pemeriksaan thorax

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PEMERIKSAAN THORAX PSIK FIKES UMM

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Page 1: Pemeriksaan Thorax

PEMERIKSAAN THORAX

PSIK

FIKES UMM

Page 2: Pemeriksaan Thorax

Ribs, clavicles, sternum Angle of Louis (manubriosternal angle): marker for:

– Where second rib meets sternum (count ribs from here)

– Carina of trachea – Arch of aorta

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Anterior Surface of Thorax• Palpate the following

– Sternum (3 parts)– Jugular notch– Sternal Angle (= 2nd rib)– Clavicle– Costal margin – Infrasternal angle– Xiphosternal joint

• Midclavicular Line• Midaxillary Line

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Garis bayangan midsternalis dan midclavikula anterior

IMAGINER LINE (Garis bayangan)

Page 6: Pemeriksaan Thorax

1. Paru• On the anterior chest, the

lungs extend from 4cm above the first rib to the 6 th rib (or so).On the posterior chest wall, lungs extend from T1 (first thoracic vertebra) down to T9 (during expiration) or T12 (duringinspiration)

Page 7: Pemeriksaan Thorax

• Ideally the patient should be sitting on the end of an exam table.

• The examination room must be quiet to perform adequate percussion and auscultation.

• Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.).

FOUR METHODS OF CHEST EXAMINATION1. Inspection 2. Palpation 3. Percussion 4. Auscultation

General Considerations

Page 8: Pemeriksaan Thorax

A. Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged

B. Shape of chest: 1. Normal chest (ellips) transverse > AP2. Pectus excavatum (funnel chest) sternum bertakuk

masuk3. pectus carinatum (pigeon chest) sternum menonjol

keluar4. Increased anteroposterior (AP) diameter (barrel chest)

dada seperti tong

C. Observe for retractions and Use of accessory muscles of respiration:sternomastoids, abdominals

Page 9: Pemeriksaan Thorax
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2. PALPATION

1. Identify any areas of tenderness or deformity by palpating the ribs and sternum Daerah nyeri tekan

2. Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and ask them to breath deeply.

– Kesimetrisan pergerakan dada – Vokal Fremitus dan Fremitus taktil

Page 11: Pemeriksaan Thorax

• tactile fremitus: Chest wall vibrations from speech (patient says "ninety-nine").

• Compare sides. Fremitus should be symmetric - the same on both sides.

• Abnormal fremitus can help you diagnose several lung abnormalities:

• Decreased fremitus occurs if something gets between the lung and chest wall:

• Air in the pleural space ( pneumothorax or "collapsed lung")

• Fluid in the pleural space ( pleural effusion )

• Scarred, thickened pleura • Increased fremitus: • In pneumonia, thick pus in the airways

and alveoli increases vibration transmission (like wobbling jello). Patients with pneumonia may have increased fremitus on that side.

Page 12: Pemeriksaan Thorax

3. PERCUSIONA. Proper Technique

1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest.

2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger.

3. Categorize what you hear as normal, dull, or hyperresonant.

4. Practice your technique until you can consistantly produce a "normal" percussion note on your (presumably normal) partner before you work with patients.

B. Posterior Chest1. Percuss from side to side and top to bottom using the

pattern shown in the illustration. Omit the areas covered by the scapulae.

2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the percussion sounds you

hear. 4. Find the level of the diaphragmatic dullness on both sides.

Page 13: Pemeriksaan Thorax

InterpretationC. Anterior Chest

1. Percuss from side to side and top to bottom using the pattern shown in the illustration.

2. Compare one side to the other looking for asymmetry.

3. Note the location and quality of the percussion sounds you hear.

Percussion Notes and Their Meaning

Flat or Dullness

liquid or solid 1. Pleural Effusion

2. Lobar Pneumonia lung area full of pus

Normal Healthy Lung or Bronchitis

Hyperresonant Emphysema or Pneumothorax

Page 14: Pemeriksaan Thorax
Page 15: Pemeriksaan Thorax

4. AUSCULTATION

TUJUAN : mendengarkan suara nafasBreath sounds are produced by turbulent air flow A. Posterior Chest

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae.

2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the sounds you hear.

B. Anterior Chest1. Auscultate from side to side and top to bottom using the

pattern shown in the illustration. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the sounds you hear.

Page 16: Pemeriksaan Thorax

Suara Nafas Normal1. Trakeal : bunyi yang terdengar kasar, keras, dan

dengan tinggi nada tinggi pada bagian trakea ekstratoraks

2. Bronkial : bunyi yang dengan tinggi nada tinggi, seperti udara mengalir melalui pipa didengar di atas manubrium sternal

3. Vesikular : bunyi yang terdengar lemah dengan tinggi nada rendah seluruh lapang paru

4. Bronkovesikular : campuran bunyi bronkial dan bunyi vesikular hanya terdengar pada ICS I dan II

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Suara nafas tambahan (Adventitious (Extra) Lung Sounds)

• Crackles/ Rales : These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. signs of water in the alveoli (heart failure), pus in the alveoli (pneumonia), or scarring (pulmonary fibrosis)

• Wheezes/Wheezing: These are generally high pitched and "musical" in quality. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup). sign of asthma or, if localized, of a tumor or foreign body

• Rhonchi : These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi. originate in larger airways than wheezes and are a sign of bronchitis

• Friction rub is a dry, leathery sound heard in inspiration and expiration. It is a sign of inflammation of the pleura.

Page 20: Pemeriksaan Thorax
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• SUARA UCAPAN1. Bronchophony is increased clarity of words,

e.g. in area of pneumonia2. Whispered pectoriloquy -- even a whisper is

clear to the stethoscope - is an extreme form of bronchophony (Suara terdengar jauh dan tidak jelas)

3. Egophony: patient says EE and stethoscope hears A - is similar to increased tactile fremitus. Egophony may be the only physical examination abnormality in early pneumonia.

Page 22: Pemeriksaan Thorax

JANTUNG/CARDIOExamination of the heart includes: •  Inspection: of jugular venous pulse and point of maximal impulse •  Palpation: of point of maximum impulse, and precordium for lifts, heaves and thrills •  Auscultation: for valve closing sounds (S1 and S2), extra sounds (S3 and S4), murmurs, clicks and rubs

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AUSCULTATION OF THE HEART •  be sure to use both sides of the stethoscope to examine

the heart •  the diaphragm is best for hearing high-pitched sounds,

including S1, S2 and most heart murmurs •  the bell is bests for hearing low-pitched sounds, including

S3, S4 and a few murmurs (e.g. mitral stenosis) •  use LIGHT TOUCH when using the bell. Pressure turns it

into a diaphragm  AUSCULTATION: WHAT MAKES NOISES IN THE HEART? Valves closing: atrioventricular - mitral and tricuspid (S1) and

semilunar   -- aortic and pulmonic (S2) Blood striking the left ventricle: S3 and S4 Increased flow across normal valves - for instance, in

pregnancy, anemia, or hyperthyroidism Turbulent flow through an abnormal valve

Page 25: Pemeriksaan Thorax

S1 and S2The Lub-dub sound of the heart is S1-S2. S1: • S1 is the sound made when the mitral and

tricuspid (atrioventricular or AV) valves close. It marks the beginning of systole

• S1 is loudest at apex or left lower sternal border

• S1 is usually single; but may be narrowly split at the LLSB. This is normal.

Page 26: Pemeriksaan Thorax

S2:• S2 is the sound made when the aortic and

pulmonic (semilunar) valves close. It marks the beginning of diastole.

• S2 is loudest at the base. The top of the heart is the base.

• S3 usually splits with inspiration.

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GALLOPS: S3 and S4 •  Both S3 and S4 are caused by blood

striking the left ventricle •  S3 and S4 are heard at the apex (PMI)

only •  S3 and S4 are both diastolic sounds •  S3 and S4 are low-pitched sounds, so

they are heard with the bell of   your stethoscope.