skill lab-1 anamnese peny-paru

7/28/2019 Skill Lab-1 Anamnese Peny-paru

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MD


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Anamnese oke


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PADAT

CAIR

GAS


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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


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Tulang-tulang (Untuk Orientasi)Sternum dan Angulus Costae

Clavicula

Arcus CostaeCostae

Scapula

Vertebra


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General Approach:

Examine both the anterior and posterior chest

Posterior

LUL

LLL

RUL

RLL

Anterior

LULLUL

LLL

RUL

RLL

RML


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AnteriorPosterior

General Approach:

RUL

RLL

RML

LUL

LLL

Posterior

Examine the lateral chest


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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.


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General Approach:

I

P

P

A

Inspection

Palpation

Percussion

Auscultation


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L t l i i li


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Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line

os er or mag nary nes


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os er or mag nary nesand landmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region

A t i i f l b


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Anterior view of lobes

P t i i f l b


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Posterior view of lobes

Ri ht l t l i f l b


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Right lateral view of lobes

L ft l t l i f l b


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Left lateral view of lobes

Th i d f it


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Thoracic deformity

Pectus excavatumBarrel chest

Kyphosis


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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


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Thorax Paralyticus / expiratoriusIndividu yang kurus dan panjang

Panjang dan pipih

Tulang iga berjalan lurus kebawahSudut epigastrium sangan tajam

Konfigurasi thorax Pyriformis


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Thorax Pyramidalis

Disebut juga tetradische thorax

Ujung sternum bagian bawah menjadik puncakpyramid

Jarang


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Thorax Inspiratorius / Emphysematous

Thorax kembung dan pendek

Iga mendatar

Sudut epigastrium tumpulOK elastisitas paru yang kurang


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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).


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Inspection:

Rhythm of breathing:

Time

Depth

Normal

Rapid Shallow

Restrictive lung process: Pneumothorax, Interstitial Fibrosis, Pleuritic Pain


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Inspection:Inspection:


Rapid Deep

Anxiety, Exercise, Metabolic acidosis (Kussmaul respirations)

Slow

Diabetic Coma, Drug-induced respiratory depression


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Inspection:Inspection:


Cheyne-Stokes Breathing

Heart Failure, Uremia, CNS Injury to both hemispheres


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Shape and symmetry of the anterior and posterior chest:

Inspection:

Normal Barrel Chest

COPD

Flail Chest

Rib Fractures


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Inspection:

Pectus Excavatum Pectus Carinatum


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Inspection:

Thoracic Kyphoscoliosis


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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


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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:


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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


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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


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Palpation:

Assessment of tactile fremitus.

Sense vibration with ulnar surface of hand as patient speaks a deep tone

Posterior positions Anterior positions


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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


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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


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Percussion

1 Method


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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


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2. Affected factors

Thickness of thoracic wall

Calcification of costal cartilage

Hydrothorax

Containing gas in alveoli

Alveolar tension

Alveolar elasticity

3 Classification


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3. Classification

Resonance (Sonor) Normal

Hyperresonance (hipersonor)

Emphysema

Tympany

Cavity or pneumothorax

Dullness (sonor memendek)

Hydrothorax, atelectasis

Flatness (beda)

Massive Hydrothorax

4 Normal sound


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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


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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


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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


Asking the pat. to expire deeply and hold


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


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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


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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


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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


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5. Abnormal sound

Specialareas on

percussion in

moderatehydrothorax

(Pleural

Effusi)

Damoiseaus curve (damoiseaus

Garlands triangle area

(tympanitic dullness)

Groccos triangle area

(dullness)


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Percussion:

Technique.

Anterior positions

Positions.

Posterior positions


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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.


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Posterior positions

Percussion:

Miscellaneous: Identify the diaphragm position and extent of excursion

Resonant

Dull

Max Exhalation

Max Inhalation


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Auscultation

Order of auscultation


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Order of auscultation

Sound of auscultation


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Sound of auscultation

1. Normal breath sound2. Abnormal breath sound

3. Adventitious sound

4. Vocal resonance

1. Normal breath sound


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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


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Abnormal vesicular breath sound

Abnormal bronchial breath sound

Abnormal bronchovesicular breath

sound


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Abnormal vesicular breath sound (2


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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


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(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


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breath sound Bronchovesicular breath sound appears

in supposed vesicular breath sound

area

The lesion is relatively smaller or mixed

with normal lung tissue



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(moist) Crackles

Rhonchi (wheezes)

Pleural friction rub

Moist crackles


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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


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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


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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


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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)


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( )

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


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1. Adventitious sound2. High pitch

3. Dominance in phase of expiration

4. Variable intensity of character or site

5. Wheezing

Classification of rhonchi


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1. Sibilant Bonchioli, bronchi

2. Sonorous Trachea, main bronchi


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Pleural friction rub


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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


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Bronchophony

Pectoriloqny

Massive consolidation

Egophony

Upper area of hydrothorax

Whispered Consolidation

Auscultation:


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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:


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Auscultation:

Positions.

Anterior positionsPosterior positions

Auscultation:


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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


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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 :


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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


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DAPAT MENGGANGGU PARU ANDA

skill lab-1 anamnese peny-paru

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