k3 prosedur diagnosis
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Joko MulyantoCHEM III – 2010
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PENDAHULUANPasien datang dengan keluhan (problem),
Dokter harus menegakkan diagnosis.Penegakan diagnosis butuh Prosedur.Langkah sistematis
- Anamnesis- Pemeriksaan Fisik- Pemeriksaan Penunjang
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ANAMNESIS Dibutuhkan komunikasi yang efektif Anamnesis : ana (hal-hal yang telah terjadi) & nesa
(ingatan) ta:1. Auto anamnesis : berasal dari penderita2. Allo anamnesis : berasal dari orang lain
Komponen yang harus ada ;1. Chief complaint (keluhan utama)2. RPS : 7 dimensi :
a. Lokasib. Kualitasc. Kuantitas/beratnyad. Kronologis/waktu (onset,durasi,frekuansi)e. Yg memperberatf. Yg memperingang. Gejala penyerta
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3. RPD4. RPK5. Riwayat sosial & pekerjaan6. Riwayat alergi
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HAL-HAL YANG HARUS DIPERHATIKAN Observation During Medical Interview
Relates well to patient during interview Pasien nyaman, sapa, kenalkan diri, kontak mata, mjd pendengar
yang baik sambail saying : Mm-hmm, Go on, I’m listening. Appropriately applies use of open-ended and closed-ended
questions What brings your here? How can I help you? What seems to be the problems?
Anything else? Tell me about it. Uses clarifying questions -- followed up positive responses
Tell me what u meant by a ‘cold’? Appropriate clustering and sequencing of questions Appropriate flow and transitioning (smooth flowing history) Prioritizes information and problems
By direct questions. Contoh : what was your chest pain like? Where did you feel it?Show me.
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Khusus ETI : taking an exposure history
1. ATSDR : Part 1. Exposure Survey
Exposures Health & safety practices at work site
Part 2. Work History Occupational profile Ocupational exposure inventory
Part 3. Environmental History2. Environmental Health Clinic Staff and
Environmental Health Committee of the Ontario College of Family Physicians is gratefully acknowledged.: A mnemonic (CH2OPD2)
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TAKING AN EXPOSURE HISTORY SUMBER : INDOOR AIR POLLUTION
AGENT ;1. ASAP ROKOK ;
Adakah anggota keluarga yang merokok? Jika ada, berapa pak/hr?
2. TUNGKU BAKAR/KOMPOR GAS ; Apakah pasien mempunyai tungku bakar? Apakah asap membaui ruangan/rumah? Kapan terakhir kali cerobongdan tungku
dibersihkan? Jika pasien pakai gas, apakah sesuai cara kerjanya? Apakah pasien pakai gas untuk pemanas?
3. MATERIAL BANGUNAN ; Apakah pasien tinggal di rumah mobil? Apakah rumah pakai busa formaldehid sbg
penyekat? Apakah mebel pakai kayu pres?
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4. ASBES Apakah rumah dibangun sebelum tahun 1970? Apakah isolasi/penyekatan asbes digunakan pada pipa atau
tangki/tank pemanas air atau untuk isolasi/penyekatan di loteng?
Apakah dinding dan langit-langit mempunyai sprayed-on atau troweled-on material?
Apakah pekerjaan renovasi di area denga asbes sudah direncanakan?
Apakah orang dewasa dalam keluarga pernah terpapar asbes pada pekerjaan yang sekarang atau lampau ( yaitu., pembuat kapal, buruh tambang)?
Jika ada, apakah pakaian kerja mereka dicuci di rumah?5. RADON
Apakah rumah pasien sudah diuji kadar radonnya? Jika ya, apa hasilnya? Adakah kadar radon yang tinggi di dalam rumah? Apakah anak-anak banyak bermain di basement atau lantai,
di mana radon berada pada konsentrasi yang lebih tinggi?
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6. PRODUK RUMAH TANGGA LAINNYA Apakah pasien menggunakan bahan-bahan seperti
berikut secara reguler: pembersih untuk gelas/kaca, tungku, lantai, saluran, dan kamar kecil; semir; air fresheners dan obat pembasmi hama; lem; bahan pelarut; mengecat pemaras; atau sealants?
Ke mana bahan-kimia ini disimpan dan dibuang?7. PESTISIDA
Apakah pasien menggunakan pestisida di kebun dan halaman ?
Apakah pasien mempekerjakan lawn-care secara profesional?
Apakah anak-anak diijinkan untuk main di (dalam) area yang baru-baru ini disemprot dengan pestisida atau lawn-care produk?
Apakah pasien menggunakan repellants? Apakah pasien mengetahui harus berbuat apa jika
terjadi keracunan?
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8. LEAD & SAMPAH Tahun bera rumah pasien dibangun? Apakah cat dalam rumah sudah jelek? Apakah bagian dalam patient’s rumah diperbaharui?
Adakah air minum pasien sudah diuji kadar leadnya? Apakah pasien menggunakan tembikar import?
Apakah ada anggota keluarga yang bekerja dengan lead (] ( e.g., instalasi penyulingan, pabrik baterei, atau pembangkit tenaga listrik)?
Jika ya, apakah pakaian kerja dibawa pulang? Apakah anggota keluarga bekerja dengan arts-and-
crafts produk yang berisi lead? Apakah pasien tinggal dekat suatu instalasi
penyulingan lead, pabrik baterei, atau pembangkit tenaga listrik?
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4 HAL YANG SERING MENYEBABKAN GANGGUAN KESEHATAN AKIBAT PENGARUH LINGKUNGAN : LINGKUNGAN RUMAH LINGKUNGAN KERJA LINGKUNGAN SEKOLAH HOBI DST
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CONTOH KASUSSEORANG ANAK PEREMPUAN 16 TH BERSAMA IBUNYA
DATANG KE DOKTER KELUARGA PADA BULAN JULI KARENA ANAK PEREMPUAN TERSEBUT SAAT BANGUN PAGI JAM 06.00 NAFAS TERASA PENDEK, BATUK, DAN DADA SESAK. ANAK PEREMPUAN TERSEBUT MEMILIKI RIWAYAT ASTMA & MEMAKAI SALBUTAMOL SEGERA SETELAH TIMBUL GEJALA.DARI CM YG ADA TIDAK ADA GEJALA SEBELUM BULAN JULI. EPISODE WHEEZING DIRASAKAN SEJAK SEBELUM MUSIM PANAS, DIMANA MEREDA DENGAN PEMAKAIAN SALBUTAMOL, & BATUK MENETAP SELAMA 2 MINGGU SETELAH INFEKSI SALURAN PERNAFASAN ATAS DI MUSIM DINGIN.DIA TIDAK MEMILIKI RIWAYAT ALERGI, HAYFEVER ATAU MASALAH KESEHATAN LAINNYA. BUKAN PEROKOK DAN KELUARGA TDK ADA RIWAYAT ALERGI.TERDENGAR WHEEZING PADA PEMERIKSAAN FISIK TAPI TIDAK TAMPAK SESAK.
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Peak expiratory flow 240 L/min (>400 L/min)15 menit setelah memakai salbutamol
semprot 2 puff : peak expiratory flow meningkat menjadi 320 L/min.
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TUGAS !INVESTIGASI APA YANG PERLU
DILAKUKAN/ANAMNESIS LEBIH LANJUT KECURIGAAN TENTANG EXPOSURES THAT MAY HAVE CONTRIBUTED TO THE ASTMA EPISODE.
THE PHYSICIAN QUICKLY TAKES AN ENVIRONMENTAL EXPOSURE HISTORY
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QUESTIONS SURROUNDING THIS CASE :1. APAKAH PAPARAN PASIEN DARI
OUTDOOR AIR POLLUTION?2. BAGAIMANA MEMBERI NASIHAT THD
FAKTOR PENCETUSNYA?3. APA KEMUNGKINAN PEMICU DARI
INDOOR AIR POLLUTION?4. BAGAIMANA PASIEN & KELUARGA TAHU
TENTANG STATUS KUALITAS OUTDOOR AIR DI MASYARAKAT/LINGKUNGANNYA?
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Langkah 2 : Physical examinationMerupakan penelusuran sistem sesuai
dengan keluhan utama (chief complaint)Pada kasus penyakit yang dicetuskan oleh
lingkungan, pada px fisik sama dengan px fisik pada umumnya.
Head to toe (dari ujung kepala sampai ujung kaki)
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PHYSICAL EXAMINATION SESUAI SYMPTOM (CASE STUDY)KU : APAKAH TAMPAK SESAK?TV : RR? NADI ? BP?KESADARAN?ENT ?PARU ?
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Contoh lung examinationThe 4 major components of the lung exam :
InspectionPalpationPercussionAuscultation
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Inspection/Observation A great deal of information can be gathered
from simply watching a patient breathe. Pay particular attention to: General comfort and breathing pattern of the
patient. Distressed, labored? Are the breaths regular and deep?
Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids).
Color of the patient, in particular around the lips and nail beds
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The position of the patient . It will often sit up-right .Breathing through pursed lips, often seen in cases of
emphysema Patient with emphysema bending over in Tri-Pod Position
Ability to speak Any audible noises associated with breathing
Wheezing Gurgling
The direction of abdominal wall movement during inspiration
Any obvious chest or spine deformities Pectus excavatum Barrel chest Spine abnormalities
Kyphosis Scoliosis
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Barrel chest
Pectus excavatum
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kiphosis
scoliasis
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PalpationSpecific situations where it may be helpful
include: Accentuating normal chest excursion
Place your hands on the patient's back with thumbs pointed towards the spine.
First rub your hands together so that they are not too cold prior to touching the patient.
Lift symmetrically outward when the patient takes a deep breath.
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Tactile Fremitus Normal lung transmits a palpable vibratory
sensation to the chest wall Investigating painful areas
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Percussion
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Auscultation
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LANGKAH KE-3: USUL PX LAB SESUAI INDIKASISPIROMETRIEOSINOFILRo THORAX
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The questions answered1. What was the patient’s exposure to outdoor The patient in the sample case was involved in a
baseball tournament for 2 days before symptom onset. She spent the time outdoors exposed to air pollutants and, by exercising and further increasing her respiratory rate, had increased her exposure. She was therefore exposed to high levels of ground-level ozone and fine particulate matter.
2. How should the patient and family be counselled about dealing with these trigger factors? Advise the patient to try to reduce exposure by
limiting or avoiding outdoor activities during smog episodes and, if necessary, to stay indoors at these times.
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Remind the patient and her family that ground-level ozone is at its highest level during the afternoon and evenings and that outdoor activities should be limited during these times. Inform them that the diurnal pattern of fine particulate matter is less pronounced, and thus it will be more difficult to know when to reschedule outdoor activities in response.
Instruct the patient to increase the monitoring of her peak expiratory flow during smog episodes and to adjust medications according to an established action plan.
Advise the patient to consider changing her lifestyle habits to reduce the production of air pollutants.
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3. What are the possible inducers and triggers from indoor air pollution? The possible inducers in the case study are dust mites
in the carpets, moulds in the damp basement and other moisture-damaged materials, and the cat.
The possible triggers are the tobacco smoke from the mother’s cigarettes, and nitrogen oxides emitted from the gas range and other combustion appliances.
4. How can the patient and family find out about the status of outdoor air quality in their community? They should be instructed to contact their provincial
ministry of the environment or the local medical officer of health. Also, smog advisories and alerts are prominently announced in newspapers and on radio and television.
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TUGAS !! TUGAS ;
CARI HAL-HAL YG PERLU DITANYAKAN DLM ANAMNESIS DGN KELUHAN UTAMA DENGAN KEMUNGKINAN KAUSANYA.1. SAKIT KEPALA (HEADACHE) :
INTOKSIKASI CO CHLORDANE GAZOLINE METHANOL METHYLEN CHLORID NITROGEN DIOKSIDA PESTISIDA TETRACHLORETHILEN TOLUEN
2. BATUK & SESAK NAFAS : INDOOR POLUTION NITROGEN DIOKSIDA RADON TOLUEN ASBESTOSIS SILICOSIS BERYLLIUM PENTACHLOR PHENOL FORMALIN
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3. RASH INTOKSIKASI CHROMIUM DIOXIN ENVIRONMENTAL EXPOSURE (ALERGEN,
IRRITAN) MERCURY METHYLMETHACRYLATE PENTACHLORPHENOL POLYCHLORINATED BIPHENYL (PCB)
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Referensihttp://www.medicine.ucsd.edu/clinicalmed/lu
ng.htmwww.cmaj.ca/cgi/reprint/166/8/1049 www.atsdr.cdc.gov/hanford/docs/
exposure_history.pdf www.ocfp.on.ca/local/file/EHC