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HISTORY AND PHYSICAL IN THE PEDIATRIC PATIENT
Bambang Mulyawan
University of Muhammadiyah School of Medicine Department of Pediatrics
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RUANG LINGKUP (KETRAMPILAN)
• ANAMNESIS • DIAGNOSIS FISIS • PEMERIKSAAN PENUNJANG• KEGAWAT-DARURATAN • ( REHABILITATIF )
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ANAMNESIS• Beberapa hal khusus pd pasien anak :• Kebanyakan tidak bisa langsung/
alloanamnesis• Sering or-tu tidak dapat menjelaskan geja-
la penyakit anaknya dg baik• Data anamnesis merupakan 80% hal yg
diperlukan dlm penegakan diagnosis
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ANAMNESIS (LANJUTAN)
• Sering data anamnesis hanya asumsi dan persepsi or-tu/pengantar (bias), dan berkaitan dg pengetahuan,adat,tradisi, kepercayaan, kebiasaan, faktor budaya.
• Meperhatikan seluruh aspek tumbuh-kembang• Tidak hanya memperhatikan keluhan pasien
saja, “tugas utama dokter bukan mengobati penyakit,melainkan mengobati pasien”.
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ANAMNESIS (LANJUTAN)
• Langkah dlm pembuatan anamnesis :• Identitas pasien lengkap• Keluhan utama• Riwayat perjalanan penyakit sekarang• Riwayat penyakit dahulu• Riwayat dlm kandungan,kelahiran, makan-
an, imunisasi, tumbuh kembang, riwayat keluarga.
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ANAMNESIS :
• C ------ 3------- B -----2----A• 4. 5. 6.7.8.9. 1.• A : SAAT PEMBUATAN ANAMNESIS
1.KELUHAN UTAMA 2. RIWAYAT PERJALANAN PENYAKIT
• B : AWAL GJL PENYAKIT 3. RIWAYAT PENY.TERDAHULU
• C : SEJAK LAHIR 4. RIWAYAT KEHAMILAN 5. RWY.KELAHIRAN 6. RWY.MAKAN 7. IMUNISASI 8.TUMBUH KEMBANG 9. RINCIAN KEAD.KLG
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Contoh kasus :
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Contoh kasus
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PEMERIKSAAN FISIS• Keadaan Umum pasien dapat diperhatikan
bersamaan waktu anamnesis• Pem.fisis dimulai dg cara yg mudah,tidak
membuat anak takut/merasakan sakit, na-mun pencatatannya logis dan berurutan ( dari kepala kaki ; inspeksi,palpasi, per-kusi, auskultasi )
• Sebaiknya tidak diawali dg penggunaan alat bantu
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PEMERIKSAAN FISIS (LANJUTAN)
• ……….URUTAN JALANNYA PEMERIK-SAAN SEDIKIT BANYAK DITENTUKAN OLEH ANAK (PASIEN) DAN BUKAN OLEH DOKTER YANG MEMERIKSA “
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Apa yang dimaksud Pemeriksaan Fisik ?
Physical examination is a fundamental examining
method, it is proceeded by the sense organs such as
eyes, ears, nose and hands or simple tools –
stethoscope and plexor.
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Empat (4) prinsip utama Pemeriksaan Fisik
• Inspection • Palpation• Percussion• Auscultation“teach the eye to see, the finger to feel, and the ear
to hear”• What is the fifth? Smelling
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Peralatan untuk Pemeriksaan Fisik
Required Optional
Stethoscope GlovesTongue blades Gauze padsPenlight Lubricant gelTape measure Nasal speculumSphygmomanometer Turning fork: 128 Hz,512HzReflex hammer Pocket visual acuity cardSafety pins Oto-ophthalmoscope
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Persiapan dalam Pemeriksaan Fisik
• Wash your hands, preferably while the patient is watching
• Washing with soap and water is an effective way to reduce the transmission of disease
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Aspek penting lainnya
Where does the examiner stand?
• Stand right side of the bed
• Exam with one’ right hand
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Yang harus diperhatikan untuk pasien anak
• Remain calm and appear confident. • You are caring for a whole family. • Honesty is important.• Inform caregiver and child often. • Keep the family together. • Provide hope and reassurance to all.
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“Children of any age who are not too big to sit on a parent’s lap
are better examined there than on the examining table.”
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Pendekatan dalam pemeriksaan fisik pasien anak
• Head-to-toe sequence for assessing adult clients
• Sequence for pediatric assessments generally altered to accommodate child’s developmental needs
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Pencapaian pada pemeriksaan pasien anak
• Minimize stress and anxiety associated with assessment of various body parts.
• Foster trusting nurse-child-parent relationships.
• Allow for maximum preparation of child.• Preserve security of parent-child
relationship.• Maximize accuracy of assessment findings.
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Persiapan untuk pasien anak
• Child’s perception of painful procedures• Cooperation usually enhanced with
parent’s presence• Age-appropriate techniques
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1) Count respirations FIRST (before disturbing the child)
2) Count apical HR SECOND3) Measure BP (if applicable) THIRD4) Measure temperature LAST
Penilaian Vital Sign pada bayi dan anak
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Vitals Respiration
PulseBlood pressure
TempHeight Weight
infants and children
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RespirationInfants – rise and fall of the abdomen facilitates
counting
• Rate, regularity and rhythm• Depth• Respiratory Effort
– Retraction (ribs, supraclavicular notch)– Contraction of SCM’s – Flaring of nostrils– Paradoxic breathing
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Respiratory / pernafasan • Count for one full minute• May want to do before you wake the infant up• Rate will be elevated with crying / fever
– Pre-term: 40 – 60– Newborn: 30 – 40– Toddler: 25– School-age: 20– Adolescent: 16
Panic levels: < 10 or > 60
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Respiration
Age Respirations per minute
Newborn 30-80
1 year 20-40
3 years 20-30
6 years 16-22
10 years 16-20
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Clinical Tip
• To accurately assess respirations in and infant or small child wait until the baby is sleeping or resting quietly.
• You might need to do this before you do more invasive exam.
• Count the number of breaths for an entire minute.
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Pulse
• Apical pulse– 5th intercostal space in
the midclavicular line
• Femoral pulse– use a point halfway from
the pubic tubercle to ASIS as a guide
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Pulse
Age Beats per minute
Newborn 120-170
1 year 80-160
3 years 80-120
6 years 75-115
10 years 70-110
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Pulse rates
• Neonate: 70 – 190• 1-year: 80 – 160• 2-year: 80-130• 4-year: 80 – 120• 6-year: 75-115• 10-year: 70-110• 14-year: 65 – 105 / males 60 – 100• 18-year: 55-95 / males 50 - 90
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Blood Pressure
• Cuff size (children)– Width should cover ~2/3 of the upper arm or
thigh
Too wide - underestimate BPToo narrow - artificially high BP
http://store.datascope.com/A
ssets/product_images/0998-00-0003-21,22_s164_jpg.jpg
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Blood Pressure / Tekanan Darah
• The width of the rubber bladder should cover 40% of the length of upper arm/leg, and the length should encircle 100% of the arm.
• Crying can cause inaccurate blood pressure reading.
• Consider norms for age.
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Ukuran manset untuk kelompok umur yang sesuai
• Umur 0 -12 bulan : 2 inci ( 5 cm )• Umur 1 – 5 tahun : 3 inci ( 7,5 cm )• Umur 6 -12 tahun : 4 inci ( 10 cm )• Umur > 12 tahun : 5 inci ( 12,5 cm )
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Blood Pressure Cuff / “manset “
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Stetoskop
• Gunakan stetoskop binaural ( sisi sungkup dan membran ) , pipa pendek (25-30 cm ), tebal pipa 3 mm, diameter lumen pipa 3 mm.
• Stetoskop pediatrik : diameter membran 3-3,5 cm, bagian mangkuk/sungkup :3 cm.
• Sisi membran utk suara dg nada tinggi, sisi sungkup utk suara dg nada rendah.
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Suhu tubuh
Position for takingaxillary temperature.
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Temperature
• Use of tympanic membrane is controversial.• Oral temperature for children over 5 to 6
years.• Rectal temperatures are contraindicated for
anal surgery, diarrhea, or rectal irritation.• Rectal temperature only when absolutely
necessary.
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Temperature
• Use of tympanic membrane is controversial.• Oral temperature for children over 5 to 6
years.• Rectal temperatures are contraindicated for
anal surgery, diarrhea, or rectal irritation.• Rectal temperature only when absolutely
necessary.
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Anamnesis mempunyai peran yang sangat penting dalam diagnosis dan tatalaksana penyakit anak. Anamnesis (bersama pemeriksaan fisis) juga me-nuntun pemeriksa untuk melakukan pemeriksaan penunjang yang mungkin diperlukan.Pada semua pasien, anamnesis tidak terbatas pd masalah yang berhubungan dengan penyakit se-karang, melainkan juga harus mencakup riwayat pasien dalam kandungan ibu sampai saat dilaku-kan wawancara.Dengan anamnesis, selain diperoleh riwayat yang rinci dan sistematis tentang penyakit sekarang, juga harus tergambar status kesehatan dan status tumbuh kembang anak secara keseluruhan.Biasakanlah membuat catatan kaki pada akhir anamnesis, terutama kesan tentang tingkat keper-cayaan Anda terhadap yang diwawancarai.
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PENTING UNTUK DIPERHATIKAN
Tujuan pemeriksaan fisik adl. memperoleh informasi yang akurat tentang tentang keadaan fisis pasien. Karena sifat alamiah bayi dan anak, urutan pemeriksa-an tidak harus ikut sistematika yg lazim pd or. dewasa.Pada bayi dan anak kecil, auskultasi abdomen dan jantung didahulukan, diikuti dg pemeriksaan lain, dan diakhiri dg pemeriksaan yg menggunakan alat.Dalam melaporkan hasil pemeriksaan mulailah dengan identitas ( umur dan jenis kelamin), diikuti dengan kea-daan umum, kesadaran, tanda vital, baru disusul dg hasil pemeriksaan sistemik.Selalu gunakanlah kedua sisi stetoskop, dahulukan sisi sungkup ( untuk suara bernada rendah dan sedang ) kemudian sisi diafragma untuk suara bernada tinggi.
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Persiapan Asepsis and reducing the risk of infection
• Good hand washing
• Good hand drying
• Aseptic technique
• Good observation and questioning of the client
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Pemeriksaan abdomen
• Pada bayi dan anak kecil pemeriksaan abdomen sering kali didahulukan daripada pemeriksaan bagian tubuh lain
• Urutan pemeriksaan : inspeksiauskultasi palpasi perkusi. Maksud urutan tsb. adalah agar interpretasi hasil auskultasi tidak salah, karena setiap manipulasi pada abdomen akan mengubah bunyi peristaltik usus.
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Secquence of Abdominal Examination
Examination secquence inspection, auscultation, palpation , percussion Recording secquence inspection, palpation, percussion, auscultation
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Abdom
inal A
rea: Four regions
right upper quadrant
right lower quadrant
left upper quadrant
Left lower quadrant
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Abdom
inal Area:
Nine regionsright hypochondriac
region
left hypochondriac
regionepigastric region
umbilieal region
hypogastric region
right lumber region
left lumber
region
right iliac region
left iliac region
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Nine regions &
P
rojectionspleen
stomach
gallbladdertransverse colon
ascending colon
small intestine
sigmoid colon
urinary bladder
ileum
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The Chest
• Inspection• Palpation• Percussion• Auscultation
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Inspection• Shape• Scars• Lesions• Resp rate• Resp depth• Mode of breathing• Abnormal inspiratory movements• Abnormal expiratory movements• Asymmetry of movement
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Chest wall
1.Pectus carinatum
3.Barrel chest,”toraks emfisematikus”
2.Pectus excavatum
: bulat seperti tong
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Palpation
• Chest expansion• Tactile vocal fremitus
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Percussion
• Illicit resonance• Compare both sides• Map out abnormal area
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Percussion technique
• Place left hand on chest wall, palm downwards with fingers separated
• 2nd phalanx over area of intercostal space• Right middle finger strikes the 2nd phalanx
producing hammer effect• Entire movement comes from wrist
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Rumple-Leede Test (1)
• Tourniquet Test
• Rumple-Leede Capillary Fragility Test
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Rumple-Leede Test (2)
• Suatu metode diagnostik klinis untuk mengetahui tendensi/kecenderungan adanya perdarahan pada seorang pasien.
• Test ini menilai fragilitas dinding kapiler dan digunakan untuk mengidentifikasi adanya trombositopeni.
• WHO : salah satu alat yg diperlukan untuk diagnostik DHF.
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Rumple-Leede Test (3)
• Cara : Cuff/manset tensimeter dipasang dan dipertahankan pada posisi tekanan darah antara diastolik dan sistolik selama 5 menit.
• Hasil positif : terdapat 20 petechiae pada daerah volar lengan seluas diameter 1 inch ( +/- seluas uang logam Rp.100,- lama )
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Selamat Belajar
T e r i m a K a s i h
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Clinical Outcomes
3. Enhanced support services to maintain family cohesion, sense of control, satisfaction with care, and informed decision making.
4. Facilitation of transitions from settings of care due to progression of condition.
5. Advanced preparation and support of families when end-of-life care becomes imminent.
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Financial Outcomes
1. Prevent unnecessary Emergency Room and Hospital admissions.
2. Facilitate earlier discharges from hospitals into home care.
3. Perform some treatments and procedures, such as chemotherapy, at home.
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Financial Outcomes
4. Supporting families to provide end-of-life care at home rather than the hospital, as appropriate.
5. Providing “hospice in the hospital” when it is appropriate for a terminal admission.*********(not covered under Florida’s Model)
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Eligibility:• Children 0-21 years of age • have a life-limiting condition as
certified by their PCP • who wish to receive PIC services• are enrolled in the CMSN.
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Program Sites: PensacolaGainesvilleJacksonvilleSt. PeteFt. MyersWest Palm BeachMiami
New: July 2007 Ft. Lauderdale
Sarasota
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PIC/PACC SERVICES
Pain and Symptom Management
Therapeutic Counseling
Expressive Therapies (music, art, play)
Respite
Specialized Nursing
Specialized Personal Care
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Enrollment Trends
Current Enrollment as of December 2006: 226 children
Majority of Children are in Midstage: Children who are 4 months or more post-diagnosis and who are on active treatment and/or intervention.
Top five ranked diagnoses: Congenital Anomaly/GeneticBrain Injury/developmentLeukemiaMuscular DystrophyCerebral Palsy
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2005-2006 Surveys
CMS Nursing Directors
Hospice Directors
Family
Child
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Summary and Conclusions
CMS Survey Results
•How children are identified and referred :The variability across the sites in how children are
identified and referred to the PIC Program has been address during the Technical Assistance and Monitoring Visits.
•Training
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Summary and Conclusions
Hospice Survey Results
•How families are approached
•How Care Plans are developed
•Ongoing care coordination activities between CMSN staff and the hospice staff is conducted.
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Summary and Conclusions
Parent Survey Results
•Survey length is acceptable, but changes are needed to avoid duplicative questions and to include responses for non applicable questions.
•Questions will be added:Satisfaction with the assigned hospice nurse, social workerSatisfaction with the PIC Program in generalParent questions to address:
enrollment experiencesservices they and their children are receiving
unmet needs
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Summary and Conclusions
Child Survey Results
Children had difficultly answering the survey questions •Questions will remain the same but answer choices will be modified.
•Open ended question about their experiences with the program and the services they received will be added.
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2006-2008Activities and Focus
Evaluation Cost EffectivenessTitle V OfficesImplement quality assurance monitoring toolSite visitsChart reviewsCreate best practicesReapplication of the waiverThe addition of 2 new program sites; Broward
Sarasota
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“There are risks and costs to a program of action. But they are far less than the long-range risks
and costs of comfortable inaction.”
John F. Kennedy
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Health Care for Children with Special Needs
Making A Difference