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DIAGNOSIS PENYAKIT
PARU
dr Indah Rahmawati, SpP
Blok Respirasi, 04-03-14
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PENDAHULUAN
Kelainan pada jaringan paru, pleura atau
dinding toraks perubahan sifat fisik
pemeriksaan fisik (tanda penyakit)
1. Bentuk / ukuran toraks
2. Pergerakan
3. Penghantaran getaran
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BENTUK/UKURAN TORAKS
Volume jaringan paru berkurang
Atelektasis, Fibrosis, Schwarte Volume jaringan bertambah
Emfisema, efusi pleura, pneumotoraks
Volume jaringan paru tetap
Konsolidasi
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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)
5. Hiperinflasi jaringan paru
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PENGHANTARAN GETARAN
Suara timbul dari getaran
NADAditentukan 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, bicara, berbisik
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PEMERIKS N D S R P RU
INSPEKSI
PALPASI
PERKUSI
AUSKULTASI
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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
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Trachea position
Lymph node enlargment
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Abnormal Finding
Skin and soft tissue
Puncture sites and Scars
(Thoracentesis, FNAB,Chest tube, Surgical scars)
Prominent collateral veins
(SVC syndrome)
Swelling (Recentthoracentesis, Empyema,
Mesothelioma, Empyema
necessitatis, Cystic hygroma)
Erythema (Empyema) Warmth (Empyema)
Tenderness ( Empyema, Rib and
chest wall lesions )
Subcutaneous nodules (Metastasis)
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TUBERKULOSIS
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Respiratory Rate and Pattern of Breathing
To evaluate one of the vital signs.
Method Of Exam
The patient should not be awarethat you are
counting his respiratory rate.
Count the RR while pretending to take the
patient's pulse.
Note the rate, pattern and comfortof
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.
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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 :
20/min: Tachypnea: (Interstitial, vascular andmultitude of diseases, anxiety)
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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)
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Abnormal Finding
Pattern
Abdominal paradox:
Instead of simultaneous chest and abdominal
expansion with inspiration abdomen retracts while
chest expands: (Diaphragmatic paralysis)
Thoracic paradox:
On the side of unstable chest wall hemithorax
retracts while the normal side expands withinspiration: (Flail chest)
Pursed lip breathing:
With lips pursed patient controls expiration
slowly: (Obstructive lung disease)
No abdominal component :
( Acute abdomen)
No thoracic component:
(Pleurisy, Chest wall pain, Ankylosing spondylitis)
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Abnormal Finding
Discomfort
Labored breathing:
(Heart and Lung diseases)
Orthopnea:
Unable to assume supine position
because of worsening shortness ofbreath: (CHF, Diaphragmatic
paralysis, SVC syndrome, Anterior
mediastinal mass)
Platypnea:Unable to erect position because
of worsening shortness of breath,
more comfortable in supine position
(Pulmonary spiders in cirrhotic)
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Chest: Observation
To evaluate chest wall
and symmetry of hemithorax .
To assess negative pressure
in the pleural space
Method Of Exam
Stand eitherat foot end or by the
head end and observe the symmetry
of hemithorax.
Inspectthe chest all around with
the patient in sitting position. Observethe intercostal space,
supraclavicular fossa and tracheal
movement during quiet respiration.
Examine the skin and soft tissue.
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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. Inspectfor the symmetry of clavicularinsertion of both sternomastoids.
3. Tracheal Position: Gently bend the head
to relax the sternomastoids. By inserting
your finger between the trachea andsternomastoid, assess and compare the
space on either side.
Normal:
Trachea is slightly tilted to right.
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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
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Abnormal Finding
Pleura
Push:
Pneumothorax
Pleural effusion
Pull:
Pleural fibrosis
Mediastinal masses and thyroid tumors
Kypho-scoliosis
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EFUSI PLEURA
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PNEUMOTORAKS
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KANKER PARU
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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 sittingposition.
Observe the intercostal space,
supraclavicular fossa and tracheal
movement during quiet respiration.
Examine the skin and soft tissue.
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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
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Chest Expansion
To assess overall chest expansion with
inspiration. To identify the side of abnormality
Method Of Exam
Overall chest expansion:
Take a tape and encircle chest around
the level of nipple. Take measurements at
the end of deep inspiration and expiration.
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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 adeep breath and expire. Watch the
symmetry of movement of the hemithorax.
Simultaneously, feel the chest expansion.
Place your hands over upper chest andapex 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.
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Cyanosis of nail beds
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Clubbing of the digits
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JARI TABUH
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PALPASI
Getaran suara (fremitus vokal)
Intensitas me pada jaringan paru padat(konsolidasi) sifat selective transmitterhilang getaran tinggi dihantarkan
Intensitas me pada atelektasis, efusi ataupneumotoraks, obesitas
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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 (tactilefremitus)
Listen with diaphragm (vocal
resonance)
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PERKUSI
Perkusi timbulkan getaran dinding dada
menjalar ke parenkim paru
Jumlah udara > normal hipersonor
Jumlah jaringan padat > normal redup
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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.
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Percussion
resonance or hyperresonant hyperinflated lungs (emphysema)
pneumothorax
Diaphragmatic excursion
diaphragm normally moves about 3-4 cm and
less in COPD and neuromuscular diseases
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AUSKULTASI
SUARA NAPAS
SUARA TAMBAHAN
SUARA BISIK
SUARA PERCAKAPAN
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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 Bronkial E > I ada suara terputus
SUARA NAPAS
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Vesikuler menguat
anak, orang kurus (bilateral)
Vesikuler melemah
pneumotoraks, efusi, obstruksi trakea
Bronkhial terdengar pada paru yang
konsolidasi, kompresi dg bronkus terbuka
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Auscultation
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Suara tambahan dari paru (ronki = crackle)
Sekret saluran napas, penyempitan lumen atau
terbukanya alveoli yang kolaps
Suara tambahan dari pleuraAkibat gesekan pleura yang kasar, jelas saat
inspirasi
Suara tambahan dari mediastinumPneumomediastinum (terputus, seirama napas dan
denyut jantung)
SUARA TAMBAHAN
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SUARA RONKI
Ronki basah (suara terputus) Inspirasi
1. RB kasar (sekret banyak di sal nps besar)
2. RB sedang (sekret di sal nps kecil/sedang)
3. RB halus/krepitasi (terbukanya mendadak alveoli
yang kolaps/terisi eksudat) Ronki kering ( tidak terputus) Ekspirasi
1. Nada rendah (sonourous) obstruksi saluran napasbesar
2. Nada tinggi (sibilan = wheeze) obstruksi sal napaskecil
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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 BISIK
(PECTORILOQUE)
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Ucapkan kata : 1, 2, 3 atau 9 berulang
Jelas terdengar di laring, semakin ke bawah
semakin lemah/kabur, di jaringan paru tidakterdengar
Bronkofoni positip (jelas)
Bronkofoni negatif (tidak jelas)
Egofoni (bronkofoni dg kualitas suara nasal)
SUARA PERCAKAPAN
(BRONKOFONI)
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Abnormal Finding
Decreased:
(Pleural effusion, Pneumothorax,
Atelectasis, Mass)
Increased: (conditions giving
bronchial breathing) Bronchophony: (Normal)
Whispering pectoroliquy ( Normal )
Qualitative: Egophony
Bronchopony Normal Whispering Normal Egophony
http://localhost/var/www/apps/conversion/tmp/scratch_5/bronchop.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/normalvr.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/whisper0.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/whispern.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/egophony.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/whispern.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/whisper0.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/normalvr.auhttp://localhost/var/www/apps/conversion/tmp/scratch_5/bronchop.au8/12/2019 Diagnosis Penyakit Paru
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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 (infiltratin alveoli)
Inspiration < or = expiration)
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Bronchovesicular softer, less coarse
intermediate airways
Medium pitch
Normal sound over carina area and betweenupper scapulae
Abnormal in perifer if there is consolidation
Inspiration = expiration (1:1)
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Vesicular softest, smooth
Low pitch
Inspiration > expiration ( 3:1)
laminar gas flow largest surface area
Normal sound over most of lung
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Adventitious lung sounds
Crackles or rales
short, intermittent sounds
air passing through fluid in the small airways air
suddenly opening up ateletatic lung unitsdecreased
reduced transmission and intensity of soundswhen compared to normal sounds in the same
area e.g., hyperinflated lungs, pleural effusion, obese
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Coarse crackles
Fine crackles
Crackles
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low pitched, continuous sound
associated with excessive secretions in the
airways which narrows the lumen of large
airways
tends to clear with coughing
Rhonchus
S id
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Stridor
hoarse sound heard on inspiration
common post extubation because of
tracheal swelling and edema causing
narrowing of the upper airway
treated with racemic epinephrine, its alpha
effects reduce mucosal swelling
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Bronchial
Tubular or tracheal sounds which are transmittedfrom the trachea through consolidation at thebases
Sounds transmit better through solid than air
Egophony: E to A
Whispered pectoriloquy: 99
Bronchophony: patients words are heard clearthrough consolidation, but muffled in normal lungs
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Pleural friction rub
Creaky or grating sounds as the patient
breathes in and out similar to old leather
when it is bent to and fro
Related to inflamed or irritated pleural
surface
pleurisy from pneumonia is common
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