and inverted T wave in at least two or more lead. In hiperkalemia the
T wave is symmetrical and similar in shape to that of a tent, and its height is 50% higher
than the R wave in QRS lead which is normally quite high (lead I, V4 V5 and V6). In a hyper
acute myocardial infarction, stadium there will be a very high T wave that appears before a
change in the QRS complex and ST segment occur. A very high T wave can also be found
in bradikardia, sub-endocardial ischemia, and excess left ventricle load.
Criteria of T wave
1. Illustrates the phase of ventricle re-polarization
2. Normal T wave is positive in lead I, II and V3-V6
3. Normal T wave is negative in lead aVR
4. There are variation in several lead (besides lead I, II, V3-V6)
5. It is normally shaped rounded, and nouching may be normal Varian in children
Q. QT Interval
QT Interval represents the time required for de-polarization and re-polarization process
in the ventricle. Therefore all diseases and medications that influence the de-polarization
and re-polarization phase will also influence the interval QT. This interval is measured from
the beginning of the wave Q until the end of the T wave. The duration can vary according
to the heart rate and also determined by gender and age. Relationship between interval QT
and the heart rate can be seen in table 1.
Qtc Interval = QT interval
√ RR interval (in second)
Note : QtcInterval=corrected interval QT

QTInterval =measured interval QT
RR Interval = interval duration between consecutive R wave
Tabel 1. Relationship between the upper boundaries of the interval QT

with the heart rate
Frequency of heart /minute QT Interval

40 0,49-0,50
50 0,45-0,46
60 0,42-0,43
70 0,39-0,40
80 0,37-0,38
90 0,35-0,36
100 0,33-0,34
110 0,32-0,33
120 0,31-0,32

Criteria of QT Interval
1. Illustrates total period of the systolic
2. Varies based on heart rate, gender and age
3. QT Interval must be less than half the R-R interval for heart rate between 65-90x/minute
4. More accurate to use QTc = QT/√ RR
5. Normal QTc 0.44 + 0.02
6. QT correction shortens in digitalis, hypocalcaemia, and hypercalemia
7. QT correction lengthens.There are two main reasons for a QTc to lengthen; congenital
abnormality called the long QT syndrome, for example in Jervell-Lange-Nielsen
syndrome and Romano-Ward syndrome, and disorders either caused by side effects
from medications such as anti arimia (kinidin and prokainamid), hypnotic medicine
and major tranquilizer; disturbance to electrolyte balance such as hypocalcaemia;
hypomagnesemia, or other diseases such as congestive heart failure and ischemia/
infarction. The lengthening of the interval QT has a strong correlation to predisposition
phenomena R on T which will continue to become ventricular tachycardia.
R. U wave
The U wave is a wave re-polarization that is slow and often seen normal in the pre-
cordial lead (V1-V6). The shape is similar to the P wave but a little bit more sloped and its
height is only 30% of the height of the T wave. Under a hypocalemia condition the height of
the U wave becomes more apparent and can reach up to or more than 50% of the T wave.
Criteria of U wave
1. Small waves that follow the T wave
2. Often seen in slow heart rates and in the right pre-cordial lead
Amplitude < 1/3 amplitude T wave in the same lead.

SYSTEMATIC OF READING AN ECG
When reading or making report on an electrocardiogram recording, the first step is to

describe each and every wave in a systematic manner, and then analyze the interpretation.
1. Rhythm
Determine whether the rhythm is sinus or not. If each QRS complex is preceded by a P
wave and the P wave is followed by a QRS or if the ratio of P wave : QRS complex =
1:1 this means it is a rhythm sinus.
2. Frequency/ rate of P wave or QRS complex

Count the rate/frequency of the heart by counting the rate of the QRS complex. If the rate
of P wave is not the same as the rate of QRS complex, then the frequency of each must be
counted individually. If both frequencies are the same, then only the rate of QRS complex
must be counted.
3. Axis of QRS complex

Determine the axis of QRS complex. The normal axis is always found between -300 through
to 1100. If the axis cannot be determined, then write undeterminable.
4. Interval of PR
Count the interval of PR, if it is more than 0.20 second it means that there is a blockage in
the atrioventricular
5. Morphology :
• P wave: determine the form of the P wave. Is the P wave in accordance with normal
criteria of P wave?
• QRS complex: determine the form of the P wave. Is the QRS complex in accordance
with normal criteria of QRS complex?
• ST segment:determine the form of the ST segment . Is the ST segment in accordance
with normal criteria of ST segment?
• T wave:determine the form of the T wave. Is the T wave in accordance with normal
criteria of T wave?
After describe the five points above, and then write the conclusion or interpretation from all leads.
For example :
Figure 18. Example of ECG recording

1. Rhythm : Sinus
2. Rate of QRS complex : 65 x / minute
3. Axis of QRS complex : 450
4. Transitional zone : V3
5. Interval
a. PR : 0.16 second
b. QRS : 0.10 second
c. QT : 0.40 second
d. QTc : 0.416 second
6. Morphology
a. P wave : Normal
b. QRS complex : normal, duration 0.10 second
c. ST segment : Iso-electric
d. T wave : Normal
e. U wave : None
Conclusion : Normal Electrocardiography
Systematically to read and interpret the cardiogram are such as cardiac frequency,
rhythm, the axis, the interval (PR, QRS, and QT), the waves (P, QRS, T and U) and the ST
segment.

REFERENCES
1. Bates, B., 1987. A Guide to Physical Examination and History Taking, Fourth Edition J/B.
Lippincott Company, Philadelphia.
2. Schiller, 1995.ECG Recorder Cardiovit AT-1. SHILLER America Inc., 3002 Dow Ave., 138
Tustin CA 92680, USA.
3. Sjarif R., 2002. Electrokardiografi. Skills Lab Jilid 5 . Fakultas Kedokteran, Universitas
Gadjah Mada, Yogyakarta.
4. Suhandiman 2002. Elektrokardiologi dan Diagnosis penyakit Jantung. Skills Lab Jilid 5.
Fakultas Kedokteran, Universitas Gadjah Mada, Yogyakarta.
5. 2004. Anatomy and function of the heart’s electricalsystem. (www.stanfordhospital.com/
healthLib/atoz/cardiac/electric.html)
6. 2004. Electrocardiogram. (www.nobel.se/medicine/educational/ecg/ecg-readmore.html)
7. Bellet S. 1971. Clinical Disorders of the Heart Beat. 3rd ed., Lea & Febiger Topan Company
Ltd, Philadelphia, Tokyo, Japan.
8. Chung EK. 1978. Electrocardiography: Practical Applications with Vectorial Principles. 2nd
ed. Harper & Raw Publishers.
9. Goldman MJ. 1973. Principle of Clinical Electrocardiography. 8th ed. Lange Medical
Publication.
10. Irawan B. 1999. Pelatihan Dasar Elektrocardiogram untuk Dokter. Naskah Lengkap Pelatihan
Dasar EKG RS Dr Sardjito Yogyakarta
11. Irawan B. 2000. Pelatihan EKG Tingkat Lanjut untuk Dokter. Naskah Lengkap Pelatihan
EKG Lanjut.
12. Irawan B. 2008. Interpretasi Elektrocardiografi Secara Praktis. Medika FK. UGM. Yogyakarta.
13. Joel WH. 1987.Cardiology for the House Officer. 2nd ed., Williams & Wilkins
Johnson R, Swarzt MH. 1986. A Simplified Approach to Electrocardiography. W.B.Saunders
Company
14. Karim S, dan Kabo P. 1996. EKG dan Penanggulangan Beberapa Penyakit Jantung untuk
Dokter Umum. FK-UI Jakarta
15. Panitia Pelantikan Dokter FK UI 1998. Kapita Selekta Kardiologi. Bagian Kardiologi FK UI
– RS Jantung Harapan Kita, Jakarta
16. Sandu E, Sigurd B. 1991. Arrhythmia Diagnose and Management. A Clinical
Electrocardiographic Guide. Wiesbadener Graphische Betriebe GmbH Greifstraße 6 D-6200
Wiesbaden.
17. Schamroth L. 1976. An Introduction Electrocardiography. 5th ed. Blackwell Scientific
Publications.
18. Yanowitz, FG., 2005, The Alan Lindsay : ECG Learning Center in Cyberspace, http://medstat.
med.utah.edu/kw/ecg/

THE FORM OF ECG INTERPRETATION
PATIENT IDENTITY
Name : Date of examination :
Age : Name of doctor :
Sex :
Please attach the result of ECG (electrocardiogram) here :
Rhythm : Frequency :
QRS Complex Axis : Morphology :
Transitional zone : • PWave :
Interval • QRSComplex :
• PR : • STSegment :
• QRS : • TWave :
• QT : • U Wave :
• QTc :

BASIC CLINICAL COMPETENCE TRAINING MATERIAL
BOOK
YEAR 1
ADULT BASIC LIFE SUPPORT

BLOCK A.3

Skills Laboratory
Yogyakarta
2020

ADULT BASIC LIFE SUPPORT
BLOCK A.3
Co-contributors:
Djayanti Sari
Department of Anesthesiology and Reanimation
Yunita Widyastuti
Department of Anesthesiology and Reanimation
Mohammad Adrian Hasdianda

Department of Medical Education
Clinical Skills Laboratory
Educational Design Reviewed by

Ery Kus Dwianingsih
Year I Coordinator Clinical Skills Laboratory
Materials Prepared by
Ika Nurvita
Assistant for Material Team
Clinical Skills Laboratory
Parts of this book were adapted from the

2020 American Heart Association Adult Basic Life Support Guideline


book.
behaviour.
a. In case the instructor could not attend the lab sessions, skills laboratory will refer the students
to the companying instructor.
be rescheduled within the week. If it is not rescheduled within the week, the instructor in
charge will be substituted by the companying instructor.
bulletin board.
behaviour.

TABLE OF CONTENTS
PREFACE..................................................................................................................... 189
GENERAL OBJECTIVES OF SKILLS TRAINING YEAR 1.......................................... 190
INTRODUCTION.......................................................................................................... 192
ADULT BLS SEQUENCE............................................................................................. 192
Immediate Recognition and Activation of the Emergency Response System.............. 193
Pulse Check................................................................................................................. 194
Early CPR..................................................................................................................... 194
Technique: Chest Compressions.................................................................................. 194
Rescue Breaths............................................................................................................ 195
Managing the Airway.................................................................................................... 197
Operating an AED........................................................................................................ 198
Terminating Resuscitative Efforts in a BLS Out-of-Hospital System............................ 198
Recovery Position........................................................................................................ 198
FEEDBACK OF BLS.................................................................................................... 207

PREFACE
Medical school students should learn and practice several clinical skills as preparation
for entering clinical rotation prior to becoming a certified doctor. Currently, the medical profession
compels medical students to be competent in clinical skills before they directly deal with real
patients experiencing real life medical cases. For this reason, clinical skills are trained as early
as possible. This clinical skills laboratory provides opportunity for students to study and practice
the clinical skills on their own. The adult basic life support skills will be related to:
No. Skills Block

A.3
1. Adult Basic Life Support
(Cardio-Respiratory System)
D.1
2. Neonatal Resuscitation
(Emergency)
D.1
3. Advanced Life Support
(Emergency)
It is important for students to recognize that all topics, including those listed above, are
interrelated. Therefore, students are expected to categorize the topics based on the main topics,
so that continuity from one topic to another can be achieved. We hope that in the future, this
manual for clinical skills training can be useful for students to improve their skills, especially in
physical examination; and for instructors who are involved in providing the trainings.

Contributors

CARDIO-PULMONARY RESUSCITATION (CPR)
BASIC LIFE SUPPORT (ADULT)
CARDIO-PULMONARY RESUSCITATION (CPR)
A. General Objectives BASIC LIFE SUPPORT
(ADULT)
of Skills Training Year 1
1. Students are able to perform basic skill procedures (communication, physical,
procedural, supporting examinations) and convey the results to the patient.
A. General Objectives
2. Students of Skills
are able Training
to consider theYear 1 reasoning aspect of communication and its
clinical
1. Students
procedureare able to perform
(communication, basic procedural,
physical, skill procedures (communication,
supporting examinations).physical,
procedural, supporting examinations) and convey the results to the patient.
2. Studentsofare
B. Objectives ableBasic
Adult to consider the clinical
Life Support reasoning
Skills Trainingaspect of communication and its
procedure (communication, physical, procedural, supporting examinations).
By the end of the sessions (Block A.3), students are expected to be able to:
1. Understand the epidemiology of cardiopulmonary arrest.
B. Objectives of Adult Basic Life Support Skills Training
2. Recognize the signs and symptoms of cardiorespiratory arrest victim.
By the end of the sessions (Block A.3), students are expected to be able to:
3. Demonstrate the technique for assessing victim’s responsiveness and breathing.
1. Understand the epidemiology of cardiopulmonary arrest.
4. Demonstrate the proper technique for chest compression on an adult.
2. Recognize the signs and symptoms of cardiorespiratory arrest victim.
5. Demonstrate the proper technique for assessing the airway (head tilt chin lift).
3. Demonstrate the technique for assessing victim’s responsiveness and breathing.
6. Demonstrate
4. Demonstratethetheproper
steps in mouth-to-mouth
technique for chestventilation (andon
compression airway adjuncts).
an adult.
7. Demonstrate the steps in operating the AED.
5. Demonstrate the proper technique for assessing the airway (head tilt chin lift).
8. Demonstrate
6. Demonstratethethesteps
proper inadult out-of-hospital
mouth-to-mouth one rescuer
ventilation (and CPR technique.
airway adjuncts).
9. Demonstrate
7. Explain the appropriate
the steps inconditions
operating for
thetermination
AED. of resuscitative efforts.
8. Demonstrate the proper adult out-of-hospital one rescuer CPR technique.
C. 9.
Level of Competence
Explain the appropriateaccording to SKDI
conditions 2012
for termination of resuscitative efforts.
Level of Competence for Clinical Skills:
The following
C. Level is the division
of Competence accordingof competence
to SKDI 2012level according to the Miller Pyramid:
 Level
Level of Competence
of Competence 4A: Able
for Clinical to perform independently on graduation.
Skills:
The The graduates
following is theofdivision
medicalofschool possesslevel
competence theoretical knowledge
according concerning
to the Miller Pyramid: this skill
• Level of Competence
(concepts, 4A: Ableortoindications,
theories, principles perform independently on graduation.
performing procedures, complications and
The
others). Besides, during their study, they had seen this skill or this skillthis
graduates of medical school possess theoretical knowledge concerning hadskill
been
(concepts, theories,
demonstrated to themprinciples
and theyorhad indications, performing
applied several times procedures, complications
under supervision; in addition,
and
theyothers).
possess Besides, during
experience to their
use study, they this
and apply had skill
seeninthis
theskill or thisofskill
context had practices
doctor been
demonstrated
independently. to them and they had applied several times under supervision; in addition,
they possess experience to use and apply this skill in the context of doctor practices
independently. Clinical Skills Level of Expected Ability
Assessment of respiration 1 2 3 4A
Clinical Skills
Carotid artery palpation Level of
1 Expected
2 Ability
3 4A
Assessment of respiration 1 2 3 4A
Basic life support 1 2 3 4A
Carotid artery palpation 1 2 3 4A
Chest compression 1 2 3 4A
Basic life support 1 2 3 4A
Chest compression 1 2 3 4A
D. Activities
D. Activities
Therewill
There willbe
be33compulsory
compulsorysessions
sessions(full
(fullattendance
attendanceisisprerequisite
prerequisiteof
ofyear
year11OSCE).
OSCE).
Peer-facilitated skill Instructor-led skill

Preparatory lecture training session training session
and class & &
demonstration formative assessment formative assessment
by skill assistant by instructor
1. Preparatory skills lecture and demonstration (50 minutes)

Students will be introduced to the concept of basic life support and watch a
1. Preparatory
demonstrationskills lectureby
performed and
thedemonstration
instructors. (50 minutes)
Students will be introduced to the concept of basic life support and watch a demonstration
2. performed by the skills
Peer-facilitated instructors.
training session (Independent) (100 minutes)
Students are required to conduct a peer-facilitated independent session outside working
hours at the clinical skills laboratory. The clinical skills assistants will facilitate the
190
session and provide formative feedback to every student (in written form). This form will
Student’s Book - Block A.3. Cardiorespiratory System
be collected on the instructor led session as a replacement of work plan. Students
without completed feedback form will be denied entry to the instructor-led session.
6
2. Peer-facilitated skills training session (Independent) (100 minutes)
Students are required to conduct a peer-facilitated independent session outside working
hours at the clinical skills laboratory. The clinical skills assistants will facilitate the session
and provide formative feedback to every student (in written form). This form will be
collected on the instructor led session as a replacement of work plan. Students without
completed feedback form will be denied entry to the instructor-led session.
3. Instructor-led skills training session (100 minutes)
Time Activity Students Instructor

5 minutes Introduction Discussion
10 minutes Feedback form
Discussion of received feedbacks.
collection
15 minutes Demonstration and Observation Step-by-step
clarification of learnt of instructor’s demonstration of the BLS
skills demonstration skills
50 minutes Performing one by
Formative feedback/ Provide feedbacks both
(10 students x one on provided
responses oral and written forms
5 minutes) manikin
20 minutes Debriefing Discussion of students performance

INTRODUCTION
Basic life support (BLS) is the foundation for saving lives following cardiac arrest. Fundamental
aspects of BLS include immediate recognition of sudden cardiac arrest (SCA) and activation
of the emergency response system, early cardiopulmonary resuscitation (CPR), and rapid
defibrillation with an automated external defibrillator (AED). Initial recognition and response to
heart attack are also considered part of BLS. Despite important advances in prevention, SCA
continues to be a leading cause of death in many parts of the world. SCA has many etiologies
(i.e., cardiac or noncardiac causes), circumstances (e.g., witnessed or unwitnessed), and
settings (e.g., out-of-hospital or in-hospital). In this session, only skills required to perform BLS
in cardiac, witnessed, and out-of-hospital SCA will be learnt. This heterogeneity suggests that
a single approach to resuscitation is not practical, but a core set of actions provides a universal
strategy for achieving successful resuscitation. These actions are termed the links in the “Chain
of Survival.” For adults they include:
• Immediate recognition of cardiac arrest and activation of the emergency response system
• Early CPR that emphasizes chest compressions
• Rapid defibrillation if indicated
• Effective advanced life support
• Integrated post– cardiac arrest care
Figure 1. Chain of survival (AHA 2020)
ADULT BLS SEQUENCE

An adult is defined as anyone 18 years old. The steps of BLS consist of a series of sequential
assessments and actions. The intent of the algorithm is to present the steps of BLS in a logical
and concise manner that is easy for all types of rescuers to learn, remember and perform. These
actions have traditionally been presented as a sequence of distinct steps to help a single rescuer
prioritize actions. However, many workplaces and most EMS and in-hospital resuscitations
involve teams of providers who should perform several actions simultaneously.

Figure 2. Health-care provider adult basic life support algorithm (AHA 2020)
Immediate Recognition and Activation of the Emergency Response System

If a lone rescuer finds an unresponsive adult (i.e., no movement or response to stimulation) or
witnesses an adult who suddenly collapses, after ensuring that the scene is safe, the rescuer
should check for a response by tapping the victim on the shoulder and shouting at the victim.
The healthcare provider can check for response and look for no breathing or no normal breathing
(i.e., only gasping) almost simultaneously before activating the emergency response system.
Bystanders (lay responders) should immediately call their local emergency number to initiate
a response any time they find an unresponsive adult victim. Healthcare providers should call
for nearby help upon finding the victim unresponsive, but it would be practical for a healthcare
provider to continue to assess for breathing and pulse simultaneously before fully activating
the emergency response system. After activation of the emergency response system, rescuers

should immediately begin CPR (see steps below) for adult victims who are unresponsive with no
breathing or no normal breathing (only gasping). When phoning 118 for help, the rescuer should
be prepared to answer the dispatcher’s questions about the location of the incident, the events
of the incident, the number and condition of the victim(s), and the type of aid provided. The
rescuer making the phone call should hang up only when instructed to do so by the dispatcher.
Pulse Check
Lay rescuers will not check for a pulse. The healthcare provider should take no more than 10
seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time
period, the rescuer should start chest compressions.
Early CPR
Chest Compressions
Chest compressions consist of forceful rhythmic applications of pressure over the lower half of
the sternum. These compressions create blood flow by increasing intrathoracic pressure and
directly compressing the heart. This generates blood flow and oxygen delivery to the myocardium
and brain.
• Effective chest compressions are essential for providing blood flow during CPR. For this
reason all patients in cardiac arrest should receive chest compressions.
• To provide effective chest compressions, push hard and push fast. It is reasonable for
laypersons and healthcare providers to compress the adult chest at a rate 100-120
compressions per minute with a compression depth of at least 5 cm. Rescuers should allow
complete recoil of the chest after each compression, to allow the heart to fill completely
before the next compression.
• Rescuers should attempt to minimize the frequency and duration of interruptions in
compressions to maximize the number of compressions delivered per minute. A compression-
ventilation ratio of 30:2 is recommended.
• It is reasonable to position hands for chest compressions on the lower half of the sternum
in adults with cardiac arrest.
• Delays in, and interruptions of, chest compressions should be minimized throughout the
entire resuscitation.
Technique: Chest Compressions

To maximize the effectiveness of chest compressions, place the victim on a firm surface
when possible, in a supine position with the rescuer kneeling beside the victim’s chest (e.g., out-
of-hospital) or standing beside the bed (e.g., in hospital). Because hospital beds are typically not
firm and some of the force intended to compress the chest results in mattress displacement rather
than chest compression, we have traditionally recommended the use of a backboard despite
insufficient evidence for or against the use of backboards during CPR. Correct performance of
chest compressions requires several essential skills. The adult sternum should be depressed
at least 5 cm, with chest compression and chest recoil/relaxation times approximately equal.
Allow the chest to completely recoil after each compression. The number of chest compressions
delivered per minute is an important determinant of return of spontaneous circulation (ROSC)
and neurologically intact survival. One study of in-hospital cardiac arrest patients showed that
delivery of >80 compressions/min was associated with ROSC. Extrapolation of data from an out-
of-hospital observational study showed improved survival to hospital discharge when at least 68
to 89 chest compressions per minute were delivered; the study also demonstrated that improved
survival occurred with chest compression rates as high as 120/min. Rescuer fatigue may lead
to inadequate compression rates or depth. Significant fatigue and shallow compressions are
common after 1 minute of CPR, although rescuers may not recognize that fatigue is present for
≥5 minutes. When 2 or more rescuers are available it is reasonable to switch chest compressors
approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio
of 30:2) to prevent decreases in the quality of compressions. Consider switching compressors
during any intervention associated with appropriate interruptions in chest compressions (e.g.,

when an AED is delivering a shock). Every effort should be made to accomplish this switch in <5
seconds. Healthcare providers should interrupt chest compressions as infrequently as possible
and try to limit interruptions to no longer than 10 seconds, except for specific interventions such
as insertion of an advanced airway or use of a defibrillator. Because of difficulties with pulse
assessments, interruptions in chest compressions for a pulse check should be minimized during
the resuscitation, even to determine if ROSC has occurred.
Rescue Breaths
The latest guideline is to recommend the initiation of compressions before ventilations/rescue
breaths. A compression-ventilation ratio of 30:2 is reasonable in adults, but further validation of
this guideline is needed. This 30:2 ratio in adults is based on a consensus among experts and
on published case series. Further studies are needed to define the best method for coordinating
chest compressions and ventilations during CPR and to define the best compression-ventilation
ratio in terms of survival and neurologic outcome in patients with or without an advanced
airway in place. Once an advanced airway is in place, 2 rescuers no longer need to pause
chest compressions for ventilations. Instead, the compressing rescuer should give continuous
chest compressions at a rate 100-120 per minute without pauses for ventilation. The rescuer
delivering ventilation can provide a breath every 6 second (which yields 10 breaths per minute).
1. 2.
Check the victim for response and signs

of normal breathing (look for chest
movement)
Unresponsive, no breathing or no normal Shout for nearby help.
breathing (only gasping) Activate emergency response
3. 4.
Place the heel of one hand in the center of Place the heel of your other hand on
the victim’s chest. top of the first hand

5. 6.
Press down on the sternum 5-6 cm. After 30 compressions, open the
Repeat at a rate of 100-120 compressions airway, using head tilt and chin lift.
per minute
7. 8.
Blow steadily into his mouth whilst

watching for his chest to rise. Take your mouth away from the
Adequate volume shown by visible chest victim and watch for his chest to fall
rise. Avoid excessive ventilation as air comes out.
9.
Continue perform cycles of 30

Give chest compressions only CPR compressions and 2 breaths.
(continuous compressions at a rate of Use AED as soon as it is available
100-120 per minute)
Figure 3. Adult BLS Sequence

Managing the Airway
Open the Airway: Healthcare Provider
A healthcare provider should use the head tilt– chin lift maneuver to open the airway of a victim
with no evidence of head or neck trauma.
Rescue Breathing
• Deliver each rescue breath over 1 second.
• Give a sufficient tidal volume to produce visible chest rise. Avoid excessive ventilation
• Use a regular breath instead of deep breath to avoid rescuers from getting dizzy or light-
headed, and prevent over inflation of the victim’s lungs.
• Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations.
Mouth-to-Mouth Rescue Breathing

Mouth-to-mouth rescue breathing provides oxygen and ventilation to the victim. To provide
mouth-to-mouth rescue breaths, open the victim’s airway, pinch the victim’s nose, and create
an airtight mouth-to-mouth seal. Give 1 breath over 1 second, take a “regular” (not a deep)
breath, and give a second rescue breath over 1 second.
Mouth-to–Barrier Device Breathing

Some healthcare providers state that they may hesitate to give mouth-to-mouth rescue breathing
and prefer to use a barrier device. When using a barrier device the rescuer should not delay
chest compressions while setting up the device.
Mouth-to-Nose and Mouth-to-Stoma Ventilation

The technique for mouth-to-nose and mouth-to-stoma ventilation was last reviewed in 2010.
Ventilation with Bag-Mask Device

When using a self-inflating bag, rescuers can provide bag- mask ventilation with room air or
oxygen. A bag-mask device can provide positive-pressure ventilation without an advanced
airway and may result in gastric inflation and its potential complications.
Bag-Mask Ventilation
As long as the patient does not have an advanced airway in place, the rescuers should deliver
cycles of 30 compressions and 2 breaths during CPR
Ventilation with an Advanced Airway

When the victim has an advanced airway in place during CPR, rescuers no longer deliver
cycles of 30 compressions and 2 breaths (i.e., they no longer interrupt compressions to deliver
2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds
(10 breaths per minute) while continuous chest compressions are being performed.
Automated External Defibrillator (AED) Defibrillation

All BLS providers should be trained to provide defibrillation because ventricular fibrillation (VF)
and Ventricular Tachycardia (VT) of the heart are common and treatable initial rhythm in adults
with witnessed cardiac arrest. Rapid defibrillation is the treatment of choice for VF/VT of short
duration, such as for victims of witnessed out-of-hospital cardiac arrest.
AED is now a common property in public places such as department stores, airports, and offices.
Availability of AED is shown by a universal AED sign (figure 4).

Figure 4. Universal AED signs
Operating an AED
Switch on the AED and attach pads on victim’s bare chest.
• Follow the voice prompts immediately.
• Attach one pad below the left armpit.
• Attach the other pad below the right collar bone, next to the breastbone.
• Follow the voice prompts immediately to analyze if the shock is necessary.
• If more than one rescuer: don’t interrupt CPR
• Nobody should touch the victim during analysis and shock delivery.
Figure 5. Placing of AED electrode pads (AHA 2010)
Terminating Resuscitative Efforts in a BLS Out-of-Hospital System

Rescuers who start BLS should continue resuscitation until one of the following occurs:
• Restoration of effective, spontaneous circulation
• Care is transferred to a team providing advanced life support
• The rescuer is unable to continue because of exhaustion, the presence of dangerous
environmental hazards
• Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are
identified, or criteria for termination of resuscitation are met.
Recovery Position
The recovery position is used for unresponsive adult victims who clearly have normal breathing
and effective circulation. This position is designed to maintain a patent airway and reduce the
risk of airway obstruction and aspiration. The victim is placed on his or her side with the lower
arm in front of the body.

Place the arm nearest to you out at Bring the far arm across the chest, and
right angles to his body, elbow bent hold the back of the hand against the
with the hand palm upper-most. victim’s cheek nearest to you.
The recovery position.
With your other hand, grasp the far

leg just above the knee and pull it
up, keeping the foot on the ground.
Figure 6. Recovery
The difference between BLS lay rescue not trained, lay rescue trained and healthcare provider
can be seen in the table below.
Table 1. The difference between BLS lay rescue not trained, lay rescue trained and healthcare
provider (AHA, 2015)
Step Lay Rescuer Not Trained Lay Rescuer Trained Healthcare Provider
1 Ensure scene safety Ensure scene safety Ensure scene safety
2 Check for response Check for response Check for response
3 Shout for nearby help. Phone Shout for nearby Shout for nearby help/
or ask someone to phone help and activate the activate the resuscitation
9-1-1 (the phone or caller emergency response team; can activate the
with the phone remains at system (9-1-1, resuscitation team at this
the victim’s side, with the emergency response). time or after checking
phone on speaker) If someone responds, breathing and pulse
ensure that the phone is
at the side of the victim
if at all possible.

4 Follow the dispatcher’s Check for no breathing Check for no breathing
instructions. or only gasping; if or only gasping and
none, begin CPR with check pulse (ideally
compressions. simultaneously). Activation
and retrieval of the AED/
emergency equipment by
either the lone healthcare
provider or by the second
person sent by the rescuer
must occur no later than
immediately after the check
for no normal breathing and
no pulse identifies cardiac
arrest.
5 Look for no breathing or only Answer the dispatcher’s Immediately begin CPR,
gasping, at the direction of questions, and follow and use the AED/defibrillator
the dispatcher. the dispatcher’s when available
instructions
6 Follow the dispatcher’s Send the second When the second rescuer
instructions. person to retrieve an arrives, provide 2-person
AED, if one is available. CPR and use AED/
defibrillator.
CPR IN AIRBORNE DISEASE

Mode of Transmission
An infectious agent can be transmitted in different ways. Breaking the chain of the ‘mode of
transmission’ is one way to stop the spread of infection. There are different classifications for
transmission modes. Infectious microorganisms can be transmitted directly and indirectly through
four main routes: contact, small droplets, airborne, and common vehicle.
Contact transmission is an infection that is spread by direct contact with an infected person (for
example, touching when shaking hands) or with objects or surfaces that have been contaminated.
The latter is sometimes referred to as “fomite transmission”.
Droplet transmission is an infection that is spread through exposure to respiratory droplets
containing the virus (for example larger and smaller droplets and particles) exhaled by an
infected person. Transmission is most likely to occur when a person is close to an infected
person, usually within a distance of less than 2 meters.
Airborne transmission is an infection that is spread by exposure to respiratory droplets containing
viruses consisting of smaller droplets and particles that can remain suspended in the air over
long distances (usually more than 2 meters) and over time (usually hours).
Common vehicle is an infection that is spread through contaminated goods such as food, water,
medications, medical devices and equipment.
Airborne Disease
Many of the clinically important airborne diseases are caused by a variety of pathogens including
bacteria, viruses and fungi. For some viruses and bacteria, airborne transmission is a very
efficient way of spreading infection.
Some of the common pathogens that can be spread through airborne transmission are: Anthrax,
Aspergillosis, Blastomycosis, Chickenpox, Adenovirus, Enterovirus, Rotavirus, Influenza,
Rhinovirus, Neisseria meningitidis, Streptococcus pneumoniae, Legionellosis, Measles,
Mumps, Smallpox, Cryptococcus, Tuberculosis Bordetella pertussis, Severe acute respiratory
syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Coronavirus Disease 2019
(COVID-19).
In addition, some medical and surgical procedures can produce aerosol infectious particles. In
most cases, these airborne particles are generated during manipulation of the lung airways.
These include: manual ventilation with bag and mask, intubation, open endotracheal suction,

bronchoscopy, cardiac pulmonary resuscitation, sputum induction, chest physiotherapy, lung
surgery, nebulizer therapy and steam inhalation, non-invasive positive pressure ventilation
(BIPAP, CPAP), and lung autopsy.
Basic Life Support Suspected or Confirmed Airborne Disease

Health care workers have become a profession with the highest risk of contracting the disease.
The challenge is to ensure that patients with or without airborne disease who have had a heart
attack have the best chance of survival without compromising the safety of the rescuer, who
will be needed to treat future patients. It is necessary to consider the risk to rescuers when
performing cardiopulmonary resuscitation (CPR) in a person with possible airborne disease
and that person’s risk if CPR is delayed. Rescuers must continually balance the urgent needs
of patients with their own safety. Safety is paramount and safety priorities are: (1) self; (2)
colleagues and observers; (3) patient.
Resuscitation carries additional risks for healthcare workers for a variety of reasons. First,
administration of CPR involves a variety of aerosol-generating procedures, including chest
compressions, positive pressure ventilation, and establishment of an advanced airway. During
the procedure, virus particles can remain suspended in the air with a half-life of ≈1 hour and
be inhaled by people around them. Second, resuscitation efforts require multiple providers to
work in close proximity to one another and with the patient. Finally, it is a high-stress emergency
where the urgent need for a patient requiring resuscitation may result in deviations in infection
control practices.
In hospitals, all aerosol-generating procedures should be performed in an airborne infection
isolation room. If a patient faints at the hospital entrance, cardiopulmonary resuscitation (CPR)
should not be started there, but must be taken to the emergency department in the Red Zone
and then CPR. Although transferring a patient to the emergency department without performing
CPR is ethically unacceptable. Many rescuers can perform passive oxygenation using a bag
mask device that attaches to a high efficiency particulate air filter (HEPA filter) with a tight seal
using two hands to hold the mask. In this way, oxygenation is expected and minimizes aerosol
diffusion. Skilled rescuers can also add ventilation to this setup.

Figure 7. Basic life support healthcare provider adult cardiac arrest algorithm for patients with
suspected or confirmed coronavirus disease 2019 (COVID-19).
Personal Protective Equipment

Personal protective equipment, commonly referred to as “PPE”, PPE is equipment that will
protect users from occupational health or safety risks. This can include items such as safety
helmets, gloves, eye protection, high-visibility clothing, safety footwear and safety straps. It
also includes respiratory protective equipment (RPE). Some health care systems have different
standards for PPE, one of which is due to a lack of equipment. Health care systems must
prioritize the protection of health care personnel and ensure that adequate PPE is available to
those expected to provide care for cardiac arrest. The European Resuscitation Council provides
recommendations for Personal Protective Equipment as follows:

• Minimum droplet-precaution PPE: gloves, short sleeve apron, liquid-resistant surgical mask,
eye and face protection (fluid-resistant surgical mask with integrated visor or full-face visor
/ visor or polycarbonate safety glasses or the like).
• Minimum airborne-precaution PPE: gloves, long sleeve dresses, filtering facepiece (FFP3)
or N99 mask / respirator (FFP2 or N95 if FFP3 is not available), eye and face protection (full
face shield / visor or polycarbonate safety goggles or equivalent), a powered air-purifying
respirator (PAPR) with a hood can be used as an alternative.
Figure 8. Respirator On / Respirator Off
How to Put On (Don) PPE Gear

More than one donning method may be acceptable. It is important to carry out training and
practice in the use of personal protective equipment in accordance with the availability of each
health center. Below is one example of donning.
1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based
on training).
2. Perform hand hygiene using hand sanitizer.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other
healthcare personnel.

4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a
respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose
with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/
facemask should be extended under chin. Both your mouth and nose should be protected.
Do not wear respirator/facemask under your chin or store in scrubs pocket between patients.*
a. Respirator: Respirator straps should be placed on crown of head (top strap) and base
of neck (bottom strap). Perform a user seal check each time you put on the respirator.
b. Facemask: Mask ties should be secured on crown of head (top tie) and base of neck
(bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric
respirator, select the proper eye protection to ensure that the respirator does not interfere
with the correct positioning of the eye protection, and the eye protection does not affect the
fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide
excellent protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient room.
Figure 8. COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel
How to Take Off (Doff) PPE Gear

More than one doffing method may be acceptable. It is important to carry out training and
practice in the use of personal protective equipment in accordance with the availability of each
health center. Below is one example of doffing.
1. Remove gloves. Ensure glove removal does not cause additional contamination of hands.
Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather
than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the
shoulders and carefully pull gown down and away from the body. Rolling the gown down is
an acceptable approach. Dispose in trash receptacle.*
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap
and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the
front of the respirator or facemask.*

a. Respirator: Remove the bottom strap by touching only the strap and bring it carefully
over the head. Grasp the top strap and bring it carefully over the head, and then pull the
respirator away from the face without touching the front of the respirator.
b. Facemask: Carefully untie (or unhook from the ears) and pull away from face without
touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again
if your workplace is practicing reuse.*
* Facilities implementing reuse or extended use of PPE will need to adjust their donning and
doffing procedures to accommodate those practices.
The general recommendations for BLS in adults by lay rescuers for suspected or confirmed
airborne disease are:
• Cardiac arrest is identified if a person is unresponsive and not breathing normally.
• Responsiveness is assessed by shaking the person and shouting. When assessing breathing,
look for normal breathing. In order to minimize the risk of infection, do not open the airway
and do not place your face next to the victims’ mouth / nose. Call the emergency medical
services if the person is unresponsive and not breathing normally.
• During single-rescuer resuscitation, if possible, use a phone with a hands-free option to
communicate with the emergency medical dispatch center during CPR.
• Lay rescuers should consider placing a cloth/towel over the person’s mouth and nose before
performing chest compressions and public-access defibrillation. This may reduce the risk
of airborne spread of the virus during chest compressions.
• Lay rescuers should follow instructions given by the emergency medical dispatch center.
• After providing CPR, lay rescuers should, as soon as possible, wash their hands thoroughly
with soap and water or disinfect their hands with an alcohol-based hand-gel and contact
the local health authorities to enquire about screening after having been in contact with a
person with suspected or confirmed COVID-19. Recommendations for emergency medical
dispatch staff for suspected or confirmed COVID-19 in adults
• For untrained rescuers, provide compression-only instructions.
• Guide rescuers to the nearest automated external defibrillator (AED) when available.
• The risk of COVID-19 should be assessed by emergency medical dispatch as early as
possible; if there is a risk of infection, the responding healthcare personnel should be alerted
immediately to enable them to take precautions such as donning airborne-precaution personal
protective equipment (PPE).
• First responders or trained volunteers should be dispatched or alerted to medical emergencies
only if they have access to and training in the use of PPE. If first responders or trained
volunteers have only droplet-precaution PPE, they should provide only defibrillation (if
indicated), and no chest compressions, for patients with suspected or confirmed COVID-19.
Recommendations for BLS in adults by healthcare personnel for suspected or confirmed
COVID-19
• Teams responding to cardiac arrest patients (both in- and out-of-hospital) should be comprised
only of healthcare workers with access to, and training in the use of airborne-precaution
PPE.
• Applying defibrillator pads and delivering a shock from an AED/defibrillator is unlikely to
be an aerosol-generating procedure and can be undertaken with the healthcare provider
wearing droplet-precaution PPE (fluid-resistant surgical mask, eye protection, short-sleeved
apron and gloves.
• Recognize cardiac arrest by looking for the absence of signs of life and the absence of
normal breathing.
• Healthcare professionals should always use airborne-precaution PPE for aerosol generating
procedures (chest compressions, airway and ventilation interventions) during resuscitation.
• Perform chest compressions and ventilation with a bag-mask and oxygen at a 30:2 ratio,
pausing chest compressions during ventilations to minimize the risk of aerosol. BLS teams

less skilled or uncomfortable with bag-mask ventilation should not provide bag-mask
ventilation because of the risk of aerosol generation. These teams should place an oxygen
mask on the patient’s face, give oxygen and provide compression-only CPR.
• Use a high-efficiency particulate air (HEPA) filter or a heat and moisture exchanger (HME)
filter between the self-inflating bag and the mask to minimize the risk of virus spread.
• Use two hands to hold the mask and ensure a good seal for bag-mask ventilation. This
requires a second rescuer – the person doing compressions can squeeze the bag when
they pause after each 30 compressions.
• Apply a defibrillator or an AED and follow any instructions where available.

REGULER HEALTH PROVIDER BLS
ON WITNESSED SUSPECTED-CARDIAC-ARREST VICTIM
INSIDE HOSPITAL/HEALTH CARE PROVIDER SETTING
no breathing, but have pulse
Name : _______________________________
Student ID number : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
1 Verify scene safety
2 • Check for responsiveness
(tap gently the shoulders & shout to wake the victim up)
• Shout for nearby help if victim no response
3 Simultaneously, (less than 10” seconds):
• Look for apnea or gasping
• Check for definite carotid pulse.
If unsure, consider as no breathing
4 • Activate Code Blue System (ask someone to call code blue
number)
• Get AED and Emergency equipment
5 If no breathing or gasping but still have pulse, give rescue breathing.
Provide Rescue Breathing:
• Open airway
• Use bag-mask device
• Give1 breath every 5-6 seconds, or about 10-12 breaths/min.
Adequate volume shown by visible chest rise. Avoid excessive
ventilation
6 Continue rescue breathing and check pulse every 2 minutes.
• If no pulse, start to CPR the victim
• In suspect opioid toxicity case, give naloxone injection
7 Monitor periodically (every 2 minutes) until advanced team
arrives, refer to hospital or higher care unit.
8 Able to start breathing support in:
• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0
DOCTOR-PATIENT INTERACTION
9 GREET
Show good interpersonal skills (to other bystanders, patient family)
10. INFORM & CONSENT
Ensure legal aspect by taking consent (if applicable)
PROFESSIONALISM
11 Able to perform skills confidently, carefully, and able to know your own
limitation as helper.
Total
Annotation : Yogyakarta, ……………………………….

Score 0 = Not done
Score 1 = Poorly done
Score 2 = Well done
Score 3 = Perfect (complete) …………………………….........................

(Total Score) GLOBAL RATING*
(Please tick one box only)
Grade = ----------------- x 100% = ….……% FAIL
33 BORDERLINE
PASS
EXCELLENT
*Students can be declared as having failed if they make an error which is considered fatal

no breathing, no pulse
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Check for responsiveness
number)
4 If there’s no breathing or gasping and no pulse, do high quality CPR.
Do the CPR:
• interlocking hands position
• perpendicular to body’s victim
• lower half of the sternum
• Begin cycles of 30 compression, open airway and give 2 breaths
using bag mask device. Adequate volume shown by visible chest
rise. Avoid excessive ventilation
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• minimal interruption
• if more than 1 rescuer, change compressor every 5 cycles or 2
min.
Use AED as soon as it is available
5 AED arrives, check rhythm
• if shockable rhythm
o Give 1 shock
o Resume CPR immediately for about 2 minutes (until prompted
by AED to allow rhythm check)
o Continue until Advance Life Support (ALS) provides take over
or victim starts to move
• If no shockable rhythm
o Continue until ALS provides take over or victim starts to move
6 If patient get ROSC (Return of Spontaneous Circulation), put the
patient in recovery position

7 Able to start CPR in:
• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0
8 GREET
9 INFORM & CONSENT
PROFESSIONALISM
10 Able to perform skills confidently, carefully, and able to know your
own limitation as helper.
Total

Score 0 = Not done
Score 2 = Well done …………………………….........................
Score 3 = Perfect (complete)
Grade = -------------------- x 100% = …….……% FAIL
33 BORDERLINE
PASS
EXCELLENT

OUT OF HOSPITAL/HEALTH CARE PROVIDER SETTING
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
3 • Activate Emergency Response System (ask someone to call
118)
Do the CPR:
using bag mask devices. Avoid excessive ventilation.
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• if more than 1 rescuer, change compressor every 2 min.
5 as AED arrives, check rhythm
o Give 1 shock
o Resume CPR immediately for about 2 minutes (until
prompted by AED to allow rhythm check)
o Continue until Advance Life Support (ALS) provides
take over or victim starts to move
o Resume CPR immediately for about 2 minutes (until
prompted by AED to allow rhythm check)
Continue until ALS provides take over or victim starts to move
7 Make sure ambulance and advance help is on the way, check
victim periodically
Able to start CPR in:
• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0

8 GREET
9 INFORM & CONSENT
PROFESSIONALISM
Total

Score 0 = Not done
Score 2 = Well done
Grade = ---------------------- x 100% = ……….……% FAIL
33 BORDERLINE
PASS
EXCELLENT

REGULER LAYRESCUER BLS
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Shout for nearby help
2 Look for apnea or gasping
3 If no response, apnea or gasping
• Activate Emergency Response System (ask someone to call
118)
4 If there’s no response, apnea or gasping, do high quality CPR.
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• interlocking hands position, in the lower half of the sternum,
perpendicular to the victim’s body
• if more than 1 rescuer, change compressor every 2 min
5 If AED is available, use AED as soon as possible:
- While still doing chest compressions, stick and place the adhesive
pad on the victim’s chest
- Turn on AED.
- Follow the instructions from AED:
1. Stop chest compressions for check rhythm according to
instructions from AED
2. If there is an order to shock:
- Make sure that no one lay rescuers touch the victim and victim’s
bed.
- Press the shock button
- Continue chest compressions
If there is no order to shock, continue chest compressions
7 Make sure help is on its way and check on the victim every 2
minutes until help arrives.
• <30 seconds = 2,
• 30 seconds - 2 minutes = 1,
• >2 minutes = 0
8 GREET
9 INFORM & CONSENT

PROFESSIONALISM
Able to perform skills confidently, carefully, and able to know your own
TOTAL

Score 0 = Not done
Score 2 = Well done
(Total Score) GLOBAL RATING* (Please tick one box
only)
Grade = --------------------- x 100% = ……….……% FAIL
33
BORDERLINE
PASS
EXCELLENT

HEALTH PROVIDER BLS
ON WITNESSED SUSPECTED-CARDIAC-ARREST VICTIM WITH AIRBORNE DISEASE
no breathing, but have pulse
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Don PPE (Personal Protective Equipment)
• Limit Personal
4 Find and put mask or anything (cloth/plastic) to cover up
patient’s face
• Activate Code Blue System (ask someone to call code blue
number)
5 If no breathing or gasping but still have pulse, give rescue breathing.
Provide Rescue Breathing:
• Use bag-mask device with filter and tight seal
• Open patient’s mask, or under cloth/plastic which cover patient’s
face up (if available), give 1 breath every 5-6 seconds, or about 10-
12 breaths/min. Adequate volume shown by visible chest rise. Avoid
excessive ventilation.
6 Continue rescue breathing and check pulse every 2 minutes.
• If no pulse, start to CPR the victim
• In suspect opioid toxicity case, give naloxone injection
7 Monitor periodically (every 2 minutes) until advanced team
arrives, refer to hospital or higher care unit.
• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0
• Doff PPE carefully
• Wash hand with soap or alcohol base hand sanitizer
9 GREET
10. INFORM & CONSENT
PROFESSIONALISM
Total

Score 0 = Not done
Score 2 = Well done
GLOBAL RATING*
(Total Score) (Please tick one box only)
Grade = ------------------ x 100% = ………………% FAIL
33 BORDERLINE
PASS
EXCELLENT

HEALTH PROVIDER BLS
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Limit Personal
• Look for apnea or gasping (If unsure, consider as no breathing)
• Check for definite carotid pulse. (If unsure, consider as no
pulse)
patient’s face
number)
Do the CPR:
using bag mask devices with filter and tight seal. Adequate volume
shown by visible chest rise. Avoid excessive ventilation.
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• if more than 1 rescuer, change compressor every 5 cycles or 2
min.
o Give 1 shock
o Continue until Advance Life Support (ALS) provides take over
or victim starts to move

• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0
10 • Doff PPE carefully
• Wash hands with soap or alcohol base hand sanitizer
11 GREET
12 INFORM & CONSENT
PROFESSIONALISM
Total
Annotation : Yogyakarta,
Score 0 = Not done ……………………………….
Score 2 = Well done
Score 3 = Perfect (complete)
…………………………….....................
....
Grade = --------------------- x 100% = ……….……% FAIL
33 BORDERLINE
PASS
EXCELLENT

HEALTH PROVIDER BLS
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Limit Personal
• Look for apnea or gasping (If unsure, consider as no breathing)
• Check for definite carotid pulse. (If unsure, consider as no pulse)
patient’s face
5 • Activate Emergency Response System (ask someone to call
118)
Do the CPR:
using bag mask devices with filter and tight seal. Adequate volume
shown by visible chest rise. Avoid excessive ventilation.
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• if more than 1 rescuer, change compressor every 5 cycles or 2 min.
o Give 1 shock
o Continue until Advance Life Support (ALS) provides take over or
victim starts to move

• < 1 min = 2,
• 1-2 min = 1,
• >2 min = 0
11 GREET
12 INFORM & CONSENT
PROFESSIONALISM
Total
Annotation : Yogyakarta,
Score 0 = Not done ……………………………….
Score 2 = Well done
Score 3 = Perfect (complete) ………………………….........................
Grade = ----------------------- x 100% = ……….……% FAIL
33 BORDERLINE
PASS
EXCELLENT

LAYRESCUER BLS
Name : _______________________________
SCORE
NO ASSESSMENT
0 1 2 3
PROCEDURAL SKILLS
• Limit Personal
• Shout for nearby help
3 Look for apnea or gasping
patient’s face
5 If no response, apnea or gasping
• Activate Emergency Response System (ask someone to call
118)
6 If there’s no response, apnea or gasping, do high quality CPR.
• rate 100-120 x/min,
• depth 5-6 cm
• full recoil
• interlocking hands position, in the lower half of the sternum,
perpendicular to the victim’s body
if more than 1 rescuer, change compressor every 2 min
7 If AED is available, use AED as soon as possible:
- While still doing chest compressions, stick and place the adhesive
pad on the victim’s chest
- Turn on AED.
- Follow the instructions from AED:
1. Stop chest compressions for check rhythm according to
instructions from AED
2. If there is an order to shock:
- Make sure that no one lay rescuers touch the victim and victim’s
bed.
- Press the shock button
- Continue chest compressions
A If there is no order to shock, continue chest compressions

9 Make sure help is on its way and check on the victim every 2
minutes until help arrives.
• <30 seconds = 2,
• 30 seconds - 2 minutes = 1,
• >2 minutes = 0
11 GREET
12 INFORM & CONSENT
PROFESSIONALISM
TOTAL

Score 0 = Not done
Score 2 = Well done
Grade = --------------------- x 100% = …….……% FAIL
33 BORDERLINE
PASS
EXCELLENT

REFERENCES
1. European Resuscitation Council. European Resuscitation Council Guidelines for

Resuscitation. 2015. Resuscitation (2015) 67S1,S3-S6
2. American Heart Association. Part 3: Adult Basic and Advanced Life Support: 2020
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, Circulation (2020); 142; S366-S468
3. American Heart Association. Interim Guidance for Basic and Advanced Life Support in
Adults, Children, and Neonates with Suspected or Confirmed COVID-19 (2020); 141;
e933-e943
4. European Resuscitation Council. European Resuscitation Council COVID-19 Guidelines.
Section 2 Basic Life Support in Adults (2020)

BASIC CLINICAL COMPETENCE TRAINING
MATERIAL BOOK
INTRODUCTION OF BASIC RADIOLOGY
BLOCK A.3

FACULTY OF MEDICINE PUBLIC HEALTH AND NURSING
SKILLS LABORATORY
2020

CONTRIBUTORS:
dr. Bambang Supriyadi. Sp. Rad. MM
dr. Amri Wicaksono Pribadi, Sp.Rad
Department of Radiology
Faculty of Medicine UGM
Educational design reviewed by

dr. Ery Kus Dwianingsih,Sp.PA(K).,P.hD
Year I Coordinator for Clinical Skills Training


book.
behaviour.
a. In case the instructor could not attend the lab sessions, skills laboratory will refer the
students to the companying instructor.
be rescheduled within the week. If it is not rescheduled within the week, the instructor
in charge will be substituted by the companying instructor.
bulletin board.
behaviour.

TABLE OF CONTENTS
INTRODUCTION OF BASIC RADIOLOGY..................................................................... 229

Foreword......................................................................................................................... 229
Content Scope................................................................................................................ 229
1. Radiological modalities are divided into two main groups based on the utilization of
ionizing ray, which are ionizing and non-ionizing modalities....................................... 229
2. Working principle of radiological modalities................................................................ 229
3. Deciding the types of radiological examination depends on the case........................ 232
4. Conventional plain photo still holds an important role in evaluating musculoskeletal
cases that could give many information such as........................................................ 232
5. It is important to follow and understand the principle of “Rule of 2”, which are:......... 232
6. asic principle of plain photo imaging is influence by the components that make up
the skeletas system.................................................................................................... 233
7. Radioanatomy of the upper and lower extremities...................................................... 233

Foreword
Skills laboratory block A.3 “Introduction of Basic Radiology” is a learning module on
radiological skill with level competency of 4 (SKDI) that has the goal for students to be able to:
- Know various radiological devices
- Understand the principle of work of each radiological modalities
- Understand the principle of radiological examination
- Understand the principle of selecting proper radiological examination
- Understand the principle of x-ray image formation
- Understand the basic principle of plain photo x-ray of the bone
- Understand the radio-anatomy of the skeletal system
Student understanding can be improved by teaching process using different methods of

lectures, bedside teachings, and skills laboratory. For skills laboratory, students are expected
to understand various radiological modalities as well as the types of examination, to be able to
decide which proper radiological examination is best used for the skeletal system, and understand
the radio-anatomy of the skeletal system.
Content Scope
1. Radiological modalities are divided into two main groups based on the utilization of ionizing
ray, which are ionizing and non-ionizing modalities.
a. Ionizing radiological modalities are:
i. Plain photo (x-ray)
ii. Fluoroscopy
iii. Computed Tomography (CT)
iv. Radio nuclear imaging, including single-photon emission computed tomography
(SPECT) and positron emission tomography (PET)
b. Non-ionizing radiological modalities are:
i. Ultrasonography (USG)
ii. Magnetic Resonance Imaging (MRI)
Besides those two main groups, improvement on the field of radiology has shown new
modalities that combine the work principle of those two groups. These new modalities
are called hybrid or fusion imaging, for example PET/CT, SPECT/CT, MR/PET, and MR/
SPECT.
2. Working principle of radiological modalities

a. Plain photo (x-ray)
Also called conventional radiology, it uses the principle of x-ray to form its image. There
are two main units, the x-ray machine and the photosensitive film plate (cassette). X-ray
penetrates the body tissue and hits the cassette. Then the cassette will be processed,
either chemically or digitally to produce a printed photo. X-ray energy hit the cassette
after it penetrates different parts of body tissue, thus forming different densities of tissue
on the image produced.

There are five types of tissue densities formed from plain photo x-ray, which are:
Air density called Hyperlucent
Fat density called Radiolucent
Fluid density called Intermediate density
Bone density called Radiopaque
Metal density called Hyper radiopaque
b. Fluoroscopy
It is a radiological modality that uses the principle of x-ray in real-time, thus forming a
dynamic image to visualize movements of the body and contrast media inserted into the
body either extravascular or intravascularly. The image produced can be seen real-time
on a monitor either as a dynamic video or instant static plain photo (spot film).
Fluoroscopy device requires a different machine compared to conventional radiology. It

transmits x-ray continuously, with the tube along with its metal plaque detector to move
in a coordinated way to capture images from various angle depending on the needs of
the operator. Examination table for the patient to lie down is also adjusted to move in
various ways.
Radiological intervention sub-specialty uses fluoroscopy modality to perform endovascular

intervention (catheterization), body tissue biopsy, and other minimally invasive
intervention. Fluoroscopy is a radiological modality used in every heart catheterization
facilities (cathlab).

c. Computed Tomography (CT) scan
Working principle of CT scan (also called CAT scan or multislice CT / MSCT) is based
on the use of x-ray. CT scan consists of a tube that produces x-ray and multiple plate
detector that spin continuously rotating the patient’s body inside gantry. The x-ray
produced penetrates the body continuously in a full circular motion and moves along
the body part. X-ray energy receives by the detector will be process digitally using a
sophisticated computer algorithm, with the end result of transversal slice image along
the body axis. The image can be format digitally to create a coronal, sagittal, or oblique
view, or even reconstructed to create a three-dimensional image (3D).
Images produced from CT scan examination are matrix from thousands of pixels. Each
pixel has a different density depending on the component of the body being examined.
Body density is measure using CT number or Hounsfield unit (HU), with a range of -1000
to +1000 HU. CT scan image has a wide range of density, much higher than plain photo
x-ray. The higher the density of a tissue, the higher the HU grade, thus opaque (white)
image will form.
Density of air has an HU of −1000

Density of fat has a range of HU between -40 up to -100
Density of water has an HU of 0
Density of soft tissue has a range of HU between 20 up to 100
Density of bone has a range of HU between 400 up to 600
d. Radionuclear
Radionuclear imaging modality uses radiation produce from an isotope, which is an
unstable molecule. The instability causes a change of nuclear atom, producing radiation
energy ray continuously until its halftime (t½) ends. Radioisotope used in medicine is also
called radionuclide. Various radionuclide use in the modality of radionuclear imaging
depends on parts of the body being examined. For example, thyroid gland examination
uses iodine, brain examination uses glucose, and bone uses phosphate.
Radionuclide binds with the drug molecule that carries it before being inserted into the
patient’s body. Combination between those molecules is called radiopharmaceutical and
can be administer with either enteral or parenteral route. Radiopharmaceutical inside
the blood circulation will then reach its corresponding target organ or tissue. Radiation
produced is then captured with a gamma camera device to measure the level of radiation
and produce an image.
e. Ultrasonography (USG)
USG imaging modality uses the principle of high frequency sound waves, between 2 to
10 mega Hertz (MHz). The device is consist of three main important components, which
are the transducer (probe), computer, and monitor. Ultrasound wave is produced from
piezoelectric crystals inside the transducer that could change the electrical wave into
mechanical wave or ultrasound. The same transducer can also receive ultrasound that
was reflected from the body tissue that will then be converted in electrical wave and run
through the computer to be processed into an image shown by the monitor.
Sound waves crosses various body tissue at different speeds. Body tissue that receives
the ultrasound wave will change that wave in different manner, some bounce the wave
directly back to the transducer while some distort the wave before bouncing it back to
the transducer in the form of echo. Different interaction of ultrasound wave from various
body tissue will produce the image shown by the monitor.

f. Magnetic Resonance Imaging (MRI)
MRI modality uses the energy potential contains in the hydrogen atom of all body tissue.
The principle is to use strong magnetic field and radiofrequency pulse to produce energy
from each specific tissues. Those energy are then captured to be process to produce a
two or three dimensional image.
MRI machine consists of three main components, which are high powered magnet
(between 0.5 to 7 Tesla), organ specific coil, and a processing computer. As patient enters
the MRI chamber, high powered magnet will align all proton axis inside the hydrogen
atom of the body to parallel the magnetic field. Before the examination is perform, coil
is attach according to the intended body part. Transmission coil functions to transmit
radiofrequency pulse, while receiver coil act as the receiver of echo signals from the
excited proton. The computer receives data from the radiofrequency echo signal from
the coil and change it to form a digital image.
MRI is superior compared to other modalities to visualize soft tissues imaging, some
examples are nervous system, muscle, tendon, and ligament.
3. Deciding the types of radiological examination depends on the case, clinical condition, and
availability of radiological devices present. In emergency situation, radiological modalities
that can be use quickly and relatively present in every hospital are x-ray and USG. In
cerebrovascular cases, head trauma, or multiple trauma on the musculoskeletal and
abdominal system, CT scan has the ability to give information accurately in a short amount
of time.
Requesting radiological examination requires detailed information of:

a. Identity
- Patient: name, medical record registry number, gender, age
- Requesting doctor: name, address, contact number
b. Clinical condition of the patient
c. Type of radiological examination being requested
4. Conventional plain photo still holds an important role in evaluating musculoskeletal cases
that could give many information such as:
a. Fracture and dislocation
b. Bone lesion and surrounding tissue
c. Source and type of lesion (benign or malignant)
d. Biopsy guide
e. Monitor development of disease
5. It is important to follow and understand the principle of “Rule of 2”, which are:
a. 2 Projection
o Antero-Posterior (AP) and Lateral
o The standard is two projections, additional oblique projection could be use
b. 2 Joints
o Proximal and distal
o Recommended to see dislocation
c. 2 Sides
o Dextra and sinistra
o Recommended for comparison
d. 2 Period
o Old and new
o Recommended for periodic evaluation

6. Basic principle of plain photo imaging is influence by the components that make up the
skeletas system. Bones are made up to these several components: 25% water, 30% organic,
and 45% inorganic (Ca Phosphate 85% and Ca Carbonate 15%). Radioopaque image of
the bone is caused by inorganic material contain within the bone.
There are three main source of blood supply for the bone:
a. Nutrisia artery, branches of the artery in the image
b. Metaphysis and epiphysis artery, directly supply the metaphysis and epiphysis
c. Periosteal artery, branch of nutrisia artery that follows Harvesian system and Volkmann
canal in the bone
7. Radioanatomy of the upper and lower extremities

a. Bone locus
Epiphyseal line
Epiphysis
Subarticular
Articular cartilage
Metaphysis
Diaphysis


b. Shoulder joint
c. Elbow joint

d. Wrist joint
e. Manus

f. Pelvis

g. Genu
h. Ankle joint

i. Pedis
Reference
1. Meschan, I. and Ott, D. (1984). Introduction to diagnostic imaging. Philadelphia: Saunders.
2. Sutton, D. and Robinson, P. (2005). Textbook of radiology and imaging. Edinburgh: Churchill
Livingstone.
3. Herring, W. (2016). Learning radiology: Recognizing the basic 3rd ed. Philadelphia: Elsevier.
4. Lloyd-Jones, G. (2017). Musculoskeletal X-ray - General principles. [online]
Radiologymasterclass.co.uk. Available at: https://www.radiologymasterclass.co.uk/tutorials/
musculoskeletal/principles/bones_joints_x-ray_start [Accessed 21 Jun. 2017].

Student Book Block A.3 Cardiorespiratory System (2020) FINAL

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Student’s Book

School of Medicine UGM 1

Arranged by Block Coordination Team of Block A.3

Published by Undergraduate Program in Medicine

Eighth edition, November 2020

2 Student’s Book - Block A.3. Cardiorespiratory System

BLOCK COORDINATORS TEAM

dr. Arta Farmawati, Ph.D

Dra. Dewajani Purnomosari, M.Si, Ph.D

dr. Junaedy Yunus, M.Sc, Ph.D

Dr. Med. dr. Putrika Prastuti Ratna Gharini, Sp.JP

dr. Rahmaningsih Mara Sabirin, M.Sc

School of Medicine UGM 3

Phase 3: Clinical Rotation – Becoming a

4 Student’s Book - Block A.3. Cardiorespiratory System

(6 weeks) (6 weeks) (6 weeks) (6 weeks) (6 weeks) (6 weeks)

School of Medicine UGM 5

Block A.3 Team.......................................................................................................... 3

6 Student’s Book - Block A.3. Cardiorespiratory System

Practical Session of Anatomy ................................................................................... 31

Basic Clinical Competence Material Book

School of Medicine UGM 7

General Instructional Objectives

Specific instructional Objectives

8 Student’s Book - Block A.3. Cardiorespiratory System

Practical session list

Relation with Other Blocks

School of Medicine UGM 9

HEART INTRODUCTION REGULATION

CARDIO - HIGH ALTITUDE

CLINICAL BASIC LIFE

1. Group discussion with Tutors using online meeting tools

2. Independent learning (Self-Study)

Students learn independently based on block’s objectives and scenario’s objectives,

3. Expert lectures using online tools synchronous and or asynchronous

School of Medicine UGM 11

12 Student’s Book - Block A.3. Cardiorespiratory System

5. Basic clinical competence training

School of Medicine UGM 13

Session Total Indicator for

BLOCK EXAMINATION REQUIREMENTS

Absence may be permitted by the 3 main reasons, those are:

14 Student’s Book - Block A.3. Cardiorespiratory System

2. Title : Anatomy of the heart

3. Title : Histology of cardiovascular system

4. Title : Development of the heart

5. Title : Electric activity of the heart

6. Title : Mechanical activity of the heart

7. Title : Biochemistry of cardiac muscle

School of Medicine UGM 15

Basic clinical competence training

16 Student’s Book - Block A.3. Cardiorespiratory System

Scenario 1 (for week 2)

2. Title : Capillary exchange

3. Title : Anatomy of blood vessels and lymphatics

4. Title : Cell membrane and permeability

5. Title : Biochemical regulation of blood vessels

6. Title : Regulation of regional blood flow

School of Medicine UGM 17

7. Title : Introduction functional disturbance of the heart

2. Title : Blood vessel

3. Title : Blood Pressure Regulation

Basic Clinical Competence Training

18 Student’s Book - Block A.3. Cardiorespiratory System