Pemeriksaan Fisik Secara Head To Toe dan Persistem Pada Pasien Tb Paru

Summary

This video script showcases a nurse's physical examination of a patient presenting symptoms of fever, coughing, shortness of breath, and fatigue. The nurse conducts a thorough check-up, including recording vital signs such as temperature, blood pressure, pulse, and respiration rate. Additionally, the nurse performs various physical assessments from head to toe, including checking the respiratory system, heart, abdomen, and extremities. After the examination, the nurse suspects the patient may be suffering from a lung disease, such as tuberculosis, and recommends further tests for a more accurate diagnosis.

Takeaways

• 😀 The nurse introduces herself and begins by gathering the patient's basic information such as name, age, and medical history.
• 😀 The patient describes symptoms including fever, cough, phlegm, and shortness of breath.
• 😀 The nurse proceeds with the physical examination, starting with checking the patient's vital signs (temperature, blood pressure, pulse, and respiration).
• 😀 The nurse explains that the normal blood pressure range is 110/80, while the patient's blood pressure is lower at 90/70.
• 😀 The patient's temperature is found to be 38.5°C, indicating a fever, as normal temperature is 37°C.
• 😀 The nurse performs a pulse check, revealing a normal pulse rate of 60 beats per minute, but the patient has an elevated respiratory rate of 23 breaths per minute, indicating difficulty breathing.
• 😀 The nurse continues with a systematic head-to-toe physical exam, starting with the scalp, face, eyes, nose, mouth, ears, and neck, checking for symmetry, lumps, or swelling.
• 😀 The nurse observes that the patient's face appears pale, likely due to the fever, and their conjunctiva (eye area) is also slightly pale.
• 😀 The nurse checks the patient's chest and lungs, noting breath sounds and chest pain when palpated, indicating possible respiratory issues.
• 😀 The nurse checks the abdomen for tenderness and swelling, finding discomfort on the left side, possibly related to gastrointestinal issues or other internal problems.
• 😀 The nurse performs reflex tests and assesses the patient's extremities, noting that the hands and legs show no swelling or abnormal findings, indicating normal circulation and health.

Q & A

What symptoms did the patient report during the examination?

The patient reported fever, coughing with sputum, shortness of breath, and a pale appearance.

What vital signs were measured during the physical examination?

The vital signs measured included temperature, blood pressure, pulse, and respiration rate.

What was the patient's temperature during the examination?

The patient's temperature was 38.5°C, which is higher than the normal temperature of 37°C.

What was the patient's blood pressure reading?

The patient's blood pressure was 90/70 mmHg, which is lower than the normal reading of 110/80 mmHg.

What did the pulse rate and respiration rate indicate about the patient's condition?

The patient's pulse rate was normal at 60 beats per minute, but the respiration rate was 23 breaths per minute, which is higher than the normal range of 12-20 breaths per minute, possibly indicating shortness of breath.

What is the purpose of conducting a physical examination like the one in the video?

The purpose of the physical examination is to assess the patient's overall health, detect any medical issues, and monitor their vital signs, which can help in diagnosing potential health conditions.

What methods were used to perform the physical examination?

The methods used included inspection, palpation (touching), percussion (tapping), and auscultation (listening with a stethoscope).

What did the examination of the patient's respiratory system reveal?

The examination revealed that the patient had difficulty breathing, with a slightly labored breath and a wheezing sound, which could indicate a respiratory condition.

What were the findings during the examination of the patient's abdomen?

The examination revealed that the abdomen was symmetrical, but the patient complained of pain on the left side, indicating potential discomfort or underlying issues in the abdominal region.

What preliminary diagnosis did the nurse suggest based on the examination?

The nurse suggested that the patient may have tuberculosis (TB) in the lungs, based on the symptoms and examination findings, but advised further tests for a definitive diagnosis.