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ANAMNESIS - PEM FISIK

PARU
dr Indah Rahmawati, SpP
Blok ECCE, 8 Nopember 2016

Keluhan pernapasan

Sesak napas
Batuk
Batuk darah
Nyeri dada

KELUHAN UTAMA

Onset
Lokasi
Kualitas
Kuantitas
Faktor yang
memperingan
Faktor yang
memperberat
Faktor yang menyertai

Anamnesis tambahan
Keluhan yang menyertai keluhan
utama
Riwayat Penyakit sebelumnya
Riwayat Pengobatan sebelumnya
(OAT dimana, kapan,
selesai/tidak, cek sputum ?)
Riwayat merokok (index
Brinkman)
Sosial ekonomi (kondisi rumah,
ventilasi, pekerjaan, cara

CONTOH
Keluhan utama : batuk darah
Batuk berdarah sejak 1 hari
SMRS, batuk berbuih, tidak
bercampur makanan, berwarna
merah segar. Setiap batuk
sekitar 1 sdm, 10xsehari. Batuk
berdarah bertambah bila pasien
bicara atau makan kacang. Batuk
berdarah berkurang apabila
pasien istirahat atau minum obat

CONTOH
Riwayat pengobatan : pasien
sudah pernah minum obat yang
menyebabkan BAK berwarna
merah seperti air teh pada th
2014 di Puskesmas Mawar.
Pasian pernah batuk darah,
diperiksa dahak dan kemudian
direncanakan pengobatan
selama 6 bulan tetapi hanya
minum selama 1.5 bulan karena

CONTOH
Riwayat pengobatan : Pasien sudah
rutin memakai obat semprot (merk X)
yang dipakai pada saat sesak dan
obat semprot/hisap yang dipakai rutin
Pasien sudah memiliki alat nebuliser
di rumah, dipakai pada saat serangan
Pasien merokok sejak usia 15 tahun
dan berhenti merokok usia 60 tahun,
sehari 2 bgks

PEMERIKSAAN TORAKS

Kelainan pada jaringan paru,


pleura atau dinding toraks
perubahan sifat fisik
pemeriksaan fisik (tanda
penyakit)
1.Bentuk / ukuran toraks
2.Pergerakan
3.Penghantaran getaran

BENTUK/UKURAN TORAKS
Volume jaringan paru berkurang
Atelektasis, Fibrosis,
Schwarte
Volume jaringan bertambah
Emfisema, efusi pleura,
pneumotoraks
Volume jaringan paru tetap
Konsolidasi

PERGERAKAN
Pergerakan dinding toraks
menurun
1. Ggn otot pernapasan
(poliomyelitis)
2. Tahanan ddg toraks me
(obesitas)
3. Pengembangan paru me
(fibrosis, atelektasis)
4. Penekanan jaringan paru
(efusi, tumor, pneumotoraks)

PENGHANTARAN GETARAN
Suara timbul dari getaran
NADA ditentukan oleh frekuensi,
panjang dan diameter saluran napas
semakin perifer makin kecil/pendek
nada tinggi
INTENSITAS (kekerasan) ditentukan
oleh energi untuk timbulkan suara &
frekuensi menurun bila lewat
pergantian medium getaran
dipantulkan/diresorbsi sedikit
diteruskan
SIFAT/KUALITAS SUARA bernapas,

PEMERIKSAAN FISIK
PARU

PEMERIKSAAN DASAR PARU

INSPEKSI
PALPASI
PERKUSI
AUSKULTASI

INSPEKSI
Bentuk/ukuran toraks
Pelebaran vena (SVCS), spider naevi,
Ginekomasti, posisi trakhea
Otot bantu napas, tulang iga, sela
antar iga, posisi dan bentuk tulang,
napas cuping
Tipe dan frekuensi napas
Jari tabuh/gada, pembesaran kelenjar
limfe

Trachea
position

Lymph node
enlargment

Pectus Carinatum

Pectus Excavatum

Abnormal Finding
Skin and soft tissue
Puncture sites and Scars
(Thoracentesis, FNAB,
Chest tube, Surgical scars)
Prominent collateral veins
(SVC syndrome)
Swelling (Recent
thoracentesis, Empyema,
Mesothelioma, Empyema
necessitatis, Cystic hygroma)
Erythema (Empyema)
Warmth (Empyema)
Tenderness ( Empyema, Rib and
chest wall lesions )
Subcutaneous nodules (Metastasis)

TUBERKULOSIS

Respiratory Rate and Pattern of Breathing


To evaluate one of the vital signs.
Method Of Exam
The patient should not be aware that you are
counting his respiratory rate.
Count the RR while pretending to take the
patient's pulse.
Note the rate, pattern and comfort of
respiration.
Normal:
Resting rate : 10-14 per min., regular with no
apparent discomfort..
Chest wall and abdomen expand during
inspiration and is symmetrical.
Periodic deep breathing (Sighs) < 5/ minute.

Abnormal Finding
Minor changes in rate and rhythm of respiration
occur due to anxiety and while it may represent an
abnormality, it may not be significant.
Rate :
<10/min: Bradypnea: (Narcotics, raised
intracranial tension, myxedema)
>20/min: Tachypnea: (Interstitial, vascular and
multitude of diseases, anxiety)

Abnormal Finding
Pattern :
Cheyne-stokes breathing
Periodic breathing------> Cyclical increase and
decrease in depth of respiration (CHF,
Cerebrovascular insufficiency)
Kussmaul breathing
Slow deep breathing: (Ketoacidosis)
Biot's breathing:
Totally irregular with no pattern:(CNS injury)
Sighs
Periodic deep breathing: : (Anxiety state)

Chest: Observation
To evaluate chest wall
and symmetry of hemithorax .
To assess negative pressure in
the pleural space
Method Of Exam
Stand either at foot end
or by the head end and observe the
symmetry of hemithorax.
Inspect the chest all around with the
patient in sitting position.
Observe the intercostal space,
supraclavicular fossa and tracheal
movement during quiet respiration.
Examine the skin and soft tissue.

Trachea Position
To evaluate the position of the upper
mediastinum
Method Of Exam
1. Position yourself in front of
the patient and note the position
of the thyroid cartilage.
2. Inspect for the symmetry of clavicular
insertion of both sternomastoids.
3. Tracheal Position: Gently bend the head
to relax the sternomastoids. By inserting
your finger between the trachea and
sternomastoid, assess and compare the
space on either side.
Normal:
Trachea is slightly tilted to right.

Abnormal Finding
Chest asymmetry
Kyphoscoliosis
Larger hemithorax :
(Pneumothorax, Pleural effusion)
Smaller hemithorax:
(Atelectasis, Pleural fibrosis, Agenesis
of Lung)
Increased pleural negative pressure:
Unilateral (airway obstruction) or
bilateral (COPD, DIF, Asthma)
Intercostal and supraclavicular fossa
retraction
Downward movement of trachea
with quiet inspiration

Chest Expansion
Method Of Exam
Symmetry of chest expansion:
Have patient seated erect or stand with
arms on the side. Stand behind patient.
Grab the lower hemithorax on either side
of axilla and gently bring your thumbs to
the midline. Have patient slowly take a
deep breath and expire. Watch the
symmetry of movement of the hemithorax.
Simultaneously, feel the chest expansion.
Place your hands over upper chest and
apex and repeat the process.
Next, stand in front and lay your hands
over both apices of the lung and anterior
chest and assess chest expansion.

Abnormal Finding
Tracheal deviation ----> E/ the diseases of :
Lung
Pleural
Mediastinal
Chest wall
Lung :
Pull: ( Loss of lung volume)
Atelectasis
Fibrosis
Agenesis
Surgical resection
Push: (Space occupying lesions)
Large mass lesions

Abnormal Finding
Pleura
Push:
Pneumothorax
Pleural effusion
Pull:
Pleural fibrosis
Mediastinal masses and thyroid tumors
Kypho-scoliosis

EFUSI PLEURA

PNEUMOTORAKS

KANKER PARU

Cyanosis of nail beds

Clubbing of the
digits

JARI TABUH

PALPASI
Getaran suara (fremitus vokal)
Intensitas me pada jaringan
paru padat (konsolidasi) sifat
selective transmitter hilang
getaran tinggi dihantarkan
Intensitas me pada atelektasis,
efusi atau pneumotoraks,
obesitas

Voice transmission
Method Of Exam
Patient to say
"99" "1, 2, 3" or "E"
Each time you lay
your hands or listen
All around the chest and
compare :
Dorsal surface of your fingers or
ulnar surface of your hand (tactile
fremitus)
Listen with diaphragm (vocal
resonance)

PERKUSI
Perkusi timbulkan getaran
dinding dada menjalar ke
parenkim paru
Jumlah udara > normal
hipersonor
Jumlah jaringan padat > normal
redup

Lungs: Percussion
To assess the amount of air in lung.
To assess movement of the diaphragm
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.

Percussion
resonance or hyperresonant
hyperinflated lungs (emphysema)
pneumothorax

Diaphragmatic excursion
diaphragm normally moves about
3-4 cm and less in COPD and
neuromuscular diseases

AUSKULTASI
SUARA NAPAS
SUARA TAMBAHAN
SUARA BISIK
SUARA
PERCAKAPAN

SUARA NAPAS
Aliran udara saat bernapas
sebabkan putaran & benturan
getaran suara via lumen dan
dinding bronkus
Alveoli sebagai selective
transmitter menahan getaran
frekuensi tinggi
Vesikuler (normal) I > E tanpa
putus

Vesikuler menguat
anak, orang kurus (bilateral)
Vesikuler melemah
pneumotoraks, efusi,
obstruksi trakea
Bronkhial terdengar pada paru
yang konsolidasi, kompresi dg
bronkus terbuka

Auscultation

SUARA TAMBAHAN
Suara tambahan dari paru (ronki =
crackle)
Sekret saluran napas, penyempitan
lumen atau terbukanya alveoli yang
kolaps
Suara tambahan dari pleura
Akibat gesekan pleura yang kasar,
jelas saat inspirasi
Suara tambahan dari mediastinum
Pneumomediastinum (terputus,
seirama napas dan denyut jantung)

SUARA RONKI

1.
2.
3.
.
1.

Ronki basah (suara terputus)


Inspirasi
RB kasar (sekret banyak di sal nps
besar)
RB sedang (sekret di sal nps
kecil/sedang)
RB halus/krepitasi (terbukanya
mendadak alveoli yang kolaps/terisi
eksudat)
Ronki kering ( tidak terputus)
Ekspirasi
Nada rendah (sonourous) obstruksi
saluran napas besar

SUARA BISIK
(PECTORILOQUE)
Tidak ada getaran pita suara,
nada tinggi
Jelas terdengar di laring,
semakin ke bawah semakin
lemah/kabur, di jaringan paru
tidak terdengar
Konsolidasi/atelektasis kompresi
dgn bronkus terbuka jelas,
keras, nada tinggi dengan fase
ekspirasi panjang

SUARA PERCAKAPAN
(BRONKOFONI)
Ucapkan kata : 1, 2, 3 atau 9
berulang
Jelas terdengar di laring, semakin
ke bawah semakin lemah/kabur, di
jaringan paru tidak terdengar
Bronkofoni positip (jelas)
Bronkofoni negatif (tidak jelas)
Egofoni (bronkofoni dg kualitas
suara nasal)

Auscultation
Normal lung sounds:
Tracheobronchial or bronchial
Loud, coarse, tubular
High pitch, there is gap
Tubulent gas flow
Normal at over upper trachea or over
manubrium
Abnormal in perifer if there is
consolidation (infiltrat in alveoli)
Inspiration < or = expiration)

Bronchovesicular

softer, less coarse


intermediate airways
Medium pitch
Normal sound over carina area and
between upper scapulae
Abnormal in perifer if there is
consolidation
Inspiration = expiration (1:1)

Vesicular

softest, smooth
Low pitch
Inspiration > expiration ( 3:1)
laminar gas flow
largest surface area
Normal sound over most of lung

Bronchial
Tubular or tracheal sounds which are
transmitted from the trachea
through consolidation at the bases
Sounds transmit better through solid
than air
Egophony: E to A
Whispered pectoriloquy: 99
Bronchophony: patients words are
heard clear through consolidation,
but muffled in normal lungs

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