Skill Lab-1 Anamnese Peny-paru
-
Upload
casillas-junior -
Category
Documents
-
view
231 -
download
0
Transcript of Skill Lab-1 Anamnese Peny-paru
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
1/104
1
MD
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
2/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
3/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
4/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
5/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
6/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
7/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
8/104
Anamnese oke
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
9/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
10/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
11/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
12/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
13/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
14/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
15/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
16/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
17/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
18/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
19/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
20/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
21/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
22/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
23/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
24/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
25/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
26/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
27/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
28/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
29/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
30/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
31/104
PADAT
CAIR
GAS
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
32/104
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
33/104
Anatomi paru
Kanan 3 lobus (atas, tengah, bawah)
Kiri 2 lobus (atas, bawah)
Topografi
Linea Mid Sternalis
Linea Mid ClavicularisLinea Axillaries anterior
Linea Mid Axillaris
Linea Axillaris posteriorLinea Sternalis kanan dan kiri
Linea Para Sternalis kanan dan kiri
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
34/104
Tulang-tulang (Untuk Orientasi)Sternum dan Angulus Costae
Clavicula
Arcus CostaeCostae
Scapula
Vertebra
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
35/104
General Approach:
Examine both the anterior and posterior chest
Posterior
LUL
LLL
RUL
RLL
Anterior
LULLUL
LLL
RUL
RLL
RML
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
36/104
AnteriorPosterior
General Approach:
RUL
RLL
RML
LUL
LLL
Posterior
Examine the lateral chest
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
37/104
General Approach:
The patient should be seated for the posterior and lateral exam.
The patient may seated or laying supine for the anterior exam.
The portion of the chest that is being examined should be exposed
while the rest of the patient remains draped.
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
38/104
General Approach:
I
P
P
A
Inspection
Palpation
Percussion
Auscultation
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
39/104
L t l i i li
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
40/104
Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line
os er or mag nary nes
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
41/104
os er or mag nary nesand landmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region
A t i i f l b
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
42/104
Anterior view of lobes
P t i i f l b
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
43/104
Posterior view of lobes
Ri ht l t l i f l b
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
44/104
Right lateral view of lobes
L ft l t l i f l b
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
45/104
Left lateral view of lobes
Th i d f it
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
46/104
Thoracic deformity
Pectus excavatumBarrel chest
Kyphosis
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
47/104
Inspeksi
Bentuk umum
- Thorak Inspiratorius/Emphysematous- Thorax Expiratorius/Paralytikus
- Simetris/asimetris
(Skoliosis, pebentukan jar. Ikat dalam thorax)
Pembesaran vena
Benjolan lokal
-Voisure cardiacus
- Perforasi- Aneurisma Aorta
- Abses
- Tumor dinding thorax
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
48/104
Thorax Paralyticus / expiratoriusIndividu yang kurus dan panjang
Panjang dan pipih
Tulang iga berjalan lurus kebawahSudut epigastrium sangan tajam
Konfigurasi thorax Pyriformis
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
49/104
Thorax Pyramidalis
Disebut juga tetradische thorax
Ujung sternum bagian bawah menjadik puncakpyramid
Jarang
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
50/104
Thorax Inspiratorius / Emphysematous
Thorax kembung dan pendek
Iga mendatar
Sudut epigastrium tumpulOK elastisitas paru yang kurang
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
51/104
Inspection:
Work of breathing:
Respiratory rate (normal = 10-14 breaths/minute).
Depth of breathing.
Accessory muscle use (sternocleidomastoid and intercostal muscles).
Paradoxical respirations (asymmetry of chest and abdomen motion).
Posture (leaning forward and arms bracing the exam table).
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
52/104
Inspection:
Rhythm of breathing:
Time
Depth
Normal
Rapid Shallow
Restrictive lung process: Pneumothorax, Interstitial Fibrosis, Pleuritic Pain
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
53/104
Inspection:Inspection:
Rhythm of breathing:
Rapid Deep
Anxiety, Exercise, Metabolic acidosis (Kussmaul respirations)
Slow
Diabetic Coma, Drug-induced respiratory depression
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
54/104
Inspection:Inspection:
Rhythm of breathing:
Cheyne-Stokes Breathing
Heart Failure, Uremia, CNS Injury to both hemispheres
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
55/104
Shape and symmetry of the anterior and posterior chest:
Inspection:
Normal Barrel Chest
COPD
Flail Chest
Rib Fractures
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
56/104
Shape and symmetry of the anterior and posterior chest:
Inspection:
Pectus Excavatum Pectus Carinatum
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
57/104
Shape and symmetry of the anterior and posterior chest:
Inspection:
Thoracic Kyphoscoliosis
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
58/104
Miscellaneous:
Inspection:
Skin Color(cyanosis as evidence of hypoxemia)
Clubbing of the fingernails(cystic fibrosis, idiopathic pulmonary fibrosis,lung cancer)
Position of Trachea(displacement with pneumothorax, pleural effusion)
Inspection
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
59/104
Inspection
1. Respiratory movement Abdominal breathing: male adult and child Thoracic breathing: female adult
2. Respiratory rate: 16-18 f/min Tachypnea: >20 f/min
Bradypnea:
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
60/104
Inspection
3. Respiratory rhythm Cheyne-Stokes breathing
Biots breathing
_____Decreased excitability ofrespiratory center
Inhibited breathing
Sudden cessation of breathing due to chest pain
Pleurisy, thoracic trauma
Sighing breathing
Depression, intension
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
61/104
Palpation:
Identification of tender areas: musculoskeletal pain vs. other
Assessment of chest wall expansion
(pleural effusion, splinting, paralyzedhemidiaphragm)
Trachea Position: deviation can occur with pneumothorax
Lymphadenopathy
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
62/104
Palpation:
Assessment of tactile fremitus.
Sense vibration with ulnar surface of hand as patient speaks a deep tone
Posterior positions Anterior positions
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
63/104
Palpation:
Assessment of tactile fremitus.
Decreased fremitus: impedance of vibration from larynx to chest wall
-Pleural effusion
-pneumothorax
-COPD
-obstructed bronchus-obesity
Increased fremitus: transmission of sound is increased from larynx to chest wall
-Consolidated lung secondary to lobar pneumonia
Palpation
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
64/104
Palpation
Thoracic expansion
Massive hydrothorax, pneumonia,
pleural thickening, atelectasis
Vocal fremitus (tactil fremitus)
Pleural friction fremitus
Cellulose exudation in pleura due
to pleurisy
Holding breathing
disappeared Tuberculous pleurisy, uremia,
pulmo embolism
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
65/104
Percussion
1 Method
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
66/104
1. Method
Mediate
Pleximeter: distal inter-phalangeal joint of left middle
finger
Plexor: right middle finger tip
Immediate
Order
Up to down, anterior to posterior
2 Affected factors
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
67/104
2. Affected factors
Thickness of thoracic wall
Calcification of costal cartilage
Hydrothorax
Containing gas in alveoli
Alveolar tension
Alveolar elasticity
3 Classification
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
68/104
3. Classification
Resonance (Sonor) Normal
Hyperresonance (hipersonor)
Emphysema
Tympany
Cavity or pneumothorax
Dullness (sonor memendek)
Hydrothorax, atelectasis
Flatness (beda)
Massive Hydrothorax
4 Normal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
69/104
4. Normal sound
Lungs sound in percussion
Resonance
Slight dullness in some areas (upper, right,back) due to thickness of muscles and
skeletons
4 Normal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
70/104
4. Normal sound
Border of lungs in percussion Apex of lungs
Kronigs isthmus: 5cm in width
Narrow: TB, fibrosis
wider: emphysema
Anterior border absolute cardiac dullness area
Lower border 6th, 8th, 10th intercostal space in midclavicular line,midaxillary line, scapular line, respectively
Down: emphysema
Up: atelectasis, intraabdominal pressure goes up
4 Normal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
71/104
4. Normal sound
s
Shifting range of
bottom of lung
6-8 cm
Shifting range of bottom of lung
Along the scapular line
Percussing bottom of lung, marking
Asking the pat. to inspire deeply and hold
Percussing bottom of lung, marking
Asking the pat. to expire deeply and hold
Percussing bottom of lung, marking
Measuring the dist. between upper and lower lines
Decreased: emphysema, atelactasis,
fibrosis, pulmo. edema, pneumonia
Detected impossibly: pleura adhesion,
massive hydrothorax, pneumothorax,
diaphragmatic paralysis
5 Abnormal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
72/104
5. Abnormal sound
Dullness, flatness, hyperresonance or
tympany appear in the area of supposed
resonance.
Unchanged sound (resonance)
The depth of the lesion > 5 cm
The diameter of the lesion 3 cm
Mild hydrothorax
5 Abnormal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
73/104
5. Abnormal sound
Dullness or flatness Decreased containing gas in alveoli Pneumonia
Atelectasis?
TB
Pulmo. embolism
Pulmo. edema
Pulmo. fibrosis
No gas in alveoli Tumor
Pulmo. Hydatid
Pneumocystis
Non-liquefied lung abscess
Others Hydrothorax
Pleural thickness
5 Abnormal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
74/104
5. Abnormal sound
Hyperresonance Emphysema
Tympany Pneumothorax
Large cavity (TB, lung abscess, lung cyst) Amphorophony
Large and shallow cavity with smooth wall
Tension pneumothorax
Tympanitic dullness Decreased tension and gas in alveoli
Atelectasis
Congestive or resolution stage of pneumonia
Pulmo. edema
5. Abnormal sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
75/104
5. Abnormal sound
Specialareas on
percussion in
moderatehydrothorax
(Pleural
Effusi)
Damoiseaus curve (damoiseaus
Garlands triangle area
(tympanitic dullness)
Groccos triangle area
(dullness)
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
76/104
Percussion:
Technique.
Anterior positions
Positions.
Posterior positions
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
77/104
Percussion:
Note Intensity Pitch Location Path.
Flat Soft Pleural Effusion
Dull
Hyperresonant
Resonant
Tympany
Medium
Loud
Loud
Very Loud
Medium
Low
High
Lower
High
Thigh
Liver
Lung
None
Gastric
Air
Lobar Pneumonia
Normal Lung
EmphysemaPneumothorax
Large
Pneumothorax
Sounds.
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
78/104
Posterior positions
Percussion:
Miscellaneous: Identify the diaphragm position and extent of excursion
Resonant
Dull
Max Exhalation
Max Inhalation
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
79/104
Auscultation
Order of auscultation
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
80/104
Order of auscultation
Sound of auscultation
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
81/104
Sound of auscultation
1. Normal breath sound2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance
1. Normal breath sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
82/104
Tracheal breath sound Bronchial breath sound Larynx, suprasternal fossa,
around 6th, 7th cervicalvertebra, 1st, 2nd thoracicvertebra
Bronchovesicular breathsound 1st, 2nd intercostal space
beside of sternum, thelevel of 3rd, 4th thoracicvertebra in interscaplararea, apex of lung
Vesicular breath sound
Bronchovesicular
Bronchial
Bronchial
Bronchovesicular
2. Abnormal breath sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
83/104
Abnormal vesicular breath sound
Abnormal bronchial breath sound
Abnormal bronchovesicular breath
sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
84/104
Abnormal vesicular breath sound (2
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
85/104
Abnormal vesicular breath sound (2
3) Prolonged expiration
Bronchitis
Asthma
emphysema
4) Cogwheel breath sound TB
Pneumonia5) Coarse breath sound
Early stage of bronchitis or pneumonia
sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
86/104
(tubular breath sound)
Bronchial breath sound appears in supposed
vesicular breath sound area
Consolidation: lobar pneumonia (consolidation
stage)
Large cavity: TB, lung abscess
Compressed atelectasis: hydrothorax,
pneumothorax
norma ronc oves cu arbreath sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
87/104
breath sound Bronchovesicular breath sound appears
in supposed vesicular breath sound
area
The lesion is relatively smaller or mixed
with normal lung tissue
3. Adventitious sound
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
88/104
(moist) Crackles
Rhonchi (wheezes)
Pleural friction rub
Moist crackles
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
89/104
Mechanism
During inspiration, air flow passes thin
secretion in the airway to rupture the
bubbles, or to open the collapse of
bronchioli due to adhesion by secretion.
Characteristics of crackles
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
90/104
1. Adventitious sound
2. Intermittent
3. Appeared in phase of inspiration or early
expiration
4. Constant in site
5. Unchanged in character6. Medium and fine crackles exist
meantime
7. Less or disappeared after cough
Classification of crackles
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
91/104
According to intensity of the sound1. Loud moist crackles
2. Slight moist crackles
According to diameter of the airway crackles
appeared1. Coarse: trachea, main bronchi, or cavity
Bronchiectasis, pulmo. edema, TB, lung abscess,coma
2. Medium: bronchi bronchitis, pneumonia
3. Fine: bronchioli
pneumonia
4. Crepitus:
Site of crackles
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
92/104
1. Local: local lesion
Pneumonia, TB, bronchiectasis
2. Both bases
Pulmo. edema, bronchopneumonia,
chronic bronchitis
3. Full fields
Acute pulmo. edema, severe
bronchopneumonia, chronic bronchitis with
severe infection
Rhonchi (wheezes)
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
93/104
( )
Mechanism
The turbulent flow is formed in trachea,bronchi or bronchioli due to airway narrow orincomplete obstruction.
Causes Congestion
Secretion
Spasma Tumor
Foreign subject
Compression
Characteristics of rhonchi
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
94/104
1. Adventitious sound2. High pitch
3. Dominance in phase of expiration
4. Variable intensity of character or site
5. Wheezing
Classification of rhonchi
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
95/104
1. Sibilant Bonchioli, bronchi
2. Sonorous Trachea, main bronchi
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
96/104
Pleural friction rub
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
97/104
1. Cellulose exudation in pleurisy (rough pleura)2. Area of auscultation
Anterolateral thoracic wall (maximal shifting area oflung)
3. Friction rub disappeared if holding breath
4. Friction rub appeared both breath and heartbeat:
mediastinal pleurisy5. Causes Tuberculous pleurisy
Pulmo. embolism
Uremia
Vocal resonance
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
98/104
Bronchophony
Pectoriloqny
Massive consolidation
Egophony
Upper area of hydrothorax
Whispered Consolidation
Auscultation:
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
99/104
Auscultation:
Technique.
-Auscultation should be performed with diaphragm of stethoscope
-Patient should breath deeply through an open mouth (quietly)
-The entire breath should be auscultated in each position (inspiration + exhalation)
-Compare on area of the lung to the same area in opposite lung
-Adjust patients depth of inspiration such that you can hear breath sounds
Auscultation:
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
100/104
Auscultation:
Positions.
Anterior positionsPosterior positions
Auscultation:
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
101/104
Sounds Intensity Pitch Duration Location
Vesicular Soft Inspir > Expir Lungs
Broncho-vesicular
Bronchial
Medium
Loud
Medium
Low
High
Normal Sounds.
Auscultation:
Inspir = Expir
Inspir < Expir
Central airways
Trachea
Note: Auscultation should be performed with diaphragm of stethoscope
A lt ti
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
102/104
Adventitious Sounds.
Auscultation:
Crackles: Intermittent brief sounds similar to rolling hair between fingers
typically heard best during inspiration.
-Fine: soft and high pitched. pulmonary fibrosis
-Coarse: loud and lower pitched. pneumonia, congestive heart failure
Wheezes: high pitched with musical character heard during inspiration
or exhalation.
-Inspiratory/loud over central aitways (stridor): airway obstruction
-Expiratory/musical: asthma
-Unilateral: obstruction of proximal bronchus (Tumor)
Rhonchi: low pitched snoring sound typically heard during inspiration
Bronchial: trachea sound heard in regions where sounds should be vesicular
pneumonia
Physical exam can identify pathology :
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
103/104
y y p gy
Normal
Pneumonia
Effusion
Pneumothorax
COPD
Condition Trachea Percussion Breath Sounds Fremitus Adventitial
Midline
Midline
Midline
Shifted
Shifted
Resonant
+/- Dull
Dull
Hyper
Hyper
Normal
Decreased
Bronchial
Decreased
Decreased
Normal
Increased
Decreased
Decreased
Decreased
None
Crackles
None
None
Wheezes
Midline Resonant Normal Normal CracklesCHF
DAPAT MENGGANGGU PARU ANDA
-
7/28/2019 Skill Lab-1 Anamnese Peny-paru
104/104
DAPAT MENGGANGGU PARU ANDA