MODUL SKILL RESPIRASI

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA LABORATORIUM ILMU PENYAKIT PARU 2011

THE RESPIRATORY SYSTEM EXAMINATION

The respiratory history Presenting symptoms COUGH AND SPUTUM Cough is a common presenting respiratory symptom. It occurs when deep inspiration is followed by explosive expiration. Flow rates of air in the trachea approach the speed of sound during a forceful cough. Coughing enables the airways to be cleared of secretions and foreign bodies. The duration of a cough is important. A cough of recent origin, particulary if associated with fever and other symptoms of respiratory tract infection, may be due to acute bronchitis or pneumonia. A chronic cough associated with wheezing may be due to asthma; sometimes asthma can present with just cough alone. An irritating chronic dry cough can result from oesophageal reflux and acid irritation of the lungs. A similar cough is not uncommonly associated with the use of the angiotensin-converting enzyme (ACE) inhibitors. These are drugs used in the treatment of hypertension and cardiac failure. A chronic cough which is productive of large volumes of purulent sputum may indicate the development of a new and serious underlying problem (e.g infection or lung cancer). The patients description of his or her cough may be helpful. A cough associated with inflammation of the epiglotis may have a barking quality. Cough caused by tracheal compression by a tumour may be loud and brassy. Cough associated with recurrent laryngeal nerve palsy has a hollow sound because the vocal cords unable to close completely; this has been described as a bovine cough. A cough that is worse at night is suggestive of asthma of heart failure, while coughing that comes on immediately after eating or drinking may be due to a tracheo-oesophageal fistula or oesophageal reflux. It is an important though, perhaps, a somewhat unpleasant task to inquire about the type of sputum produced. Be warned that some patients have more interest in their sputum than others and may go into more detail than you really want. A large volume of purulent (yellow or green) sputum suggests the diagnosis or bronchiectasis or lobar pneumonia. Foul-smelling dark-coloured sputum may indicate the presence of a lung abscess with anaerobic organisms. Pink frothy secretions from the trachea, which occur in pulmonary oedema, should not be confused with sputum. Haemoptysis (coughing up of blood) can

be a sinister sign of lung disease and must always be investigated. It is best to rely on the patients assessment of the taste of the sputum which is, not unexpectedly, foul in conditions like bronchiectasis or lung abscess. BREATHLESSNESS (DYSPNOEA) The awareness that an abnormal amount of work is required for breathing is called dyspnoea. It can be due to respiratory or cardiac disease. Careful question-ing about the timing of onset, severity and pattern of dysponea is helpful in making the diagnosis. The patient may be aware of this only on heavy exertions or have much more limited exercise tolerance. Dyspnoea can be graded from I to IV based on the New York Heart Association classification: Class I disease present but no dyspnoea or dyspnoea only on heavy exertion Class II - dyspnoea on moderate exertion Class III dyspnoea on minimal exertion Class IV dyspnoea at rest

It is more useful, however, to determine the amount of exertion that actually causes dyspnoea, i.e. the distance walked, or the number of steps climbed. The association of dyspnoea with wheeze suggests airways disease, which may be due to asthma or chronic airflow limitation. The duration and variability of the dyspnoea are important. Dyspnoea that worsens progressively over a period of weeks, months or years may be due to pulmonary fibrosis. Dyspnoea of more rapid onset may be due to an acute respiratory infection (including bronchopneumonia or lobar pneumonia) or to pneumonitis (which may be infective or secondary to a hypersensitivity reaction). Dyspnoea that varies from day to day or even from hour to hour suggests a diagnosis of asthma. Dyspnoea of very rapid onset associated with sharp chest pain suggest a pneumothorax. Dyspnoea, described by the patient as inability to take a breath big enough to fill the lungs and associated with sighing, suggests anxiety. Dyspnoea on moderate exertion may be due to the combination of obesity and a lack of physical fitness (a not uncommon combination)

WHEEZE A number of conditions can cause continuous whistling noise during breathing. These include asthma or chronic airflow limitation, and airways obstruction by a foreign body or tumour. Wheeze is usually maximal during expiration and is accompanied by prolonged expiration. CHEST PAIN Chest pain due to respiratory disease is usually different from that associated with myocardial ischaemia. The pleura and central airways have pain fibres and may be the source of respiratory pain. Pleural pain is characteristically pleuritic in nature, i.e. sharp and made worse by deep inspiration and coughing. It is typically localized to one area of the chest. It may be of sudden onset in patients with lobar pneumonia, pulmonary infraction or pneumothorax and is often associated with dyspnoea. OTHER PRESENTING SYMPTOMS Patients may occasionally with episodes of fever at night. Tuberculosis, pneumonia and mesothelioma ahould always be considered in these cases. Occasionally patients with tuberculosis present with episodes of drenching sweating at night. Hoarseness may sometimes be considered a respiratory system symptom. It can be due to transient inflammation of the vocal cords (laryngitis), vocal cord tumour or recurrent laryngeal nerve palsy Sleep apnoea is an abnormal increase in the periodic cessation of breathing during sleep. Patients with obsructive sleep abnoea (where airflow stops during sleep for periods of at least 10 seconds and sometimes for over 2 minutes, despite persistent respiratory efforts) typically present with daytime somnolence, chronic fatigue, morning headaches and personality disturbances. Very loud snoring may be reported by anyone within earshot. These patients are often obese and hypertensive. Patients with central sleep apnoea (where there is cessation of inspiratory muscle activity) may also present with somnolence but do not snore excessively. Some patients respond to anxiety by increasing the rate and depth of their breathing. This is called hyperventilation. The result is an increase in CO2 excretion and the development of alkalosis - a rise in the pH of the blood. These patients may complain of variable dyspnoea; they have more difficulty breathing in

than out. The alkalosis results in paraesthesiae of the fingers and around the mouth, lightheadedness, chest pain and a feeling of impending collapse. Treatment It is important to find out what drugs the patient is using, how often they are taken and whether they are inhaled or swallowed. The patients previous and current medications may give a clue to the current diagnosis. Bronchodilators and inhaled steroids are prescribed for chronic airflow limitation, asthma and bronchiectasis. Chronic respiratory disease including sarcoidosis, hypersensitivity pneumonias and asthma may have been treated with oral steroids. Oral steroid use may predispose to tuberculosis. Patients with chronic lung conditions like cystic fibrosis or bronchiectasis will often be very knowledgeable about their treatment and can describe the various forms of physiotherapy that are essential for keeping their airways clear. Almost every class of drug can produce lung toxicity. Examples include pulmonary embolism from use of the oral contraceptive pill, interstitial lung disease from cytotoxic agents (e.g. methotrexate, cyclophosphamide, bleomycin), bronchospasm from beta-blockers or non-steroidal anti-inflammatory drugs and cough from ACE inhibitors. Some medications known to cause lung disease may not be mentioned by the patient because they are illegal (e.g.cocaine), are used sporadically (e.g. taken orally (e.g timolol eye drops). The clinician therefore needs to ask about these types of drug specifically. Past history One should always ask about previous respiratory illness including pneumonia, tuberculosis or chronic bronchitis , or abnormalities of the chest X-ray which have been previously reported to the patient. Patients with the acquired immunodeficiency syndrome (AIDS) have a high risk of developing Pneumocystis carinii pneumonia and indeed other chest infections including tuberculosis. The commonest pathogens in these patients are still S.pneumoniae and H. Influenzae. Occupational history In no system are the patients present and previous occupations of more importance. A detailed occupational history is essential. One must ask about exposure to dusts in mining industries and factories

(e.g. asbestos, coal, silica, iron oxide, tin oxide, cotton, beryllium, titanium oxide, silver, nitrogen, dioxide, anhydrides). Working or household exposure to animals, including birds, is also relevant (e.g. Q fever or psittacosis). Exposure to mouldy hay, humidifiers or air conditioners may also result in lung disease (e.g. allergic alveolitis). The patient may be unaware that his or her occupation involved exposure to dangerous substances; for example, factories making insulating cables and boards very often used asbestos until 20 years ago. Asbestos exposure can result in the development of asbestosis, mesothelioma or carcinoma of the lung up to 30 years later. Relatives of people working with asbestos may be exposed when handing work clothes. It is most important to find out the patient actually does when at work, the duration of any exposure, use of protective devices and whether other workers have become ill. An improvement in symptoms over the weekend is a valuable clue to the presence of occupational lung disease, particularly occupational asthma. This can occur as a result of exposure to spray paints or plastic or soldering fumes. Social history A smoking history should be routine, as it is the major cause of chronic airflow limitation and lung cancer. It is also increases the risk of spontaneous pneumothorax and of Goodpastures syndrome. It is necessary to ask how many packers of cigarettes a day a patient has smoked and how many years the patients has smoked. An estimate should be made of the number of packet years of smoking. Remember that this is based on 20-cigarette packets and that packets of cigarettes are getting larger; curiously, most manufacturers now make packets of 30 or 35. More recenthly, giant packets of 50 have appeared. These are too large to fit into pockets and must be carried in the hands as a constant reminder to the patient of his or her addiction. Occupation may further affect cigarette smokers; for example, asbestos workers who smoke are at an especially high risk of lung cancer. Passive smoking is now regarded as a significant risk, and exposure to other peoples cigarette smoke at home and at work should be asked about. Many respiratory conditions are chronic and may interfere with the ability to work. Housing conditions may be inappropriate for a person with a limited exercise tolerance or an infectious disease. An inquiry about the patients alcohol consumption is important. The drinking of large amounts of alcohol in binges can sometimes result in aspiration pneumonia, and alcoholics are more likely to develop

pneumococcal or Klebsiella pneumonia. Such information may influence the decision about whether to advise treatment at home or in hospital. Family history A family history of asthma, cystic fibrosis or emphysema should be sought. Alpha 1 antitrypsin deficiency, for example, is an inherited disease, and carries are extremely susceptible to the development of emphysema. A Family history or infection with tuberculosis is also important. THE RESPIRATORY EXAMINATION The Trachea The position of the trachea is most important, and time should be spent establishing it accurately. Form in front of the patient the forefinger of the right hands is pushed up and backwards from the suprasternal notch until the trachea is felt. If the trachea is displaced to one side its edge rather than is middle will be felt and a larger space will be present on one side than the other. Slight displacement to the right is fairly common in normal people. This examination is uncomfortable for the patient, so one must be gentle. Significant displacement of the trachea suggests, but is not specific for, disease of the upper lobes of the lung. Tracheal tug is demonstrated when the finger resting on the trachea feels it move inferiorly with each inspiration. This is a sign of gross overexpansion of the chest because of airflow obstruction. If the patient appears dyspnoeic and use of the accessory muscles of respiration is suspected, the examiners fingers should be placed in the supraclavicular fossae. When the scalene muscles are recruited they can be felt to contract under the fingers. Even more severe dyspnoea will result in use of the sternomastoid muscles. Their contraction is also easily felt with inspiration. Use of these muscles for long periods is exhausting and a sign if impending respiratory failure. The Chest The chest should be examined anteriorly and posteriorly by inspection, palpation, percussion and auscultation. Compare the right and left sides during each part of the examination.

Inspection Shape and symmetry of the chest. When the anteroposterior (AP) diameter is increased compared with the lateral diameter. The chest is described as barrel-shaped. An increase in the AP diameter indicates hyperinflation and is seen often in patients with severe asthma or emphysema. It is not always a reliable guide to the severity of the underlying lung disease. A pigeon chest (pectus carinatum) is a localised prominence (an outward bowing of the sternum and costal cartilages). It may be a manifestation of chronic childhood respiratory illness, in which case it is thought to result from repeated strong contractions of the diaphragm while the thorax is still pliable. It also occurs in rickets. A funnel chest (pectus excavatum) is a developmental defect involving is usually an aesthetic one but in severe cases lung capacity may be restricted. Harrisons* sulcus is a linear depression of the lower ribs just above the costal margins at the site of attachment of the diaphragm. It can result from severe asthma in childhood, or rickets. Kyphosis refers to an exaggerated forward curvature of the spine, while scoliosis is lateral bowing. Kyphoscoliosis may be idiopathic (80%), secondary to poliomyelitis, or associated with Marfans syndrome. Severe thoracic kyphoscoliosis may reduce the lung capacity and increase the work of breathing. Lesions of the chest wall may be obvious. Look for scars from previous thoracic operation, or from chest drains for a previous pneumothorax or pleural effusion. Thoracoplasty causes severe chest deformity: this operation was performed for tuberculosis and involved removal of a large number of ribs on one side of the chest to achieve permanent collapse of the affected lung. It is no longer performed because of the availability of effective antituberculosis chemotherapy. Radiotherapy may cause erythema and thickening of the skin over the irradiated area. There is sharp demarcation between abnormal and normal skin. There may small tattoo marks indicating the limits of the irradiated area. Signs of radiotherapy usually indicate that the patient has been treated for carcinoma of the lung, breast or, less often, for lymphoma. Subcutaneous emphysema is a crackling sensation felt on palpating the skin of the chest or neck. On inspection, there is often diffuse swelling of the chest wall and neck. It is caused by air tracking from the lungs and is usually due to a pneumothorax; less commonly it can follow rupture of the oesophagus or a pneumomediastinum (air in the mediastinal space).

Prominent veins may be seen in patients with superior vena caval obstruction. It is important to determine the direction of blood flow . Movement of the chest wall should be noted. Look for asymmetry of chest wall movement anteriorly and posteriorly. Assesment of expansion of the upper lobes is best achieved by inspection from behind the patients, looking down at the clavicles during moderate respiration. Diminished movement indicates underlying lung disease. The affected side will show delayed or decreased movement. For assessment of lower lobe expansion, the chest should be inspected posteriorly. Reduced chest wall movement on one side may be due to localized pulmonary fibrosis, consolidation, collapse, pleural effusion or pneumothorax. Bilateral reduction of chest wall movement indicates a diffuse abnormality such as chronic airflow limitation or diffuse pulmonary fibrosis. Look for paradoxical inward motion of the abdomen during inspiration when the patient is supine (indicating diaphragmatic paralysis). Palpation Chest expansion. Place the hands firmly on the chest wall with the fingers extending around the sides of the chest. The thumbs should almost meet in the middle line and should be lifted slightly off the chest so that they are free to move with respiration. As the patient takes a big breath in, the thumbs should move symmetrically apart at least 5cm. Reduced expansion on one side indicates a lesion on that side. The causes have been discussed above. Lower lobe expansion is assessed from the back in this way. Some idea of upper and middle lobe expansion is possible when the manoeuvre is repeated on the front of the chest, but this is better gauged by inspection. Apex beat, When the patient is lying down, establishing the position of the apex beat may be helpful, as displacement towards the side of the lesion can be caused by collapse of the lower lobe or by localized pulmonary fibrosis. Movement of the apex beat away from the side of the lung lesion can be caused by pleural effusion or tension pneumothorax. The apex beat is often impalpable in a chest which is hyperexpanded secondary to chronic airflow limitation.

Vocal fremitus.. Palpate the chest wall with the palm of the hand while the patient repeats ninety-nine. The front and back of the chest are each palpated in two comparable positions with the palm of one hand on each side of the chest. In this way differences in vibration on the chest wall can be detected. This can be a difficult sign to interpret. It depends on the recognition of changes in vibration conducted to the examiners hands while the patient speaks. Practice is needed to appreciate the difference between normal and abnormal but comparing one side with the other is often helpful. The causes of change in vocal fremitus are the same as those for vocal resonance. Ribs. Gently compress the chest wall anteroposteriorly and laterally. Localized pain suggest a rib facture, which may be secondary to trauma, or may be spontaneous as a result of tumour deposition, bone disease or sometimes the result of severe and prolonged coughing. Percussion With the left hand on the chest wall and the fingers slightly separated and aligned with the ribs, the middle finger is pressed firmly against the chest. Then the pad of the right middle finger is used to strike firmly the middle phalanx of the middle finger of the left hand. The percussing finger is quickly removed so that the note generated is not dampened. The percussing finger must be held partly flexed and a loose swinging movement should come from the wrist and not from the forearm. Medical students will soon learn to keep the right middle fingernail short. Percussion of symmetrical areas of the anterior, posterior and axilarry regions is necessary. Percussion in the supraclavicular fossa over the apex of the lung should not be forgotten. Percuss the clavicle directly with the percussing finger. On percussion posteriorly the scapulae should be moved out of the way by asking the patient to move the elbows forward across the front of the chest; this rotates the scapulae anteriorly. The feel of the percussion note is as important as its sound. The note is affected by the thickness of the chest wall, as well as by underlying structures. Percussion over a solid structure, such as the liver or a consolidated area of lung, produces a dull note. Percussion over a fluid-filled area, such as a plaural effusion, produces an extremely dull (stony dull) note. Percussion over the normal lung produces a resonant note and percussion over hollow structures, such as the bowel a pneumothorax, produces a hyperresonant note.

Considerable practice is required before expert percussion can be performed, particularly in front of an audience. The ability to percuss well is usually obvious in clinical examination and counts in a students favour, as it indicates a reasonable amount of experience in the wards. Liver dullness. The upper level of liver dullness is determined by percussing down the anterior chest in the mid-clavicular line. Normally, the upper level of the liver dullness is the fifth rib in the right mid-clavicular line. If the chest is resonant below this level it is a sign of hyperinflation, usually due to emphysema or asthma. Auscultation Breath sounds. Using the diaghragm of the stethoscope one should listen to the breath sound in the some areas. It is important to compare each side with the other. Remember to listen high up into the axillae and, using the bell of the stethoscope applied above the clavicles, to listen to the lung apices. A number of observations must be made while auscultating and, as with auscultation of the heart different parts of the cycle must be considered. Listen for the quality of the breath sounds; the intensity of the breath sounds; and the presence of additional (adventitiour) sounds. Quality of breath sounds: normal breath sound are heard with the stethoscope over all parts of the chest. The patients should be asked to breathe through the mouth so that added sounds from the nasopharynx do not interfere. These sounds are produced in the airways rather than the alveoli. They had once been thought to arise in the alveoli (vesicles) of the lungs and are therefore called vesicular sounds. They have rather fancifully been a compared to the sound of wind rustling in leaves. Their intensity is related to total airflow at the mouth and to regional airflow. Normal (vesicular) breath sounds are louder and longer on inspiration than on expiration and there is no gap between the inspiratory and expiratory sounds. They are due to the transmission of air turbulence in the large airways filtered through the normal lung to the chest wall. Bronchial breath sounds here turbulence in the large airways is heard without being filtered by the alveoli, producing a different quality. Bronchial breath sounds have a hollow, blowing quality. They are audible throughout expiration and there is often a gap between inspiration and expiration. The expiratory sound has a higher intensity and pitch than the inspiratory sound. Bronchial breath sounds are more easily

remembered than described. They are heard over areas of consolidation, as solid lung conducts the sound of turbulence in main shown in . Occasionally breath sounds over a large cavity have an exaggerated bronchial quality. They very hollow or amphoric sound has been likened to that heard when air passes over the top of a hollow jar (Greek amphoreus). Intensity of the breath sounds : it is better to describe breath sounds as being of normal or reduced intensity than to speak about air entry. The entry of air into paints of the lung cannot be directly gauged from the breath sounds. Causes of reduced breath sounds include chronic airflow limitation (especially emphysema), pleural effusion, pneumothorax, pneumonia, a lrge neoplasm, and pulmonary collapse. Added (adventitious) sounds: there are two types of added sounds: continous (wheezes) and interrupted (crackles) Continous sounds are called wheezes. They are abnormal findings and have a musical quality. The wheezes must be timed in relation to the repiratory cycle. They may be heard in expiration or inspiration or both. Wheezes are due to continous oscilation of opposing airway walls and imply significant airway narrowing. Wheezes tend to be louder on expiration. This is because the airways normally dilate during inspiration and are narrower during expiration. An inspiratory wheeze implies severe airway narrowing. The pitch (frequency) of wheezes varies. It is determined only by the velocity of the air jet and is not related to the length of the airway. High pitched wheezes are produced in the smaller bronchial and have a whistling quality, whereas low pitched wheezes arise from the larger bronchi. Wheezes are usualy the result of acute or chronic airflow obstruction due to asthma (often high pitched) or chronic airflow limitation (often low pitched). Here a combination of bronchial muscle spasm, mucosal oedema and excessive secretions results in airflow limitation. Wheezes are a poor guide to the severity of airflow obstruction. In severe airways obstruction wheeze can be absent because ventilation is so reduced that the velocity of the air jet is reduced below a critical level necessary to produce the sound. A fixed bronchial obstruction, usually due to carcinoma of the lung, tends to cause a localized wheeze, which has a single musical note (monophonic) and does not clear with coughing. Interrupted non-musical sounds are best called crackles. There is a lot of confusion about the naming of these sounds, perhaps as a result of mistranslation of lannec. Some authors describe low

pitched crackles as rales and high pitched ones as crepitations, but others do not make this distinction. The simplest approach is to call all these sounds crackles, but also to describe their timing and pitch. Crackles are probably the result of loss of stability of peripheral airways which collapse on expiration. With high inspiratory pressures, there is rapid air entry into the distal airways. This causes the abrupt opening of alveoli and of small-or medium-sized bronchi containing secretions in regions of the lung deflated to residual volume. More compliant (distensible) areas open up first followed by the increasingly stiff areas. Fine and medium pitched crackles are not caused by air moving through secretions as was once thought but by the opening and closing of small airways. Late or pan-inspiratory crackles suggest disease confined to the alveoli. They may be fine, medium or coarse in quality. Fine crackles have been likened to the sound of hair rubbed between the fingers or to the sound Velero makes when being unstrapped they are typically caused by pulmonary fibrosis. As fibrosis becomes more severe the crackles extend earlier into inspiration and are heard further up the chest. Medium crackles are usually due to left ventricular failure. Here the presence of alveolar fluid disrupts the function of the normally secreted surfactant. Course crackles are characteristic of pools of retained secretion and have an unpleasant gurgling quality. They tend to change with coughing, Which also has an unpleasant gurgling quality. Bronchiectasis is a common cause, but any disease that leads to retention of secretions may produce these features. Pleural friction rub: when thickened, roughened pleural surfaces rub together as the lungs expand and contract, and a continous or intermitten grating sound may be audible. A pleural rub indicates pleurisy, which may be secondary to pulmonary infarction or pneumonia. Rately, malignant involvement of the pleura, a spontaneous pneumothorax or pleurodynia may cause a rub. Vocal resonance. Auscultation over the chest while a patient speaks gives further information about the lungs ability to transmit sounds. Over normal lung the low pitched components of speech are heard with a booming quality and high pitched components are attenuated. Consolidation lung, however, tends to transmit high frequencies so that specch heard throught the stethoscope takes on bleathing quality (called aegophony Greek alx goat, phone voice). When a patient with aegophony says e as in been it sounds like a as in bay. Ask the patient to say ninety-nine while you listen over each part of the chest. Over consolidated lung the numbers will become clearly audible, while over normal lung the sound is muffled. If vocal

resonance is present, bronchial breathing is likely to be heard. Sometimes vocal resonance is increased to such an extent that whispered speech is distinctly heard: this is called whispering pectoriloquy. If a very localized abnormality is found at auscultation, try to determine the lobe and approximately which segment or segments are involved.

History Taking (Respirasi) I. No 1. 2. 3. 4. 5. 6. 7. CHECK LIST Jenis kegiatan Menyapa pasien dan mempersilahkannya duduk dengan pengaturan yang nyaman Memperkenalkan diri kepada pasien Menanyakan kembali identitas pasien: nama, usia, tempat tinggal, pekerjaan, status keluarga Menjelaskan tujuan wawancara Menanyakan keluhan utama pasien Menggali keluhan riwayat penyakit saat ini (History of present illness) : cough, sputum production ( amount, colour, frequency, hemoptysis), chest pain, wheezing / stridor, dyspnea, hoarseness. Mengidentifikasi keluhan secara lengkap dengan menanyakan tentang: Onset ( saat ) Aggravating/Alleviating factors Location ( tempat ) Radiation Duration ( lama berlangsung ) Timing Character ( sifat ) Mengidentifikasi permasalahan kesehatan masa lalu (Past History) Permasalahan medis kronis, Penyakit sewaktu masa kecil infeksi paru Riwayat ginekologis Pernah mondok di RS Pemeriksaan kesehatan rutin (prolonged hospital stay) Riwayat pembedahan Riwayat trauma Mengidentifikasi pemakaian obat-obatan Nama obat Frekuensi Tujuan Efek samping Apakah memakai resep dokter? Dosis Rute pemberian Mengidentifikasi penyakit yang diderita oleh keluarga pasien ( asthma, kanker, penyakit di usia muda, tuberkulosis paru) Mengidentifikasi kehidupan pribadi dan sosial pasien: Status pernikahan Kebiasaan merokok, jumlah batang per hari, lama kebiasaan Pekerjaan (debu, asbestos, smoke) Binatang peliharaan Akomodasi Faktor resiko HIV-AIDS ( IDU, tatto, free sex) 0 Nilai 1 2

8.

9.

10.

11.

Menanyakan beberapa keluhan sistematik yang mungkin dirasakan pasien: Sistem saraf pusat: pusing, Sistem genito-urinari: sulit visus, vertigo, tinitus, ... miksi, hematuri, nyeri sewaktu menstruasi, disfungsi ereksi. Kardiovaskular-respirasi: sesak nafas, pembengkakan tungkai, Sistem lokomotor: nyeri dan 12. palpitasi, nyeri dada,.. kaku sendi, ... Sistem pencernakan: nafsu makan, mual, muntah, penurunan berat badan, nyeri abdomen,.... 13. Merangkum hasil wawancara 14. Memberi kesempatan kepada pasien untuk mengungkapkan apa yang belum jelas 15. Menutup pertemuan Jumlah nilai Keterangan: 0 1 2 = tidak dikerjakan = dikerjakan tetapi kurang sesuai/benar = dikerjakan dengan benar Jumlah nilai Nilai akhir = -------------------------- x 100 = 30 Catatan: Mahasiswa/peserta dinyatakan LULUS apabila nilai akhir mencapai 80

PEMERIKSAAN THORAX
II. DESKRIPSI MODUL Latar Belakang Pemeriksaan fisik merupakan salah satu bagian yang sangat penting dalam menegakkan diagnosis. Diperkirakan > 70% diagnosis dapat ditegakkan dari anamnesis yang baik. Dengan anamnesis yang baik ditambah dengan pemeriksaan fisik yang baik pula, maka akan dapat ditegakkan diagnosis yang lebih akurat lagi. Seorang dokter seharusnya sudah mempunyai data pendahuluan dari pasien sebelum melakukan pemeriksaan fisik melalui anamnesa yang telah dilakukan sebelumnya, melihat data cataan medik yang sudah ada sebelumnya. Selama pemeriksaan hendaknya dokter pemeriksa berkomunikasi dengan pasien agar merasa lebih nyaman sehingga diperoleh hasil pemeriksaan yang tepat dan efisien. Tujuan Pembelajaran Setelah selesai mengikuti pelatihan, peserta mampu melakukan : 1. Inspeksi dada saat istirahat (statis) 2. Inspeksi saat respirasi (dinamis) 3. Palpasi ekspansi pernafasan 4. Palpasi tactile fremitus 5. Palpasi apex jantung 6. Perkusi paru 7. Auskultasi paru Metoda Pembelajaran - Kuliah singkat - Video session - Demonstrasi dengan model anatomik - Berlatih mandiri dengan sesama teman Alat Bantu - Model anatomik (manekin) 2 buah lengkap alat pemeriksaan

- Stetoskop 5 buah - Audio visual 1 set - Kapas alkohol 10 sachet Waktu Daftar Instruktur 4 X 50 menit - dr. Yani Jane Sugiri SpP - dr. Susanthy Dj, SpP - dr. Putu P. Putra, SpP - dr Triwahju Astuti, SpP - dr. Suryanti Dwi Pratiwi, SpP - dr. Iin Noor Chozin, SpP Evaluasi Referensi Check list 1. Talley N J, OConnor S, 2003. Clinical Examination, A Systemic Guide To Physical Diagnosis, 4th Edition. APAC Publishers Singapore 2. Berg D; Worzala K, 2006. Atlas of Adult Physical Diagnosis. Lippincott Williams & Wilkins 3. Delp MH; Manning RT, 1981. Majors Physical Diagnosis An Introduction to the Clinical Process. 9th Edition. WB. Saunders Company. Philadelphia. 4. Burnside JW, 1981. Physical Diagnosis 16th Edition. William & Wilkins Baltimore / London. 5. Handono Kalim, 1996. Pedoman Diagnostik Fisik Ilmu Penyakit Dalam. Laboratorium Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Brawijaya Malang.

III. PROSEDUR PEMERIKSAAN RESPIRASI

Posisi

Pasien

& Have the patient undress to the waist, ideally sitting on the edge of the bed. Wash your hands and cleanse your stethoscope with alcohol wipe. (a) Chest wall deformities: Are there any chest wall deformities? (e.g. pectus excavatum / pectus carinatum) Does the chest appear over expanded? (i.e. Barrel shaped chest ) Is there any Kyphosis present? Scoliosis?

Persiapan Pencegahan infeksi Inspeksi

Pectus excavatus (b) Scars: Is there any evidence of scars from previous surgery? (c) Respiratory rate: Consider this opportunity to measure the patients respiratory rate. Often when you tell a patient that you are measuring their respiratory rate they often tend to breath slower or faster. Therefore respiratory rate is often measured surreptitiously by observing the respiratory movements of the chest wall, while placing you fingers over the patient's radial pulse and telling them that you are Taking their pulse where as in fact you are measuring their respiratory rate! The normal respiratory rate in an adult is 12 breaths per minute. A raised respiratory rate is called tachypnoea Palpasi (a) Apex beat : Feel for the patients apex beat. The apex beat is often impalpable in a chest which is hyper-expanded secondary to chronic airflow obstruction. Movement of the apex beat from one side to the other may be caused by several

conditions including pleural effusion, tension pneumothorax

(b) Chest expansion : By assessing chest expansion the examiner aims to assess the range and symmetry of chest wall movements. Place your hands firmly on the chest wall, with your thumbs slightly lifted off the chest so that they are free to move with respiration (placing your thumbs up provides the examiner with a visible marker to assess the range and symmetry of chest wall movements). Ask the patient to take a deep breath in and observer the range and symmetry of movement. Reduced expansion on one side indicates a lesion on that side. This should be performed on the front and the back of the patients chest.

Assessment of anterior and posterior chest wall expansion

Perkusi

(a) Place you hand on the patients chest wall with the fingers slightly separated and aligned with the ribs and pressing the middle finger firmly again the chest.

(b) With the other hand (usually the middle finger) strike firmly the middle phalanx of the middle finger that is on the patients chest wall.

(c) The percussing finger is removed quickly therefore not to dampen the generated noise. The percussing finger should be held partly flexed and a loose swinging motion should come form the wrist

Auskultasi

(a) Breath sounds : Normal breath sounds are called vesicular. The intensity of the sounds increase during inspiration and then fade away during the first third of expiration. Bronchial breath sounds, heard in inspiration and expiration, result from enhanced transmission of higher frequency sounds through solid lung tissue as in consolidation or fibrosis. (b) Intensity of the breath sounds : Usually described as being normal, reduced or absent. It is important to compare air entry in all areas of the chest. For example breath sounds may be absent locally over a pneumothorax or a pleural effusion.

(c) Added sounds : Wheeze, rhonchi, crepitations (crackles), pleural rub Penutup Pencatatan

IV. CHECK LIST Nama NIM Kelompok Tanggal : : : : Penilaian 0 1 2

JENIS KEGIATAN PEMERIKSAAN RESPIRASI Inspeksi 1. 2. 3. 4. 5. 6. 7. Menempatkan pasien dlm posisi duduk ditepi tempat tidur pemeriksaan Mengamati dan melaporkan abnormalitas yang ditemukan Melihat adakah simetri/asimetri dan melaporkan abnormalitas yang ditemukan Memeriksa ekspansi dada muka dan belakang dan melaporkan hasilnya Memeriksa stem fremitus dan melaporkan hasilnya Melakukan perkusi dada bagian depan pada tempat yang telah ditentukan dan melaporkan hasilnya Melakukan perkusi dada bagian belakang pada tempat yang telah ditentukan dan melaporkan hasilnya Auskultasi 8. 9. 10. Memeriksa suara nafas dan melaporkan hasilnya Memeriksa ada tidaknya perubahan intensitas suara nafas dan melaporkan hasilnya Memeriksa ada tidaknya suara nafas tambahan (ronchi, wheezing, dll) dan melaporkan hasilnya

Palpasi

Perkusi

Tutor,

Keterangan:

0 1 2

= tidak dikerjakan = dikerjakan tetapi kurang sesuai/benar = dikerjakan dengan benar Jumlah nilai

Nilai akhir = -------------------------- x 100 = 20 Catatan: Mahasiswa/peserta dinyatakan LULUS apabila nilai akhir mencapai 80

MODUL SKILL ILMU KESEHATAN FISIK DAN REHABILITASI

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA LABORATORIUM ILMU KEDOKTERAN FISIK DAN REHABILITASI 2011

Chest Physical Therapy Lab. Ilmu Kedokteran Fisik dan Rehabilitasi FK Unibraw Malang /RSU Dr. Saiful Anwar Chest Physical Therapy : Yaitu penggunaan metoda fisik untuk perawatan pernafasan pada penderita dengan penyakit paru. Bila penderita berbaring terlentang, maka gerakan otot diafragma dan intercostal menurun, pernafasan menjadi lebih dangkal. Juga terjadi pengumpulan sekret di bagian bawah dan pengeluaran sekret lebih sukar karena gerakan cilia yang kurang efektif disamping posisi terlentang tersebut. Maka akan terjadi mikro atelektasis. Batuk juga lebih sukar dilakukan dalam posisi terlentang tersebut. Keadaan-keadaan tersebut diatas disertai dengan kelemahan otot abdomen menyebabkan penderita mudah terkena infeksi saluran nafas bagian atas dan pneumonia hipostatik. Itulah sebabnya penderita perlu turning setiap waktu tertentu (2 jam) untuk mencegah hal-hal tersebut di atas, juga mencegah komplikasi lain seperti : dekubitus, tromboplebitis dll. Tujuan : o meningkatkan efisiensi ventilasi o meningkatkan toleransi latihan Chest Physical Therapy t.a. : 1. 2. 3. 4. 5. Teknik Relaksasi Breathing Control Breathing Exercise Postural Drainage Teknik Manual

Teknik Manual : a. Perkusi b. Shaking c. Vibrasi Indikasi Chest P.T. : 1. 2. 3. 4. 5. PPOM : asma, bronkhitis khronis, emfisema Post OP. thoraks, sistem kardiovaskular Berbaring lama Penyakit neuromuskular dengan refleks batuk menurun Yang tergantung alat ventilasi Penderita Post Operasi : perlu diberikan latihan sebelum operasi, karena bila setelah operasi maka penderita sulit kooperatif karena rasa nyeri disamping pengaruh analgesik. Teknik Relaksasi : Tujuan : 1. me < tegangan otot-otot pernafasan tambahan 2. me < kecemasan karena dyspnea 3. merangsang sense of well being

Terdiri dari : 1. Posisi optimal untuk latihan pernafasan diafragma : Semifowler Miring

2. gentle repetitive movements : dengan peregangan manual, pasif, gentle dan shaking technique oleh terapis pada leher, bahu dan lengan sehingga mengurangi tegangan. II. Breathing Control (gentle breathing) : Yaitu pernafasan : Manfaat : 1. Mengurangi kerja pernafasan 2. Mengurangi sesak nafas 3. Membantu pernafasan ke pola normal 4. Perbaiki ventilasi bagian basal paru Cara : Posisi : duduk / miring Dinding abdomen relaks, lutut sedikit fleksi Tangan pada bagian ant.costal margin Bernafas tenang lewat hidung Bahu dan dada atas relaks Gerakkan iga-iga bawah ke bawah dan medial Merasakan gerakan dada bagian bawah Memakai bagian bawah dada Membutuhkan sedikit tenaga Mengurangi sesak nafas

Otot-otot yang dipakai : intercostal, scalenus, diafragma dan abdomen.

Penting :bernafas dengan usaha minimal dan lewat hidung.

Hindari : 1. forced expiration karena ekspirasi harus pasif 2. Ekspirasi yang memanjang yang menyebabkan pola nafas tak teratur dan tak efisien 3. Gerakan otot-otot abdomen yang akan mengganggu pernafasan 4. Gerakan dada bagian atas dan otot-otot pernafasan yang bekerja berlebihan III. Breathing Exercise : Penderita aktif pada waktu fase inspirasi dan ekspirasi sesuai kebutuhan. Tujuan : Mencapai fungsi paru yang optimal Manfaat : 1. Melepaskan perlekatan sekret bronkhus 2. Membantu pengeluaran sekret 3. Membantu pengembangan jar.paru (re-expansion) 4. Mobilisasi dinding thoraks 5. Perbaiki hubungan ventilasi-perfusi 6. Melatih otot-otot pernafasan 7. Melatih mengatasi dyspnea

Macam-macamnya : 1. Thoracic Expansion Exercises : a. Unilateral Lower Thoracic Expansion b. Bilateral Lower Thoracic Expansion c. Apical Thoracic Expansion d. Posterior Lower Expansion 2. The Forced Expiration Technique 1. Thoracic Expansion Exercises Merupakan latihan inspirasi untuk memperbaiki gerakan dinding dada. Dengan inspirasi, volume paru meningkat, aliran udara masuk melalui saluran ventilasi kolateral meningkat dan membantu melepaskan perlekatan sekret ketika melalui bronkhus yang mengandung sekret. Juga alveoli yang kolaps akan berkembang. Waktu inspirasi penuh, tahan 3 detik, dan ini merupakan metoda efektif untuk mengurangi terjadinya atelektasis. Metoda ini menggunakan gerakan dinding dada pada daerah tertentu. a. Unilateral Lower Thoracic Expansion - Penderita duduk / setengah duduk - Taruh telapak tangan (ipsilateral / kontralateral) pada garis mid axiliar iga ke 7, 8, 9 - Penderita relaks, bernafas sambil merasakan iga bawah bergerak ke bawah dan dalam - Pada akhir espirasi, tangan menekan untuk memberi rangsangan proprioseptif - Pada inspirasi penuh, ditahan 2-3 detik, lalu lepaskan tekanan tangan - Waktu menaruh telapak tangan, jangan angkat bahu - Inspirasi : aktif, ekspirasi : pasif

b. Bilateral Lower Thoracic Expansion - Posisi seperti di atas - Tekanan pada kedua sisi garis mid axiliar bagian bawah dada dengan telapak tangan / punggung tangan - Teknik bernafas seperti di atas - Tak dipakai untuk dada bagian atas karena sulit untuk relaksasi sendi bahu adekuat - Dilakukan terutama setelah operasi c. Apical Thoracic Expansion - Berguna bila ada gerakan terbatas dinding dada bagian atas, misal : gross pleural effusion pengembangan tak sempurna jaringan paru, terutama apical pneumothoraks, misal setelah lobektomi - Tekanan dengan ujung jari-jari di sebelah bawah clavicula - Tarik nafas, kembangkan dada ke depan dan ke atas melawan tekanan tersebut - Bahu harus relaks - Pengembangan dinding dada ditahan selama 2-3 detik - Bila latihan ini sulit, disarankan tahan nafas sebentar pada saat inspirasi penuh, lalu mendengus 2-3 kali sebelum ekspirasi

d. Posterior Lower Expansion - Duduk bersandar ke depan, punggung lurus - Tekanan oleh fisioterapis atau sendiri pada bagian posterior unilatral bagian bawah iga - Bisa memakai belt selebar 5-7 cm, panjang 2 m, penderita duduk di kursi karena lebih efektif - Belt diletakkan setinggi ziphisternum, dipegang oleh tangan kontra lateral lalu dililitkan ke dinding dada - 1 ujung dipegang tangan kontra lateral setinggi ziphisternum, sisi lain dilibatkan ke paha dan ujungnya dipegang dengan tangan kontra lateral. 2. The Forced Expiration Technique Yaitu cara untuk membantu membuang / mengeluarkan sekresi bronkhus yang berlebihan dari jalan nafas yanpa menyebabkan spasme bronkhus. Terdiri atas 1 atau 2 forced expiration, diikuti periode relaksasi dan breaking control. Bila sekret mencapai saluran nafas yang besar, dibuang dengan dibatukkan dengan high lung volume. Periode breaking control perlu mencegah terjadinya bronkhospasme. Dengan teknik ini terjadi kompresi dan pengecilan jalan nafas pada daerah tertentu. Misal : pada high lung volume, daerah tersebut terletak pada trakhea dan bronkhus utama. Bila volume paru menurun, daerah tersebut akan turun ke distal dan diikuti gerakan bergetar dari daerah bronkhus. Pada penderita dengan obstruksi jalan nafas, penyempitan lebih jelas dan tersebar tak merata. Supaya batuk, perlu usaha expirasi yang besar dengan cara menutup glottis sehingga tekanan intra thoracic meningkat, lalu dibuka tiba-tiba, terjadi perbedaan tekanan yang besar antara tekanan alveolar dan tekanan trakheal atas. Tekanan intra thoracic meningkat, menekan membran posterior trakhea dan mengecilkan sampai 1/6 nya. Dengan aliran cepat dan penyempitan tersebut maka mukus dan pertikel-pertikel asing terdorong ke trakhea dan dapat dibatukkan.

Batuk yang efektif : Tarik nafas dalam batuk sambil kontraksikan otot-otot abdomen. Kemudian diikutibreaking control. IV. Postural Drainage : Penderita diberi posisi sedemikian agar gaya gravitasi membantu drainase sekret dari daerah tertentu paru. Posisi berdasarkan anatomi bronkhial. Tujuan : Membersihkan sekret seefektif mungkin tanpa menyebabkan kelelahan Lama : 10-20 menit 1-5 x sehari Perlu partisipasi aktif disertai : 1. Thoracic Expansion Exercise : untuk membantu melepaskan sekret bronkhus 2. Breathing Control untuk mencegah hiperventilasi dan lelah 3. The Forced Expiration Technique : untuk membersihkan sekret dan mencegah kemungkinan peningkatan obstruksi saluran nafas 4. Teknik Manual Penderita dimiringkan 10o atau 15 o atau diganjal bantal. Kontra indikasi Postural Drainage : 1. Bentuk darah 2. Hipertensi berat 3. Edema Serebri 4. Aneurisma Aorta dan Serebral 5. Aritmia jantung 6. Edema paru 7. Kelainan esofagus atau diafragma (terjadi gastric reflux)

Terapi Tambahan : 1. Bronkhodilator 2. Humidifikasi 3. Obat Mukolitik 4. IPPB (Intermittent Positive Pressure Breathing) 5. PEP (Positive Expiratory Pressure) Asma akut dan emfisema berat : dispneu meningkat dengan postural drainage, jadi posisi harus dimodifikasi. Penderita osteoporosis dan deposit metastatik pada iga / tulang belakang, maka clapping / shaking harus dengan gentle. Penderita dengan penyakit paru unilateral : Pertukaran gas akan meningkat dengan posisi berbaring pada paru yang sehat, lalu diberikan perkusi dan vibrasi. Penderita dengan penyakit paru bilateral : Berbaring pada sisi kanan, mungkin karena tekanan jantung pada paru kiri atau karena volume paru kiri yang kurang, lalu diberikan perkusi dan vibrasi. Pursed Lip Breathing Yaitu mengeluarkan nafas melalui mulut yang sedikit terbuka sehingga menimbulkan obstruksi dan mengurangi kecepatan aliran udara, meningkatkan tekanan dalam mulut. Akibatya : 1. Tekanan pada trakheobronkhial meningkat, saluran nafas tetap terbuka untuk periode lebih lama pada waktu ekspirasi, mengurangi tekanan saluran nafas dan air trapping. 2. Mengurangi dispneu. 3. Sirkulasi pada capillary bed paru meningkat sehingga mencegah merembesnya serum ke dalam alveoli.

Diafragmatic Breathing Yaitu pernafasan memakai otot pernafasan utama diafragma, posisi semi fowler / side lying. 1 tangan pada bagian atas abdomen, tangan lain pada thoraks atas. Kontraksikan diafragma, mka ia akan bergerak ke bawah, abdomen menonjol dan bagian bawah dada melebar, tekanan pleura menurun dan udara masuk ke paru. Guna : 1. Untuk penderita yang bernafas dengan otot-otot nafas tambahan dan sedikit gerakan abdomen. 2. Untuk meningkatkan tidal colume dan menurunkan RR. 3. Untuk memperbaiki gas darah. Abdominal Breathing Yaitu pernafasan dengan mengontraksikan otot-otot abdomen untuk membantu ekspirasi dan memperbaiki posisi diafragma untuk inspirasi berikutnya. Pernafasan ini mengurangi kadar CO 2 . V. Teknik Manual : 1. Perkusi : Dinding dada digetarkan, maka saluran nafas akan juga bergetar sehingga mukus terlepas dan hal ini akan lebih efektif bila disertai dengan Thoracic Expansion Exercises. o Clapping : Dengan tangan dalam posisi seperti mangkuk, lalu dengan cepat ditepukkan pada dinding dada dengan gerakan fleksi-ekstensi pergelangan tangan. Kulit ditutupi pakaian / handuk supaya tidak luka. o Gentle Clapping : Merangsang batuk pada infant dan anak-anak. o Tapping : Dengan ujung jari-jari tangan (ke II / III) terutama untuk small infant.

2. Shaking : Yaitu gerakan ritmis ke bawah pada dinding dengan tekanan gentle memakai tangan terapis. Dilakukan waktu ekspirasi. Hal ini berguna untuk memperbaiki aerasi pada area khusus. 3. Vibrasi : Yaitu gerakan getaran halus pada dinding dada dengan tekanan ringan oleh tangan fisioterapis. Sangat efisien untuk membersihkan sekret dan dapat dipakai bila daerah tersebut terasa nyeri. Pada bronkhospasme berat, perlu bronkhodilator, dan bila efeknya kurang maka clapping sangat bermanfaat (60x / m). Mechanical Percussor misalnya : High Frequency Oscillator. Kontra Indikasi Teknik Manual 1. Batuk darah. 2. Nyeri pleuritik akut. 3. TBC paru aktif. Posisi Postural Drainage Upper Lobus 1. 2. Apical Bronchus : duduk tegak dengan sedikit variasi tergantung letak lesi, bisa bersandar ke depan, belakang dan samping. Posterior Bronchus : a. b. 3. Kanan : tidur pada sisi kiri horizontal, kemudian berputar 45 o ke arah wajah, istirahat pada bantal dan kepala diganjal. Kiri : tidur pada sisi kanan, berputar 45o ke arah wajah dengan 3 bantal mengganjal bahu (30 cm) dari kasur. Anterior Brochus : tidur terlentang dengan lutut sedikit fleksi.

Lingula 1. Superior Bronchus : tidur terlentang dengan tubuh bagian berputar ke kanan, diganjal bantal pada bagian kiri bahu sampai paha. Kaki tempat tidur ditinggikan 35 cm, dada dinaikkan sampai 15 o. 2. Inferior Bronchus : idem.

Lobus Medialis 1. Lateral Bronchus : tidur terlentang dengan tubuh bagian berputar ke kiri, diganjal bantal pada bagian kanan bahu sampai paha. Kaki tempat tidur ditinggikan 35 cm, dada dinaikkan sampai 15 o. 2. Medial Bronchus : idem.

Lower Lobe 1. 2. 3. Apical Bronchus : tidur tengkurap dengan bantal dibawah perut. Medial Basal Bronchus : tidur pada bagian kanan dengan bantal pada paha, kaki tempat tidur ditinggikan 45 cm, dada dinaikkan 20 o. Anterior Basal Bronchus : tidur terlentang dengan pantat diganjal bantal dan lutut fleksi, kaki tempat tidur ditinggikan 45 cm, dada dinaikkan 20 o.

4. 5.

Lateral Basal Bronchus : tidur pada sisi berlawanan dengan bantal dibawah paha, kaki tempat tidur ditinggikan 45 cm, dada dinaikkan 20 o. Posterior Basal Bronchus : tidur tengkurap dengan bantal dibawah paha, kaki tempat tidur ditinggikan 45 cm, dada dinaikkan 20 o.

BATUK Batuk yang efektif diperlukan untuk menghilangkan obstruksi saluran pernapasan dan memelihara paruparu tetap bersih. Batuk merupakan bagian penting pada pengobatan pasien pada kondisi penyakit paru akut maupun kronis. Mekanisme terjadinya batuk : 1. Terjadi inspirasi dalam 2. Glottis menutup dan corda vocalis mengeras 3. Otot-otot abdomen kontraksi dan diaphragma elevasi sehingga tekanan intrathoracal dan abdominal meningkat 4. Glottis membuka 5. Terjadi letupan udara expirasi Daftar Kepustakaan 1. Haas F, Axen K : Pulmonary Therapy and Rehabilitation : In Principles and Practice, Baltimore, Williams & Wilkins Co, 1979, p. 123 134. 2. Helmholz HF, Stonmington HH : Rehabilitation for Respiratory Dysfunction : In Kotte FJ, Lehmann JF : Krusens Handbook of Physical Medicine and Rehabilitation, 4 Ed, Philadelphia, WB Sauders, 1990, p. 858 873. 3. Rondinelli RD, Hill NS : Rehabilitation of the Patient with Pulmonary Disease, In Delisa : Rehabilitation Medicine, Principles and Pratice , Philadelphia, JB Lippincott, 1988, p. 696 -697. 4. Webber BA : The Brompton Hospital Guide to Chest Physiotherapy, Oxford, Blackwell Scientific Publication, 1988, p. 15 -36.

K E T R A M P I L A N MELAKUKAN CHEST PHYSICAL THERAPY

Nama NIM Kelompok Tanggal

: ____________________________________________ : ____________________________________________ : ____________________________________________ : ____________________________________________ Kesempata

NO PERSIAPAN 1 2 3 1 2 3 4 Mencuci tangan

DAFTAR KETRAMPILAN 1**

n 2 3

Pemeriksa memperkenalkan diri dan menjelaskan tentang tujuan pemeriksaan Menempatkan diri di sebelah didepan pasien ( PURSED LIP ) BREATHING EXERCISE Posisi pasien semifowler, comfortable, relax menghadap kedepan / tidur terlentang Menginstruksikan pasien untuk tarik napas dalam ( inspirasi ) melalui hidung dan mulut tertutup, gerakan dada kedepan dan terangkat keatas. Kemudian mengistruksikan pasien megeluarkan udara pelan pelan melalui mulut dengan bibir mencucu dalam waktu 2 kali waktu inspirasi Mengulang point 6 dan 7 minimal 10 kali POSTURAL DRAINAGE Posisikan pasien sesuai dengan area sputum yang paling banyak diatas

Lakukan teknik manual (clapping, tapping ) pada area sputum yang paling banyak (10 15 menit ) COUGH EXERCISE

1 2

Pasien diinstruksikan napas pelan dan dalam dengan menggunakan diaphragma Pasien menahan napas 2 detik

3 4 5 6.

Lakukan batuk 2 kali dengan mulut sedikit terbuka Pause / berhenti Tarik napas pelan Istirahat

Total tindakan benar. Prosentase **** Keterangan * : Diisi dengan tanda check () jika dilakukan dengan benar dan tanda (-) jika tidak dilakukan atau dilakukan tetapi salah. ** : Setiap mahasiswa diberi kesempatan 3 kali. Nomor 1,2,3 merupakan nomor kesempatan pemeriksaan, jika dalam satu atau dua kali kesempatan pemeriksaan telah dapat dilakukan dengan benar maka kolom berikutnya tidak perlu diisi. *** = (total tindakan benar / 12) x 100 %

MODUL SKILL FARMAKOLOGY

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA LABORATORIUM FARMAKOLOGY 2011

PENGANTAR

Pemilihan terapi baik obat dan non obat merupakan proses akademik dan pengalaman..

Pemilihan obat

dan penulisan resep memerlukan pemahaman patofisiologi penyakit, farmakologi dasar ( al farmakodinamik, faramakokinetik obat ) dan sosiobudaya pasien perlu dipertimbangkan. Selain itu respon terhadap obat sangat individual sehingga pemilihan obat terhadap pasien sangat individual. Pemilihan obat berdasar konsep rational drug used merupakan hak dokter, tetapi penentuan terapi / obat adalah hak pasien. Untuk itu perlu komunikasi yang cukup antara dokter pasien sebelum resep ditulis dan pelaksanaan pengobatan dimulai (a.l informasi tentang efek obat, efek samping, instruksi penggunaan, larangan selama pengunaan obat dan hal lain yang kontekstual).Pengobatan belum dianggap selesai tanpa diakhiri dengan monitoring dan evaluasi hasil pengobatan. Untuk mencapai kemampuan pemilihan obat atau ketrampilan terapi dengan menggunakan konsep farmakoterapi berbasis rational drug used diperlukan pelatihan berulang dan tidak melakukan kesalahan yang sama pada proses pelatihan berikutnya. Latihan awal sampai akhir merupakan satu kesatuan yang tidak terpisahkan. Aplikasi sesungguhnya terhadap pasien akan Saudara terapkan pada saat kepaniteraan dan program internship dokter. Dengan kemampuan ketrampilan terapi diharapkan tidak terjadi pemilihan obat hanya menyalin resep dari senior, tetapi kemampuan yang berdasar pada penggunaan obat yang rasional.

Selamat bekerja,

Ka Lab Farmakologi FKUB

Ketrampilan terapi meliputi kemampuan melakukan proses terapi dengan mengikuti 6 langkah berikut : 1. Menentukan problem pasien, 2. Menentukan tujuan terapi, 3. Menentukan intervensi terapi, 3. Memulai terapi dengan menulis resep, 5. Memberikan komunikasi tentang obat dan 6. Kemampuan melakukan monitoring dan evaluasi hasil terapi. Pada pelatihan ketrampilan terapi untuk sistem pernafasan, kardiovaskular dan urinarius akan diberikan kasus yang sesuai dengan masing-masing sistem. Untuk setiap kasus kerjakan sesuai 6 langkah proses terapi. Kerjakan kasus-kasus berikut sesuai dengan 6 langkah proses terapi : Kasus sistem pernafasan Seorang anak 4 th, dibawa kedokter dengan keluhan panas sudah 3 hari ini. Sudah diberi parasetamol, panas turun sebentar kemudian naik lagi. Pagi ini anak tersebut batuk-batuk, tanpa diikuti pilek. Anak tersebut masih mau bermain. Pada pemeriksaan didapatkan BB=20 kg, suhu tubuh=38,5o C, pharynx tampak merah, sekret (+) kental warna kekuningan. Pemeriksaan fisik yang lain dalam batas normal Seorang pasien wanita 30 th, datang dg serangan asma akut yang kemungkinan dipicu oleh infeksi virus di tenggorokan. Wheezing (+), batuk khususnya malam hari, suhu 37,5 0C. Sebelumnya tidak sakit infeksi tenggorokan dan tidak minum obat. Kasus kardiovaskular Laki-laki bernama P.Umar 45 th memeriksakan diri ke dokter karena merasa kepala terasa berat. Dari pemeriksaan didapatkan tekanan darah 150/100 mm Hg. Penderita sudah diberi advis rendah garam, tetapi tekanan darah belum turun. Pasien adalah penderita asma bronkhiale dan sudah biasa menggunakan salbutamol inhaler kalau sesak nafas. Sekarang tidak ada keluhan sesak. Laki-laki berusia 60 th, tanpa riwayat penyakit lain sebelumnya. Pada akhir bulan ini dia merasakan beberapakali nyeri dada seperti tercekik yang membuat lemas. Nyeri dada timbul pada saat aktivitas fisik dan segera hilang setelah aktivitas dihentikan. Pasien ini sudah berhenti merokok selama 4 th. Dari riwayat keluarga didapatkan, bapak dan saudaranya meninggal karena serangan jantung. Pasien tidak minum obat, hanya kadang-kadang minum parasetamol. Dari pemeriksaan auskultasi didapatkan mur-mur pada

arteri karotis dan arteri femoralis kanan. Tekanan darah 130/85 mm Hg, nadi 78 x/menit teratur dan BB normal. Kasus Traktus Urinarius Bu Ati (38 th), 3 hari ini mengeluh sering kencing, sedikit-sedikit. Setiap kencing dirasakan tidak tuntas dan diakhir kencing terasa sakit dan panas di daerah keluarnya kencing. Warna kencing kuning bening. Badan terasa demam dan tidak ada keluhan lain. Pemeriksaan fisik lain dalam batas normal Pak Amat (65 th), datang ke UGD puskesmas, pada jam 7 pagi dengan keluhan tidak bisa kencing. Penderita merasa mulai jam 9 tadi malam kencingnya hanya sedikit-sedikit dan sakit. Mulai jam 12 tengah malam sampai datang di puskesmas tidak bisa kencing sama sekali, padahal rasanya ingin kencing. Sekarang perutnya di bagian bawah terasa sangat nyeri. Pada pemeriksaan didapatkan pembesaran kelenjar prostat. Referensi Modul Lab Farmakologi Untuk PANUM Guide to good Prescribing, WHO

KETRAMPILAN FARMAKOTERAPI Nama NIM Kelompok Tanggal : : : : Penilaian 0 1 2

No 1. 2. 3. 4. 5.

Jenis kegiatan Menyapa pasien dan mempersilahkannya duduk dengan pengaturan yang nyaman Memperkenalkan diri kepada pasien Menanyakan kembali identitas pasien: nama, usia, tempat tinggal, pekerjaan, status keluarga Menetapkan problem / diagnosa pasien Menentukan tujuan terapi Menentukan P-treatment (Advis, non drug) Menentukan pemilihan obat (P-drug) dengan mempertimbangkan ; - Efficacy - Safety - Suitability - Cost Mengidentifikasi obat yang dipilih meliputi : - Nama obat - Bentuk obat - Dosis - Lama pengobatan Menulis resep lengkap - Nama & alamat - Tanggal - Nama generik obat - Bentuk obat - Dosis - Cara pemberian - Jumlah - Instruksi - Signature - Nama & alamat pasien Memberikan informasi, instruksi dan perhatian yang meliputi : - Efek obat (efeknya apa, kapan efek muncul, berapa lama efeknya) - Efek samping (berupa apa, apa yang akan dilakukan)

6.

7.

8.

9.

10.

- Instruksi (cara minum/penggunaan obat, dosis, interval, berapa lama, apa yang harus diperhatikan) - Perhatian (dosis maksimum, interaksi, efek yang tidak dikehendaki, penghentian obat) Menyampaikan kapan kontrol untuk monitoring & evaluasi pengobatan Catatan : Komunikasi yang disampaikan untuk no 9 dan 10 harus : - Jelas dan dapat dimengerti - Struktur pembicaraan runtut - Beri kesempatan pasien (atau keluarga yang mengantar) untuk mengekspresikan dirinya atau memberikan pertanyaan ke dokter - Pastikan pasien (keluarganya) mengerti instruksi yang diberikan. Pasien (keluarganya) diminta untuk mengulangi instruksi

Jumlah Penilaian dimulai dari no urut 4 10 (jumlah soal 7) Keterangan: 0 = tidak dikerjakan 1 = dikerjakan tetapi kurang sesuai/benar 2 = dikerjakan dengan benar Jumlah nilai Nilai akhir = -------------------------- x 100 = 10 Catatan: Mahasiswa/peserta dinyatakan LULUS apabila nilai akhir mencapai 90
(.) Malang, Tutor,

(..)

MODUL SKILL RADIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA LABORATORIUM RADIOLOGI 2011

MODUL SKILL RADIOLOGI RESPIRASI

Tujuan Pembelajaran : 1. 2. Mahasiswa mampu membuat permintaan pemeriksaan radiologi sesuai dengan indikasi dan kontra indikasi dari klinis pasien. Mahasiswa mampu menunjukkan radioanatomi thorax Soft Tissue Pleura Costa, Scapula, Clavicula, Vertebra thoracalis Pulmo : - Parenchym paru - A. pulmonalis dan cabang-cabangnya - Trachea dan cabang-cabangnya Hilus Diafragma 3. 4. Mahasiswa memahami dan mampu menunjukkan radioanatomi dari foto thorax PA dan lateral pada kasus foto thorax normal, infiltrat, cavitas, bronchiectasis, tumor paru primer dan metastase. Memahami dasar menegakkan diagnosa dari foto thorax

CHECK LIST RADIOLOGI RESPIRASI Berhasil (1) Gagal (0)

1. X - Foto Thorax PA Normal Soft tissue Pleura

Item

Costa, Scapula, Clavicula, Vertebra thoracalis Pulmo Parenchym paru A. pulmonalis dan cabang-cabangnya Trachea dan cabang-cabangnya Hilus Diafragma 2. X- Foto Infiltrat 3. X- Foto Cavitas 4. X- Foto Bronchiectasis 5. X- Foto Tumor Paru Primer 6. X- Foto Tumor Paru Metastase NILAI TOTAL Malang, Tutor

(dr. ... )