Gambar Modul IIb

8/7/2019 Gambar Modul IIb

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Buku Modul Skills Lab Semester IIb 2007/2008, Ax & Dpx Thoraks 1


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Pectus excavatum

Learning point!The apex beat is the furthest

position laterally and inferiorly,at which the cardiac impulsecan be palpated. The apex beat

is due mainly to the action ofthe left ventricle. In a normal

patient, the apex beat is usuallypositioned at the 5th intercostal

space (ICS) in the midclavicular line (MCL).


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Palpation for the apex beat

Palpation for a parasternal heave

Palpasi daerah subxyphoid. Cara ini untuk meraba ventrikel kanan bila

terjadi hipertrofi ventrikel kanan.

Palpation for the apex beat.

To palpate for the apex beatplace your hand over the left

hemi-thorax region and feel forthe most lateral and inferior

pulsation. To count intercostalspaces (ICS), first identify the

manubriosternal junction. Therib attached along side this is

the 2nd rib and the space belowthe rib is the 2nd ICS. Count

down until you are at the levelwhere you can feel the apex

beat.

Palpation for heaves:Place your hand on the patients

chest in the left parasternalregion to palpate for any heaves

that may be caused by rightventricular enlargement.

Dengan menggunakan telapak

tangan dapat ditentukan bataskanan bila terdapat pembesaran

ventrikel kanan (right ventriclehypertrophy)


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Palpation for thrills

The diaphragm side

Palpation for thrills:

Turbulent blood flow, which causes

cardiac murmurs on auscultation (seelater) can sometimes be palpable

i.e. a thrill. Place your hand over thepulmonary and aortic areas (see

later) to palpate for any thrills.

Stethoscope:A stethoscope usually has twocomponents:

The diaphragm is better for listening

to higher pitched sounds(e.g. 1st &2nd heart sounds systolic and aortic

diastolic murmurs).

.

Menentukan batas kananjantung. Caranya terlebih

dahulu menentukan batas paru-hati (BPH). BPH normal berada

di ICS Vgaris midklavikuler.Dua jari diatas BPH diperkusi

ke medial, suara keredupanpertama menunjukkan batas

kanan jantung.

Menentukan batas atas jantung.

Caranya : perkusi sepanjanggaris midklavikuler dari atas ke

bawah. Keredupan pertamamerupakan batas atas jantung


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The bell side

Learning point! Auscultation of the heart can detect many important sounds includingheart sounds, murmurs and other additional sounds (e.g. opening snaps, clicks,pericardial friction rubs, prosthetic heart sounds)

The bell is best used to detect lower

pitched sounds (e.g. the murmur of

mitral stenosis). The bell should not be

placed too tightly to the skin -otherwise it could function as a

diaphragm

Location of the auscultatory areas:Heart valve sounds are best heard in

the following areas:

Mitral area (5th ICS MCL)Tricuspid area (Lower left sternal edge)

Aortic area (2nd ICS right sternal edge)Pulmonary area (2nd ICS left sternal

edge)

Lokasi Auskultasi Katub Jantung


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Mitral area

Tricuspid area

Pulmonary area

Auskultasi katup mitral ICS Vgaris midklavikuler

Auskultasi katup mitral ICS V

garis sternal kiri

Auskultasi katup mitral ICS II

parasternal kiri


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Aortic area

Mitral area

It is essential to simultaneouslyexamine the carotid pulse long

enough to give you an indication ofthe timing of systole and enable

sounds to be placed in the correctpart of the cardiac cycle.

Now with the Bell component

of the stethoscope listen to the :

- Mitral area- Tricuspid area

Auskultasi katup mitral ICS II

Parasternal kanan


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Tricuspid area

Aortic area

Roll the patient on to their left lateral

position. Palpate for the apex beat

and listen with the bell component

of your stethoscope for the murmurof mitral stenosis. The murmur of

mitral stenosis is quite localised justmedial to the apex beat. Also listen

into the axilla area for the murmur ofmitral incompetence. You may want

the patient to lie on their back whenlistening for the radiation of mitral

regurgitation as it may be difficult toplace the stethoscope in the axilla

when the patient is lying on their leftside.

Ask the patient to lean forward, take a deep

breath, exhale and to hold their breath for ashort period of time. (In doing this

manoeuvre, it will increase the intensity of

the murmur of aortic incompetence).

Auscultate with the diaphragm component ofthe stethoscope the following areas:

- Aortic area- Tricuspid area


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Pada beberapa keadaan perlu

dilakukan pemeriksaan dalam posisikhusus misalnya jongkok, berdiri,

valsava, isometerik dan setelahpemberian amilnitrit.

Bising fungsionil akan menghilang

bila dilakukan pemeriksaan dengan

cara berdiri.


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Image of a patient who presented with shortness of breath. Clinically the patient was found to have pale

conjunctiva. The patients Hb level was 6.6g/dl and the cause for his anaemia was due to a bleeding

duodenal ulcer.

A patient with finger clubbing due to pulmonary fibrosis


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Nicotine staining on a patient who smokes cigarettes

Assessment of anterior chest wall expansion

Assessment of posterior chest wall expansion

Palpasi waktu pergerakan. Perhatikan derajat pergerakan dan bandingkanantara yang kanan dan kiri (perhatikan pergerakan dari tangan pemeriksa)

Pemeriksaan fremitus suara dengan

Palpasi kedua tangan bagian ulnarsecara sistematis dari bawah, tengah

dan atas, waktu Palpasi penderitamengucapkan suara getar misalnya

menyebut angka delapan berulang kali.Hasil pemeriksaan dibandingkan antara

paru kiri dan kanan, mana yang lebihkeras


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Palpation for position of the trachea

Percussion techniquei) Place you hand on the patients chest wall with the fingers slightly separated andaligned with the ribs and pressing the middle finger firmly again the chest.

ii) With the other hand (usually the middle finger) strike firmly the middle phalanx

of the middle finger that is on the patients chest wall.

iii) 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

In essence you will be comparing the quality of one percussion note with another

over the entire chest wall. Therefore percussion should always compare left to right

at each level throughout the chest wall.


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When percussing the anterior chest wall start in the supraclavicular area, percuss

the clavicle directly with the perusing finger and then the rest of the anterior chestwall. Do not forget to percuss the axilla.

Areas to percuss in the anterior chest wall

When percussing the posterior aspect of the chest, the scapula should be moved outof the way. Therefore ask the patient to move their arms forward by doing this

will rotate their scapula anterioly.

Areas to percuss in the posterior chest wall.


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Areas to auscultate in the anterior chest wall Areas to auscultate in the posterior chestaspect of the chest

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Gambar Modul IIb