I. DESKRIPSI MODUL

Latar Belakang

Tujuan PembelajaranSetelah selesai mengikuti pelatihan, peserta mampu melakukan :

1. Inspeksi dada saat istirahat (statis)

2. Inspeksi saat respirasi (dinamis)

3. Palpasi ekspansi pernafasan

4. Palpasi tactile fremitus5. Palpasi apex jantung

6. Perkusi paru dan jantung

7. Auskultasi paru

8. Auskultasi jantung

9. Inspeksi payudara

10. Palpasi payudara

Metoda Pembelajaran- Video session

- Demonstrasi dengan model anatomik

- Berlatih mandiri dengan sesama teman

Alat Bantu- Arloji/stopwatch 5 buah

- Stetoskop 5 buah

- Audio visual 1 set

- Kapas alkohol 10 sachet

Waktu

5 menit

Daftar Instruktur

- dr. BP Putra Suryana, SpPD-KR

- dr. Supriono, SpPD- dr. Putu, SpP

EvaluasiCheck list

Referensi

II. PROSEDURII.3.1. PEMERIKSAAN JANTUNG

Pendahuluan

Posisi Pasien & PersiapanYou will need to expose the patient's chest for this examination. For female patients you may want to use an examination gown or drape. Place your patient in a semi-supine position, at an angle of 45%. Make sure that the patient is comfortable in this position.

Pencegahan infeksiPrior to examining the patient, make sure you properly wash your hands and cleanse the diaphragm / bell components of your stethoscope with alcohol wipes.

Inspeksi Observe the chest carefully. Specifically note for any: Scars (e.g. median sternotomy scar; thoracotomy scar); chest wall deformities (e.g. pectus excavatus )

Sternotomy scar Pectus excavatus

Palpasi (a) Palpation for the apex beat.

The apex beat is the furthest position laterally and inferiorly, at which the cardiac

impulse can be palpated. The apex beat is due mainly to the action of the left

ventricle. In a normal patient, the apex beat is usually positioned at the 5th intercostal space (ICS) in the mid clavicular line (MCL). To palpate for the apex beat place your hand over the left hemi-thorax region and feel for the most lateral and inferior pulsation. To count intercostal spaces (ICS), first identify the manubriosternal junction. The rib attached along side this is the 2nd rib and the space below the rib is the 2nd ICS. Count down until you are at the level where you can feel the apex beat.

Palpation for the apex beat

b) Palpation for heaves.

Place your hand on the patients chest in the left parasternal region to palpate for

any heaves that may be caused by right ventricular enlargement. Palpation for heaves

(c) Palpation for thrills :

Turbulent blood flow, which causes cardiac murmurs on auscultation (see later) can sometimes be palpable i.e. a thrill. Place your hand over the pulmonary and aortic areas (see later) to palpate for any thrills.

Palpation for thrills

PerkusiPercussion of the heart is rarely performed and will not be discussed further here.

Auskultasia) Heart sounds : The heart sounds are sometimes described as sounding like lupp dubb (1st followed by 2nd heart sounds) The first heart sound is caused by vibrations arising from closure of the mitral and the tricuspid valves. It coincides with the beginning of ventricular systole and so each first sound comes at the beginning of the pulse wave. The second heart sound is softer, shorter and of higher frequency and is caused by closure of the aortic and the pulmonary valves. It coincides with the end of ventricular systole and so occurs at the end of each pulse. Because of their relationship to the pulse wave it is useful to listen to the heart sounds while feeling the pulse.

b) Murmurs : The presence of a murmur indicates either increased or turbulent blood flow. Increased flow across a normal valve may occur in high output states, such as pregnancy, severe anaemia, or associated with a significant pyrexia. Turbulent flow may arise because of abnormal flow across a valve or as a result of an abnormal communication between the chambers of the heart / great vessels. If a murmur is heard, the following should be noted: timing of the murmur (systole [ejection, pan, mid, late] or diastole [early, mid]); quality; radiation; intensity (grading); location where murmur is best heard; variation with respiration (murmurs on the right side of the heart increase during inspiration). You will learn more about murmurs in the CSEC, clinical attachments and in other modules in your undergraduate career.

It is essential to simultaneously examine the carotid pulse long enough to give you an indication of the timing of systole and enable sounds to be placed in the correct part of the cardiac cycle

Penutup

Pencatatan

II.3.2. PEMERIKSAAN RESPIRASI

Posisi Pasien & PersiapanHave the patient undress to the waist, ideally sitting on the edge of the bed.

Pencegahan infeksiWash your hands and cleanse your stethoscope with alcohol wipe.

Inspeksi(a) Chest wall deformities: Are there any chest wall deformities? (e.g. pectus excavatum / pectus carinatum) Does the chest appear over expanded? (i.e. Barrel shaped chest ) Is there any Kyphosis present? Scoliosis? Pectus excavatus

(b) Scars: Is there any evidence of scars from previous surgery?

(c) Respiratory rate: Consider this opportunity to measure the patients respiratory rate. Often when you tell a patient that you are measuring their respiratory rate they often tend to breath slower or faster. Therefore respiratory rate is often measured surreptitiously by observing the respiratory movements of the chest wall, while placing you fingers over the patient's radial pulse and telling them that you are Taking their pulse where as in fact you are measuring their respiratory rate! The normal respiratory rate in an adult is 12 breaths per minute. A raised respiratory rate is called tachypnoea

Palpasi(a) Apex beat : Feel for the patients apex beat. The apex beat is often impalpable in a chest which is hyper-expanded secondary to chronic airflow obstruction. Movement of the apex beat from one side to the other may be caused by several conditions including pleural effusion, tension pneumothorax

(b) Chest expansion : By assessing chest expansion the examiner aims to assess the range and symmetry of chest wall movements. Place your hands firmly on the chest wall, with your thumbs slightly lifted off the chest so that they are free to move with respiration (placing your thumbs up provides the examiner with a visible marker to assess the range and symmetry of chest wall movements). Ask the patient to take a deep breath in and observer the range and symmetry of movement. Reduced expansion on one side indicates a lesion on that side. This should be performed on the front and the back of the patients chest.

Assessment of anterior and posterior chest wall expansion

Perkusi(a) Place you hand on the patients chest wall with the fingers slightly separated and aligned with the ribs and pressing the middle finger firmly again the chest.

(b) With the other hand (usually the middle finger) strike firmly the middle phalanx of the middle finger that is on the patients chest wall.

(c) 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

Auskultasi(a) Breath sounds : Normal breath sounds are called vesicular. The intensity of the sounds increase during inspiration and then fade away during the first third of expiration. Bronchial breath sounds, heard in inspiration and expiration, result from enhanced transmission of higher frequency sounds through solid lung tissue as in consolidation or fibrosis.

(b) Intensity of the breath sounds : Usually described as being normal, reduced or absent. It is important to compare air entry in all areas of the chest. For example breath sounds may be absent locally over a pneumothorax or a pleural effusion.

(c) Added sounds : Wheeze, rhonchi, crepitations (crackles), pleural rub

Penutup

Pencatatan

III. CHECK LIST

Nama:

NIM:

Kelompok:

Tanggal:

JENIS KEGIATANPenilaian

IIIIII

PEMERIKSAAN JANTUNG

1.Infection control measures : Prior to examining the patient, make sure you properly wash your hands and cleanse the diaphragm / bell components of your stethoscope with alcohol wipes.

2.Patient positioning : You will need to expose the patient's chest for this examination. For female patients you may want to use an examination gown or drape. Place your patient in a semi-supine position, at an angle of 45%. Make sure that the patient is comfortable in this position.

3.Inspection : Observe the chest carefully. Specifically note for any: Scars (e.g. median sternotomy scar; thoracotomy scar); chest wall deformities (e.g. pectus excavatus )

Sternotomy scar Pectus excavatus

4.Palpation :

(a) Palpation for the apex beat.

The apex beat is the furthest position laterally and inferiorly, at which the cardiac

impulse can be palpated. The apex beat is due mainly to the action of the left

ventricle. In a normal patient, the apex beat is usually positioned at the 5th intercostal space (ICS) in the mid clavicular line (MCL). To palpate for the apex beat place your hand over the left hemi-thorax region and feel for the most lateral and inferior pulsation. To count intercostal spaces (ICS), first identify the manubriosternal junction. The rib attached along side this is the 2nd rib and the space below the rib is the 2nd ICS. Count down until you are at the level where you can feel the apex beat. Palpation for the apex beat

(b) Palpation for heaves.

Place your hand on the patients chest in the left parasternal region to palpate for any heaves that may be caused by right ventricular enlargement. Palpation for heaves

(c) Palpation for thrills :

Turbulent blood flow, which causes cardiac murmurs on auscultation (see later) can sometimes be palpable i.e. a thrill. Place your hand over the pulmonary and aortic areas (see later) to palpate for any thrills.

Palpation for thrills

5.Percussion : Percussion of the heart is rarely performed and will not be discussed further here.

6.Auscultation

(a) Heart sounds : The heart sounds are sometimes described as sounding like lupp dubb (1st followed by 2nd heart sounds) The first heart sound is caused by vibrations arising from closure of the mitral and the tricuspid valves. It coincides with the beginning of ventricular systole and so each first sound comes at the beginning of the pulse wave. The second heart sound is softer, shorter and of higher frequency and is caused by closure of the aortic and the pulmonary valves. It coincides with the end of ventricular systole and so occurs at the end of each pulse. Because of their relationship to the pulse wave it is useful to listen to the heart sounds while feeling the pulse.

(b) Murmurs : The presence of a murmur indicates either increased or turbulent blood flow. Increased flow across a normal valve may occur in high output states, such as pregnancy, severe anaemia, or associated with a significant pyrexia. Turbulent flow may arise because of abnormal flow across a valve or as a result of an abnormal communication between the chambers of the heart / great vessels. If a murmur is heard, the following should be noted: timing of the murmur (systole [ejection, pan, mid, late] or diastole [early, mid]); quality; radiation; intensity (grading); location where murmur is best heard; variation with respiration (murmurs on the right side of the heart increase during inspiration). You will learn more about murmurs in the CSEC, clinical attachments and in other modules in your undergraduate career.

7.It is essential to simultaneously examine the carotid pulse long enough to give you an indication of the timing of systole and enable sounds to be placed in the correct part of the cardiac cycle

PEMERIKSAAN RESPIRASI

1.Infection control measures : Wash your hands and cleanse your stethoscope with alcohol wipe.

2.Patient position : Have the patient undress to the waist, ideally sitting on the edge of the bed.

3.Inspection :

(a) Chest wall deformities: Are there any chest wall deformities? (e.g. pectus excavatum / pectus carinatum) Does the chest appear over expanded? (i.e. Barrel shaped chest ) Is there any Kyphosis present? Scoliosis? Pectus excavatus

(b) Scars: Is there any evidence of scars from previous surgery?

(c) Respiratory rate: Consider this opportunity to measure the patients respiratory rate. Often when you tell a patient that you are measuring their respiratory rate they often tend to breath slower or faster. Therefore respiratory rate is often measured surreptitiously by observing the respiratory movements of the chest wall, while placing you fingers over the patient's radial pulse and telling them that you are Taking their pulse where as in fact you are measuring their respiratory rate! The normal respiratory rate in an adult is 12 breaths per minute. A raised respiratory rate is called tachypnoea

4.Palpation :

(a) Apex beat : Feel for the patients apex beat. The apex beat is often impalpable in a chest which is hyper-expanded secondary to chronic airflow obstruction. Movement of the apex beat from one side to the other may be caused by several conditions including pleural effusion, tension pneumothorax

(b) Chest expansion : By assessing chest expansion the examiner aims to assess the range and symmetry of chest wall movements. Place your hands firmly on the chest wall, with your thumbs slightly lifted off the chest so that they are free to move with respiration (placing your thumbs up provides the examiner with a visible marker to assess the range and symmetry of chest wall movements). Ask the patient to take a deep breath in and observer the range and symmetry of movement. Reduced expansion on one side indicates a lesion on that side. This should be performed on the front and the back of the patients chest.

Assessment of anterior and posterior chest wall expansion

5.Percussion :

(a) Place you hand on the patients chest wall with the fingers slightly separated and aligned with the ribs and pressing the middle finger firmly again the chest.

(b) With the other hand (usually the middle finger) strike firmly the middle phalanx of the middle finger that is on the patients chest wall.

(c) 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

6.Auscultation :

(a) Breath sounds : Normal breath sounds are called vesicular. The intensity of the sounds increase during inspiration and then fade away during the first third of expiration. Bronchial breath sounds, heard in inspiration and expiration, result from enhanced transmission of higher frequency sounds through solid lung tissue as in consolidation or fibrosis.

(b) Intensity of the breath sounds : Usually described as being normal, reduced or absent. It is important to compare air entry in all areas of the chest. For example breath sounds may be absent locally over a pneumothorax or a pleural effusion.

(c) Added sounds : Wheeze, rhonchi, crepitations (crackles), pleural rub

Keterangan penilaian :

= dikerjakan dengan benar/sesuai urutan prosedur

X = dikerjakan tetapi kurang benar/tidak sesuai urutan prosedur

- = tidak dikerjakan

II.3

THORAX

II.4

KETRAMPILAN

PEMERIKSAAN THORAX

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)

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)