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PEMERIKSAAN THORAX. PSIK FIKES UMM. Faqih Ruhyanudin. 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 . Anterior Surface of Thorax.

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pemeriksaan thorax

PEMERIKSAAN THORAX

PSIK

FIKES UMM

FaqihRuhyanudin

surface anatomy of the chest
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
anterior surface of thorax
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

1 paru
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

Inspection

Palpation

Percussion

Auscultation

General Considerations
1 inspection
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 > 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 respiration:sternomastoids, abdominals

2 palpation
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

slide11
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
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.

interpretation
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.

4 auscultation
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.

slide16
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

slide19
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.

slide21
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.

jantung cardio
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

slide24
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

slide25

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.
slide26

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.
slide27

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.

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