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The reasoning behind identifying ECG as not being included in the physical examination of the heart lies in the definition and scope of what constitutes a physical examination. A physical examination typically involves methods that a physician can perform at the bedside, using direct techniques such as inspection, palpation, percussion, and auscultation.

Auscultation involves listening to heart sounds using a stethoscope, which is a key component of heart assessment during a physical exam. Percussion can also provide insight into heart size or the presence of fluid. However, both of these methods are limited to what can be assessed through direct interaction with the patient.

In contrast, an electrocardiogram (ECG) is a diagnostic test that requires specific equipment to measure the electrical activity of the heart, capturing the rhythm and electrical impulses. While it provides invaluable information about cardiac function and is critical for diagnosing various cardiac conditions, it is not performed during the traditional physical examination since it necessitates external devices and is not a hands-on technique. Similarly, echocardiography, which uses ultrasound to visualize heart structures and functions, also falls into the category of diagnostic tests rather than a physical examination technique.

Therefore, understanding the distinction between direct examination techniques and those requiring diagnostic equipment clarifies why