diagnosis penyakit paru

8/12/2019 Diagnosis Penyakit Paru

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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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10/65Pectus CarinatumPectus Excavatum


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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.
http://localhost/var/www/apps/conversion/tmp/scratch_5/trachpos1.mov


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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.
http://localhost/var/www/apps/conversion/tmp/scratch_5/exptape.movhttp://localhost/var/www/apps/conversion/tmp/scratch_5/exptape.movhttp://localhost/var/www/apps/conversion/tmp/scratch_5/exptape.mov


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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.
http://localhost/var/www/apps/conversion/tmp/scratch_5/chestexp.movhttp://localhost/var/www/apps/conversion/tmp/scratch_5/expbkpex.movhttp://localhost/var/www/apps/conversion/tmp/scratch_5/chestexp.mov


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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.au


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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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diagnosis penyakit paru

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