cr piopneumothoraks nicky fixd
TRANSCRIPT
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
1/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
2/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
3/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
4/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
5/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
6/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
7/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
8/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
9/62
Abdomen
Inspection : abdomen flat, no tension, no dilatedveins
Palpation : no percussion pain, no defense
muscular, no enlarged liver Percussion : timpanic, percussion pain (-), shifting
dullness (-)
Auscultation : bowel movement (+), normal
Extemity : warm , oedem regio dorsum pedis dextra etsinistra (+), oedem regio antebrachii dextra (+), cyanosis (-)
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
10/62
Laboratory and Imaging(RSAM July 23rd 2013)
Hb 14.0 g/dl (N : 13,5-18 gr% )
ESR 40 mm/jam (N : 0-10 mm/jam)
Leucocyte 96.000/ml (N : 4500-10.700)
Diff count 0/0/0/60/34/6 (N : 0-1/ 1-3/2-6/50-70/20-40/2-8)
Trombocyte 460.000 /ul (N : 150.000-400.000/ul)
Chemical Blood
OT/PT 19/23 ul (N : 6-30/6-45 ul) Ureum 19 u/l (N : 10-40 u/l)
Creatinin 23 u/l (N : 0,7-1,3 u/l)
GDS 151 mg/dl (N : 70-200 mg/dl)
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
11/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
12/62
Sensitivity Test:
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
13/62
Postero-anterior chest Roentgen ( July 8th2013)
Conclusion : Hidropneumothoraks dextra withcolaps in right lung field
Interpretation :
Bones and joints (clavicula, scapula,
costae, vertebrae) are intact
Trachea deviasi (-)
Avascular and hyperluscent area in
left lung field
Blunting of right costophrenic angle
(air fluid level form)Invisible infiltrat in left lung field
Size of cor is normal
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
14/62
RESUME
Os came with complaints of left chest pain through to the back and abdomen,
accompanied by shortness, and productive cough. Chest pain felt since 2 months
before entering the hospital but patients do not care and continued to work. Osfeel chest pain severe increasingly since 2 days. Os feel nauseous and he vomit
since 2 days before entering the hospital. Os complained of shortness. Tightness is
felt if he in activity. He can not work as usual. Tightness has been felt since 2 days
before entering the hospital. Tightness is reduced when at rest but he was still
difficult to breathe. Os also complained of productive cough, cough has been felt
since first week before entering the hospital. Cough is persistent with sputum and
the colour is yellowish, now he is not cough anymore. He did not notice any
wheezing or weird breath sounds. He also said that he never been sweaty night,
low appetite, and weight loss. Him weight is same with he has illness. Os came to
the clinic and recommended to get x-rays examination . X-rays examination results
illustrated there was fluid in the lungs. Os has a history of intermittent fever and
the fever still common when taking the stall medicine. Os did not has a long cough
history. Os did not has a history of ATD (Anti Tuberculosis Drug). Os did not has a
history of dibetes melitus. Os did not has a history of hypertension.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
15/62
Physical examination revealed the patient looks ill but notin acute distress, compos mentis, Pulse 74 bpm, regular,Temperature 38.70C, Respiration Rate 36 x/minute, BMI22,49 kg/m2, Ananemic conjunctiva +/+. Chest examinationrevealed WSD tube inserted into fifth intercostal space, left
axillary line. Decreased left side thoracic expansion andabsent breath sound on the left side. Laboratory findingsrevealed mild anemia (Hb 14 g/dl), total leucocyte count of26.000. The posteroanterior chest x ray revealed a leftpneumothorax with left lung infiltrat.
From WSD fluid we found secret like pus, and the result ofbactery culture found gram-negative rods bacteria(Alkaligenes Sp)
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
16/62
Diagnosis
Piopneumothoraks
Treatment
O2 2 Litres/minute IVFD RL gtt X/minute
Ceftriaxone 1 g/ 12 hours (IV)
Metronidazol / 12 hours (IV)
Ambroxol sirup 3x1C Observe the development of WSD till the undulations and
Bubble negative
Chest X-Ray if the lug re-expands, then off WSD
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
17/62
Prognosis
Quo ad vitam : dubia
Quo ad functionam : dubia
Quo ad sanationam : dubia ad bonam
Recommended Examination
Lipid profile, uric acid serum
ECG
Acid-resistant bacteria
Sitology bacteria
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
18/62
SECTION 2nd
REFERENCE
A. PLEURAL EFFUSION
1.1 EtiologyAlthough the etiologic spectrum of pleural
effusion is extensive, most pleural effusions
are caused by congestive heart failure,
pneumonia, malignancy, or pulmonary
embolism.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
19/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
20/62
Pleural effusions are generally classified astransudates or exudates, based on themechanism of fluid formation and pleural fluidchemistry. Transudates result from an imbalance in oncotic and
hydrostatic pressures, whereas
exudates are the result of inflammation of the pleuraor decreased lymphatic drainage.
In some cases, the pleural fluid may have acombination of transudative and exudativecharacteristics.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
21/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
22/62
1.3 Clinical Manifestations
The clinical manifestations of pleural effusion
are variable and often are related to the
underlying disease process.
The most commonly associated symptoms are
progressive dyspnea,
cough, and
pleuritic chest pain.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
23/62
1.4 Physical Examinations
Physical findings in pleural effusion are variableand depend on the volume of the effusion.
Generally, there are no physical findings foreffusions smaller than 300 mL.
With effusions larger than 300 mL, findings mayinclude the following:
asymmetrical chest expansion, with diminished ordelayed expansion on the side of the effusion,
decreased tactile fremitus, and
Dullness to percussion,
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
24/62
Mediastinal shift away from the effusion - This is
observed with effusions of greater than 1000 mL;
Displacement of the trachea and mediastinum towardthe side of the effusion is an important clue to
obstruction of a lobar bronchus by an endobronchial
lesion, which can be due to malignancy or, less
commonly, to a nonmalignant cause, such as a foreign
body.
Diminished or inaudible breath sounds
Egophony ("e" to "a" changes) at the most
superior aspect of the pleural effusion Pleural friction rub
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
25/62
Other physical findings, as follows, may suggest
the underlying cause of the pleural effusion:
Peripheral edema, distended neck veins, and S3gallop
suggest congestive heart failure. Edema may also be amanifestation of nephrotic syndrome; pericardial
disease; or, combined with yellow nails, the yellow
nail syndrome.
Cutaneous changes with ascites suggest liver disease
Lymphadenopathy or a palpable mass suggests
malignancy.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
26/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
27/62
These criteria require simultaneousmeasurement of pleural fluid and serum proteinand LDH. However, a meta-analysis of 1448patients suggested that the following combined
pleural fluid measurements might have sensitivityand specificity comparable to the criteria fromLight et al for distinguishing transudates fromexudates:
Pleural fluid LDH value greater than 0.45 of the upperlimit of normal serum values
Pleural fluid cholesterol level greater than 45 mg/dL
Pleural fluid protein level greater than 2.9 g/dL
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
28/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
29/62
The more common causes of exudates include thefollowing: Parapneumonic causes,
Malignancy (most commonly, lung or breast cancer,lymphoma, leukemia; less commonly, ovarian carcinoma,stomach cancer, sarcomas, melanoma)[9], Pulmonaryembolism, Collagen-vascular conditions (rheumatoidarthritis, systemic lupus erythematosus),
Tuberculosis (TB), Pancreatitis,
Trauma,
Postcardiac injury syndrome,
Esophageal perforation, Radiation pleuritis, Sarcoidosis, Fungal infection,
Pancreatic pseudocyst, Intra-abdominal abscess, Status-post coronary artery bypass graft surgery, Pericardialdisease, Meigs syndrome (benign pelvic neoplasm withassociated ascites and pleural effusion),
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
30/62
Ovarian hyperstimulation syndrome,
Drug-induced pleural disease (see Pneumotox On
Linefor an extensive list of drugs that can cause
pleural effusion), Asbestos-related pleural disease, Yellow nail syndrome
(yellow nails, lymphedema, pleural effusions),
Uremia,
Trapped lung (localized pleural scarring with theformation of a fibrin peel prevents incomplete lung
expansion, at times leading to pleural effusion),
http://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=en -
7/22/2019 CR Piopneumothoraks Nicky FIXd
31/62
1.6 Radiography Effusions of more than 175 mL are usually apparent as
blunting of the costophrenic angle on uprightposteroanterior chest radiographs.
On supine chest radiographs, which are commonly used inthe intensive care setting, moderate to large pleuraleffusions may appear as a homogenous increase in densityspread over the lower lung fields.
Apparent elevation of the hemidiaphragm, lateraldisplacement of the dome of the diaphragm, or increaseddistance between the apparent left hemidiaphragm andthe gastric air bubble suggests subpulmonic effusions. (Seethe images below.)
http://refimgshow%289%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
32/62
http://refimgshow%289%29/http://refimgshow%289%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
33/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
34/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
35/62
1.9 Treatment and Management
Transudative effusions are usually managed by treating theunderlying medical disorder. However, whether transudates
or exudates, large, refractory pleural effusions causingsevere respiratory symptoms, even if the cause isunderstood and disease-specific treatment is available, canbe drained to provide relief.
The management of exudative effusions depends on theunderlying etiology of the effusion. Pneumonia, malignancy, or TB causes most diagnosed exudative
pleural effusions, with the remainder typically deemedidiopathic.
Complicated parapneumonic effusions and empyemas shouldbe drained to prevent development of fibrosingpleuritis.
Malignant effusions are usually drained to palliate symptomsand may require pleurodesis to prevent recurrence.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
36/62
Medications cause only a small proportion of all pleuraleffusions and are associated with exudative pleuraleffusions.
However, early recognition of these iatrogenic causes
of pleural effusion avoids unnecessary additionaldiagnostic procedures and leads to definitive therapy,which is discontinuation of the medication.
Implicated drugs include medications that cause drug-
induced lupus syndrome (eg, procainamide,hydralazine, quinidine), nitrofurantoin, dantrolene,methysergide, procarbazine, and methotrexate.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
37/62
B. PNEUMOTHORAX
2.1 Background
Pneumothorax is defined as the presence of air orgas in the pleural cavity (ie, the potential spacebetween the visceral and parietal pleura of thelung). The clinical results are dependent on the
degree of collapse of the lung on the affectedside. Pneumothorax can impair oxygenationand/or ventilation.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
38/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
39/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
40/62
Tension pneumothorax
A tension pneumothorax is a life-threatening
condition that develops when air is trapped in
the pleural cavity under positive pressure,
displacing mediastinal structures and
compromising cardiopulmonary function.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
41/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
42/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
43/62
2.4 Risk Faktor
A wide variety of disease states and circumstances mayresult in a pneumothorax.
Primary and secondary spontaneous pneumothorax
Risks factors for primary spontaneous pneumothorax (PSP)include the following:
Smoking
Tall, thin stature in a healthy person
Marfan syndrome
Pregnancy
Familial pneumothorax
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
44/62
Diseases and conditions associated with secondaryspontaneous pneumothorax include the following:
Chronic obstructive lung disease (COPD) or emphysema:Increased pulmonary pressure due to coughing with abronchial plug of mucus or phlegm bronchial plug may playa role.
Asthma Human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) with PCP infection
Necrotizing pneumonia
Tuberculosis
Sarcoidosis Cystic fibrosis
Bronchogenic carcinoma or metastatic malignancy
http://emedicine.medscape.com/article/296301-overviewhttp://emedicine.medscape.com/article/230802-overviewhttp://emedicine.medscape.com/article/1001602-overviewhttp://emedicine.medscape.com/article/1001602-overviewhttp://emedicine.medscape.com/article/230802-overviewhttp://emedicine.medscape.com/article/296301-overview -
7/22/2019 CR Piopneumothoraks Nicky FIXd
45/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
46/62
Causes of traumatic pneumothorax include thefollowing: Trauma: Penetrating and nonpenetrating injury
Rib fracture
High-risk occupation (eg, diving, flying)
Traumatic pneumothoraces can result from bothpenetrating and nonpenetrating lung injuries.Complications include hemopneumothorax andbronchopleural fistula. Traumatic
pneumothoraces often can create a 1-way valvein the pleural space (only letting in air withoutescape) and can lead to a tension pneumothorax.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
47/62
2.5 Physical Examination The presentation of a patient with pneumothorax
may range from completely asymptomatic to life-threatening respiratory distress. Symptoms may include diaphoresis, splinting chest
wall to relieve pleuritic pain, and cyanosis (in the caseof tension pneumothorax).
Findings on lung auscultation also vary depending on
the extent of the pneumothorax. Affected patients may also reveal altered mental
status changes, including decreased alertness and/orconsciousness (a rare finding).
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
48/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
49/62
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
50/62
2.6 Diagnostic Considerations
Spontaneous Pneumothorax
Because patients with primary spontaneous
pneumothorax (PSP) will have apical emphysematouspulmonary disease on computed tomography (CT)
scanning or thoracoscopy,
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
51/62
2.7 Differential Diagnoses Acute Coronary Syndrome
Acute Respiratory Distress Syndrome
Aortic Dissection
Congestive Heart Failure and Pulmonary Edema
Esophageal Rupture and Tears
Myocardial Infarction
Pericarditis and Cardiac Tamponade
Pulmonary Embolism
Rib Fracture
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
52/62
http://refimgshow%281%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
53/62
Figure 2.1 Radiograph of a patient with a small spontaneous primary pneumothorax
Figure 2.2 Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
http://refimgshow%282%29/http://refimgshow%281%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
54/62
http://refimgshow%286%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
55/62
Figure 2.6 Radiograph of a patient with a large spontaneous tension pneumothorax.
http://refimgshow%286%29/ -
7/22/2019 CR Piopneumothoraks Nicky FIXd
56/62
2.9 Treatment
Pharmacotherapy
Observation without oxygen
Supplemental oxygen
Simple aspiration
Chest tube placement
One-way valve insertion (portable system)
Thoracostomy with continuous wall suction
SECTION 3rd
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
57/62
SECTION 3
DISCUSSION
How is the mechanism of piopneumothoraks in this patient?
Many mechanisms can result in abnormal amounts of pleural fluid, including:
Increased hydrostatic pressures in the microvascular circulation.
Decreased oncotic pressures in the microvascular circulation.
Decreased pleural space pressure (resulting from lung collapse).
Increased permeability of the microvascular circulation.
Obstruction of lymphatic drainage
Pleural effusion is a secondary disease being related to tuberculosis or other lung disease such as TB,pneumonia, trauma, etc., because there is irritation on the lining of pleural cavity, thus altering the
permeability of the membrane and decreasing the oncotic pressure needed to drain the excess fluid in the
pleural space. normally there is a small amount of pleural fluid in the pleural space that lubricates the
parietal and visceral pleura during expiring and inspiring.
If the primary lesion enlarges, pleural effusion is a distinguishing finding. This effusion develops because
the bacilli infiltrate the pleural space from an adjacent area. Dullness to percussion and a lack of breathsounds are physical findings indicative of a pleural effusion because excess fluid has entered the pleural
space.
Pio Pneumothorax is Pneumothorax with empiema in one field of lung, the common etiology of pio
pneumotorax is that from the lungs like pneumonia, lungs abces, fistula bronkopleural, tuberculosa, and
from extra pulmonal is thorax injury, thorax surgery, thorakocentecis in pleural effusion, etc.
What are the problems of the patient ?
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
58/62
What are the problems of the patient ?
The problem of the patient that we found including :
Piopneumothorax
The patient was admitted to the hospital because complaints of left chest
pain through to the back and abdomen, accompanied by shortness, and
productive cough. Chest pain felt since 2 months before entering the
hospital but patients do not care and continued to work. Os feel chest
pain severe increasingly since 2 days. Os feel nauseous and he vomit since
2 days before entering the hospital. Os complained of shortness. Tightness
is felt if he in activity. He can not work as usual. Tightness has been feltsince 2 days before entering the hospital. Tightness is reduced when at
rest but he was still difficult to breathe. Os also complained of productive
cough, cough has been felt since first week before entering the hospital.
Cough is persistent with sputum and the colour is yellowish, now he is not
cough anymore. Besides, the absence of weird breath sounds (likewheezing) and no history of asthma attack make asthma is unlikely. The
absence of high fever makes pneumonia is unlikely too.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
59/62
Then, it could be confirmed by physical examination.
The absence of breath sound in one side of the
chest along with decreased expansion movement ,decreased vocal fremitus, and hypersonor percussion
could lead to the pneumothorax diagnosis.
Pneumothorax itself is one of the complication of
empiema.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
60/62
Is the management of the patient ?
O2 2 Litres/minute
IVFD RL gtt X/minute
Ceftriaxone 1 g/ 12 hours (IV) Metronidazol / 12 hours (IV)
Ambroxol sirup 3x1C
Observe the development of WSD till theundulations and Bubble negative
Chest X-Ray if the lug re-expands, then off WSD
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
61/62
What is the complications that may in this
patient?
Complications of pleural effusions include collapse
of the lung; pneumothorax, or air in the chestcavity, which is a common side effect of the
thoracentesis procedure; and empyemas
(abscesses) caused by infection of the pleural
fluid, which require drainage of the fluid.
-
7/22/2019 CR Piopneumothoraks Nicky FIXd
62/62
A pleural effusion may cause or worsen a lung infection, such aspneumonia. The extra fluid may get infected and form a pocket ofpus, which is called empyema (em-peye-EE-ma). You may haveother problems, such as a collapsed lung. The problems you mayhave depend on what is causing your pleural effusion. Talk to yourcaregiver about any concerns you may have about your illness or
treatment.
Pio Pneumothorax is Pneumothorax with empiema in one field oflung, the common etiology of pio pneumotorax is that from thelungs like pneumonia, lungs abces, fistula bronkopleural,
tuberculosa, and from extra pulmonal is thorax injury, thoraxsurgery, thorakocentecis in pleural effusion, etc, the commoncomplication from piopneumothorax is syok septic and it will becaused of death for this patient.