PEMERIKSAAN THORAX

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PEMERIKSAAN THORAX
Faqih Ruhyanudin

• PSIK
• FIKES UMM

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SURFACE ANATOMY OF THE CHEST

• 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)
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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)

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General Considerations

• 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 EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation

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1. INSPECTION

• A. Observe the rate, rhythm, depth, and effort of
  breathing. Note whether the expiratory phase is
  prolonged
• B. Shape of chest
• Normal chest (ellips) ? transverse gt AP
• Pectus excavatum (funnel chest) ? sternum
  bertakuk masuk
• pectus carinatum (pigeon chest) ? sternum
  menonjol keluar
• Increased anteroposterior (AP) diameter (barrel
  chest) ? dada seperti tong
• C. Observe for retractions and Use of accessory
  muscles of respirationsternomastoids, abdominals

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2. PALPATION

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

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• 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.

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3. PERCUSION

• A. Proper Technique
• Hyperextend the middle finger of one hand and
  place the distal interphalangeal joint firmly
  against the patient's chest.
• With the end (not the pad) of the opposite middle
  finger, use a quick flick of the wrist to strike
  first finger.
• Categorize what you hear as normal, dull, or
  hyperresonant.
• Practice your technique until you can
  consistantly produce a "normal" percussion note
  on your (presumably normal) partner before you
  work with patients.
• B. Posterior Chest
• Percuss from side to side and top to bottom using
  the pattern shown in the illustration. Omit the
  areas covered by the scapulae.
• Compare one side to the other looking for
  asymmetry.
• Note the location and quality of the percussion
  sounds you hear.
• Find the level of the diaphragmatic dullness on
  both sides.

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Interpretation

• C. Anterior Chest
• Percuss from side to side and top to bottom using
  the pattern shown in the illustration.
• Compare one side to the other looking for
  asymmetry.
• Note the location and quality of the percussion
  sounds you hear.

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4. AUSCULTATION

• TUJUAN mendengarkan suara nafas
• Breath sounds are produced by turbulent air flow
• A. Posterior Chest
• Auscultate from side to side and top to bottom
  using the pattern shown in the illustration. Omit
  the areas covered by the scapulae.
• Compare one side to the other looking for
  asymmetry.
• Note the location and quality of the sounds you
  hear.
• B. Anterior Chest
• Auscultate from side to side and top to bottom
  using the pattern shown in the illustration.
• Compare one side to the other looking for
  asymmetry.
• Note the location and quality of the sounds you
  hear.

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• Suara Nafas Normal
• Trakeal bunyi yang terdengar kasar, keras, dan
  dengan tinggi nada tinggi pada bagian trakea
  ekstratoraks
• Bronkial bunyi yang dengan tinggi nada tinggi,
  seperti udara mengalir melalui pipa ? didengar di
  atas manubrium sternal
• Vesikular bunyi yang terdengar lemah dengan
  tinggi nada rendah seluruh lapang paru
• 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.

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• SUARA UCAPAN
• Bronchophony is increased clarity of words, e.g.
  in area of pneumonia
• Whispered pectoriloquy -- even a whisper is clear
  to the stethoscope - is an extreme form of
  bronchophony (Suara terdengar jauh dan tidak
  jelas)
• 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.

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JANTUNG/CARDIO
Examination 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

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• S1 and S2
• The 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.

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• 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.