PEMERIKSAAN THORAX

PSIK
FIKES UMM

Ribs, clavicles, sternum

Angle of Louis
(manubriosternal
angle): marker for:
Where second rib
meets sternum (count
ribs from here)
Carina of trachea
Arch of aorta

Anterior Surface of Thorax

Palpate the following
Sternum (3 parts)
Jugular notch
Sternal Angle (= 2nd rib)
Clavicle
Costal margin
Infrasternal angle
Xiphosternal joint

Midclavicular Line
Midaxillary Line

IMAGINER LINE (Garis bayangan)

Garis bayangan midsternalis

dan midclavikula anterior

1. Paru
On the anterior chest, the
lungs extend from 4cm above
the first rib to the 6 th rib (or
so).
On the posterior chest wall,
lungs extend from T1 (first
thoracic vertebra) down to T9
(during expiration) or T12
(duringinspiration)

General Considerations
Ideally the patient should be sitting on the
end of an exam table.
The examination room must be quiet to
perform adequate percussion and
auscultation.
Observe the patient for general signs of
respiratory disease (finger clubbing,
cyanosis, air hunger, etc.).
FOUR METHODS OF CHEST EXAMINATION
1.
2.
3.
4.

Inspection
Palpation
Percussion
Auscultation

A. Observe the rate, rhythm, depth, and effort of

breathing. Note whether the expiratory phase is
prolonged
B. Shape of chest:
1. Normal chest (ellips) transverse > AP
2. Pectus excavatum (funnel chest) sternum bertakuk
masuk
3. pectus carinatum (pigeon chest) sternum menonjol
keluar
4. Increased anteroposterior (AP) diameter (barrel chest)
dada seperti tong

C. Observe for retractions and Use of accessory

muscles of respiration:sternomastoids, abdominals

2. PALPATION
1. Identify any areas of tenderness or
deformity by palpating the ribs and
sternum Daerah nyeri tekan
2. Assess expansion and symmetry of the
chest by placing your hands on the
patient's back, thumbs together at the
midline, and ask them to breath deeply.
Kesimetrisan pergerakan dada
Vokal Fremitus dan Fremitus taktil

tactile fremitus: Chest wall vibrations

from speech (patient says "ninety-nine").
Compare sides. Fremitus should be
symmetric - the same on both sides.
Abnormal fremitus can help you
diagnose several lung abnormalities:
Decreased fremitus occurs if something
gets between the lung and chest wall:
Air in the pleural space ( pneumothorax
or "collapsed lung")
Fluid in the pleural space ( pleural
effusion )
Scarred, thickened pleura
Increased fremitus:
In pneumonia, thick pus in the airways
and alveoli increases vibration
transmission (like wobbling jello).
Patients with pneumonia may have
increased fremitus on that side.

3. PERCUSION
A. 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.
4. Practice your technique until you can consistantly produce
a "normal" percussion note on your (presumably normal)
partner before you work with patients.

B. Posterior Chest
1. Percuss from side to side and top to bottom using the
pattern shown in the illustration. Omit the areas covered by
the scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you
hear.
4. Find the level of the diaphragmatic dullness on both sides.

Interpretation
C. Anterior Chest
1. Percuss from side to side
and top to bottom using
the pattern shown in the
illustration.
2. Compare one side to the
other looking for
asymmetry.
3. Note the location and
quality of the percussion
sounds you hear.

Percussion Notes and Their

Meaning
Flat or
Dullness

liquid or solid
1. Pleural Effusion
2. Lobar Pneumonia
lung area full of pus

Normal

Healthy Lung or
Bronchitis

Hyperresonant

Emphysema or
Pneumothorax

4. AUSCULTATION
TUJUAN : mendengarkan suara nafas
Breath sounds are produced by turbulent air flow
A. Posterior Chest
1. Auscultate from side to side and top to bottom using the pattern
shown in the illustration. Omit the areas covered by the
scapulae.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

B. Anterior Chest
1. Auscultate from side to side and top to bottom using the pattern
shown in the illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

Suara Nafas Normal

1. Trakeal : bunyi yang terdengar kasar, keras, dan
dengan tinggi nada tinggi pada bagian trakea
ekstratoraks
2. Bronkial : bunyi yang dengan tinggi nada tinggi,
seperti udara mengalir melalui pipa didengar di atas
manubrium sternal
3. Vesikular : bunyi yang terdengar lemah dengan tinggi
nada rendah seluruh lapang paru
4. Bronkovesikular : campuran bunyi bronkial dan bunyi
vesikular hanya terdengar pada ICS I dan II

Suara nafas tambahan (Adventitious (Extra) Lung

Sounds)
Crackles/ Rales : These are high pitched, discontinuous
sounds similar to the sound produced by rubbing your
hair between your fingers. signs of water in the alveoli
(heart failure), pus in the alveoli (pneumonia), or scarring
(pulmonary fibrosis)
Wheezes/Wheezing: These are generally high pitched
and "musical" in quality. Stridor is an inspiratory wheeze
associated with upper airway obstruction (croup). sign
of asthma or, if localized, of a tumor or foreign body
Rhonchi : These often have a "snoring" or "gurgling"
quality. Any extra sound that is not a crackle or a wheeze
is probably a rhonchi. originate in larger airways than
wheezes and are a sign of bronchitis
Friction rub is a dry, leathery sound heard in inspiration
and expiration. It is a sign of inflammation of the pleura.

 SUARA UCAPAN
1. Bronchophony is increased clarity of words,
e.g. in area of pneumonia
2. Whispered pectoriloquy -- even a whisper is
clear to the stethoscope - is an extreme form
of bronchophony (Suara terdengar jauh

dan tidak jelas)

3. Egophony: patient says EE and stethoscope

hears A - is similar to increased tactile fremitus.
Egophony may be the only physical
examination abnormality in early pneumonia.

JANTUNG/CARDIO
Examination of the heart
includes:
Inspection: of jugular venous
pulse and point of maximal
impulse
Palpation: of point of
maximum impulse, and
precordium for lifts, heaves and
thrills
Auscultation: for valve closing
sounds (S1 and S2), extra
sounds (S3 and S4), murmurs,
clicks and rubs

AUSCULTATION OF THE HEART

be sure to use both sides of the stethoscope to examine
the heart
the diaphragm is best for hearing high-pitched sounds,
including S1, S2 and most heart murmurs
the bell is bests for hearing low-pitched sounds, including
S3, S4 and a few murmurs (e.g. mitral stenosis)
use LIGHT TOUCH when using the bell. Pressure turns it
into a diaphragm
AUSCULTATION: WHAT MAKES NOISES IN THE HEART?
Valves closing: atrioventricular - mitral and tricuspid (S1) and
semilunar -- aortic and pulmonic (S2)
Blood striking the left ventricle: S3 and S4
Increased flow across normal valves - for instance, in
pregnancy, anemia, or hyperthyroidism
Turbulent flow through an abnormal valve

S1 and S2
The Lub-dub sound of the heart is S1-S2.
S1:
S1 is the sound made when the mitral and
tricuspid (atrioventricular or AV) valves
close. It marks the beginning of systole
S1 is loudest at apex or left lower sternal
border
S1 is usually single; but may be narrowly
split at the LLSB. This is normal.

S2:
S2 is the sound made when the aortic and
pulmonic (semilunar) valves close. It
marks the beginning of diastole.
S2 is loudest at the base. The top of the
heart is the base.
S3 usually splits with inspiration.

GALLOPS: S3 and S4
Both S3 and S4 are caused by blood
striking the left ventricle
S3 and S4 are heard at the apex (PMI)
only
S3 and S4 are both diastolic sounds
S3 and S4 are low-pitched sounds, so
they are heard with the bell of your
stethoscope.