PEMERIKSAAN THORAX

PSIK FIKES UMM

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

Anterior Surface of Thorax

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

IMAGINER LINE (Garis bayangan)

Garis bayangan midsternalis dan midclavikula anterior

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)

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
1. 2. 3. 4. Inspection Palpation Percussion Auscultation

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 > AP 2. Pectus excavatum (funnel chest) sternum bertakuk masuk 3. pectus carinatum (pigeon chest) sternum menonjol keluar 4. Increased anteroposterior (AP) diameter (barrel chest) dada seperti tong

C. Observe for retractions and Use of accessory muscles of

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

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.

3. PERCUSION
A. 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 Chest
1. 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.

Interpretation C. 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 Emphysema or Pneumothorax

Hyperresonant

4. AUSCULTATION
TUJUAN : mendengarkan suara nafas Breath 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 Chest
1. 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.

Suara Nafas Normal 1. 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

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.

 SUARA UCAPAN 1. Bronchophony is increased clarity of words, e.g. in area of pneumonia 2. 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.

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

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

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.

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.

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.