Gambar Modul IIb
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Transcript of 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