MD

Anamnese oke

PADAT

CAIR

GAS

Anatomi paru Kanan 3 lobus (atas, tengah, bawah) Kiri 2 lobus (atas, bawah) Topografi Linea Mid Sternalis Linea Mid Clavicularis Linea Axillaries anterior Linea Mid Axillaris Linea Axillaris posterior Linea Sternalis kanan dan kiri Linea Para Sternalis kanan dan kiri

Tulang-tulang (Untuk Orientasi) Sternum dan Angulus Costae Clavicula Arcus Costae Costae Scapula Vertebra

General Approach:
Examine both the anterior and posterior chest

LUL

RUL

RUL

LUL

LUL

LLL

RLL

RML

RLL

LLL

Posterior

Anterior

General Approach:
Examine the lateral chest

Posterior

RUL

LUL

Anterior

Posterior

RML RLL LLL

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.

General Approach:

Inspection

Palpation

Percussion

Auscultation

Anterior imaginary lines and landmarks

Suprasternal fossa Supraclavicular fossa Infraclavicular fossa

Sternal line

Anterior midline

Parasternal line

Midclavicular line
epigastric angle

Lateral imaginary lines

Posterior axillary line Anterior axillary line Midaxillary line

Posterior imaginary lines and landmarks

Suprascapular region

Interscapular region

Infrascapular region Scapular line

Posterior midline

Anterior view of lobes

Posterior view of lobes

Right lateral view of lobes

Left lateral view of lobes

Thoracic deformity
Pectus excavatum
Barrel chest

Kyphosis

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

Thorax Paralyticus / expiratorius Individu yang kurus dan panjang Panjang dan pipih Tulang iga berjalan lurus kebawah Sudut epigastrium sangan tajam Konfigurasi thorax Pyriformis

Thorax Pyramidalis Disebut juga tetradische thorax Ujung sternum bagian bawah menjadik puncak pyramid Jarang

Thorax Inspiratorius / Emphysematous Thorax kembung dan pendek Iga mendatar Sudut epigastrium tumpul OK elastisitas paru yang kurang

Inspection:

Work of breathing:
Respiratory rate (normal = 10-14 breaths/minute). Depth of breathing. Accessory muscle use (sternocleidomastoid and intercostal muscles). Posture (leaning forward and arms bracing the exam table). Paradoxical respirations (asymmetry of chest and abdomen motion).

Inspection:
Rhythm of breathing:
Normal
Depth

Time

Rapid Shallow

Restrictive lung process: Pneumothorax, Interstitial Fibrosis, Pleuritic Pain

Inspection:
Rhythm of breathing:
Rapid Deep

Anxiety, Exercise, Metabolic acidosis (Kussmaul respirations) Slow

Diabetic Coma, Drug-induced respiratory depression

Inspection:
Rhythm of breathing:

Cheyne-Stokes Breathing

Heart Failure, Uremia, CNS Injury to both hemispheres

Inspection:
Shape and symmetry of the anterior and posterior chest:

Normal

Barrel Chest COPD

Flail Chest Rib Fractures

Inspection:
Shape and symmetry of the anterior and posterior chest:

Pectus Excavatum

Pectus Carinatum

Inspection:
Shape and symmetry of the anterior and posterior chest:

Thoracic Kyphoscoliosis

Inspection:
Miscellaneous:
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
1. Respiratory movement
Abdominal breathing: male adult and child Thoracic breathing: female adult Tachypnea: >20 f/min Bradypnea: <12 f/min Shallow and fast

2. Respiratory rate: 16-18 f/min

respiratory muscular paralysis, elevated intraabdominal pressure, pneumonia, pleurisy Agitation, intension Severe metabolic acidosis (Kussmauls breathing)

Deep and fast

Deep and slow

Inspection
3. Respiratory rhythm
Cheyne-Stokes breathing Biots breathing _____Decreased excitability of respiratory center Inhibited breathing
Sudden cessation of breathing due to chest pain

Pleurisy, thoracic trauma Sighing breathing

Depression, intension

Palpation:
Identification of tender areas: musculoskeletal pain vs. other Trachea Position: deviation can occur with pneumothorax Lymphadenopathy

Assessment of chest wall expansion (pleural effusion, splinting, paralyzed hemidiaphragm)

Palpation:
Assessment of tactile fremitus.
Sense vibration with ulnar surface of hand as patient speaks a deep tone

Posterior positions

Anterior positions

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
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

Percussion

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
Thickness of thoracic wall Calcification of costal cartilage Hydrothorax Containing gas in alveoli Alveolar tension Alveolar elasticity

3. Classification
Resonance (Sonor)

Normal
Emphysema Cavity or pneumothorax Hydrothorax, atelectasis Massive Hydrothorax

Hyperresonance (hipersonor) Tympany Dullness (sonor memendek) Flatness (beda)

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
Border of lungs in percussion Apex of lungs
Kronigs isthmus: 5cm in width Narrow: TB, fibrosis wider: emphysema absolute cardiac dullness area

Anterior border

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

Shifting range of bottom of lung

Along the scapular line

s
Percussing bottom of lung, marking Asking the pat. to inspire deeply and hold Percussing bottom of lung, marking Asking the pat. to expire deeply and hold
6-8 cm Shifting range of bottom of lung

Percussing bottom of lung, marking

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
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
Dullness or flatness
Decreased containing gas in alveoli

Pneumonia Atelectasis? TB Pulmo. embolism Pulmo. edema Pulmo. fibrosis

Tumor Pulmo. Hydatid Pneumocystis Non-liquefied lung abscess

No gas in alveoli

Others
Hydrothorax Pleural thickness

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
Special areas on percussion in
moderate
Garlands triangle area (tympanitic dullness)

Damoiseaus curve (damoiseaus E

hydrothorax (Pleural Effusi)

Groccos triangle area (dullness)

Percussion:
Technique. Positions.

Posterior positions

Anterior positions

Percussion:
Sounds.
Note Intensity Pitch High Medium Low Lower Location Thigh Liver Lung None Gastric Air Path. Pleural Effusion Lobar Pneumonia Normal Lung Emphysema Pneumothorax Large Pneumothorax

Flat
Dull Resonant Hyperresonant Tympany

Soft
Medium Loud Very Loud Loud

High

Percussion:
Miscellaneous: Identify the diaphragm position and extent of excursion

Max Exhalation Max Inhalation

Resonant

Dull

Posterior positions

Auscultation

Order of auscultation

Sound of auscultation
1. Normal breath sound 2. Abnormal breath sound 3. Adventitious sound 4. Vocal resonance

1. Normal breath sound

Tracheal breath sound Bronchial breath sound
Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra
Bronchial

Bronchovesicular

Bronchovesicular breath sound

1st, 2nd intercostal space beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung

Bronchial

Bronchovesicular

Vesicular breath sound

2. Abnormal breath sound

Abnormal vesicular breath sound Abnormal bronchial breath sound Abnormal bronchovesicular breath sound

Abnormal vesicular breath sound(1)

1) Decreased or disappeared
Movement of thoracic wall Respiratory muscle weakness Obstruction of airway Hydrothorax or pneumothorax Abdominal diseases: ascites, large tumor

2) Increased
Movement of respiration

Abnormal vesicular breath sound (2)

3) Prolonged expiration
Bronchitis Asthma emphysema TB Pneumonia Early stage of bronchitis or pneumonia

4) Cogwheel breath sound

5) Coarse breath sound

Abnormal bronchial breath sound

(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

Abnormal bronchovesicular breath sound

Bronchovesicular breath sound appears in supposed vesicular breath sound area
The lesion is relatively smaller or mixed with normal lung tissue

3. Adventitious sound
(moist) Crackles Rhonchi (wheezes) Pleural friction rub

Moist crackles
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
1. Adventitious sound 2. Intermittent 3. Appeared in phase of inspiration or early expiration 4. Constant in site 5. Unchanged in character 6. Medium and fine crackles exist meantime 7. Less or disappeared after cough

Classification of crackles
According to intensity of the sound
1. Loud moist crackles 2. Slight moist crackles

According to diameter of the airway crackles appeared

1. 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
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)
Mechanism The turbulent flow is formed in trachea, bronchi or bronchioli due to airway narrow or incomplete obstruction. Causes
Congestion Secretion Spasma Tumor Foreign subject Compression

Characteristics of rhonchi
1. Adventitious sound 2. High pitch 3. Dominance in phase of expiration 4. Variable intensity of character or site 5. Wheezing

Classification of rhonchi
1. Sibilant
Bonchioli, bronchi

2. Sonorous
Trachea, main bronchi

Site of rhonchi
1. Both fields
Asthma Chronic bronchitis Acute left heart failure

2. Local site
Tumor Endobronchial TB

Pleural friction rub

1. Cellulose exudation in pleurisy (rough pleura) 2. Area of auscultation
Anterolateral thoracic wall (maximal shifting area of lung)

3. Friction rub disappeared if holding breath 4. Friction rub appeared both breath and heart beat: mediastinal pleurisy 5. Causes
Tuberculous pleurisy Pulmo. embolism Uremia

Vocal resonance
Bronchophony Pectoriloqny
Massive consolidation

Egophony
Upper area of hydrothorax

Whispered
Consolidation

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:
Positions.

Posterior positions

Anterior positions

Auscultation:
Normal Sounds.
Sounds Intensity Pitch Low Medium High Duration Inspir > Expir Inspir = Expir Inspir < Expir Location Lungs

Vesicular
Broncho-vesicular Bronchial

Soft
Medium Loud

Central airways
Trachea

Note: Auscultation should be performed with diaphragm of stethoscope

Auscultation:
Adventitious Sounds.
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 :

Condition Trachea Percussion Breath Sounds Fremitus Adventitial

Normal Pneumonia

Midline Midline

Resonant +/- Dull

Normal Bronchial

Normal Increased

None Crackles

Effusion

Shifted

Dull

Decreased

Decreased

None

Pneumothorax

Shifted

Hyper

Decreased

Decreased

None

COPD

Midline

Hyper

Decreased

Decreased

Wheezes

CHF

Midline

Resonant

Normal

Normal

Crackles

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