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INFEKSI DAN KEGANASAN
PADA THORAX
DEWI WIDYASARI
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PA vs. AP
PA Less stressful, better for heart
Diaphragm rounded
Caudal pulmonary vessels better visualized Better to see small amount of pleural air
AP Better for lungs
Hear appears elongated Flat diaphragmMickey Mouse ears
Better to see small amount of pleural fluid
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PA vs AP
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Right vs. Left Lateral
Right Lateral Better cardiac detail
R crus forward
See Cava go into it Left Lateral
Heart appears round
L crus forward
See Cava go past Anesthesia
Breed Differences
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Lateral View
Make a Plus sign
Bermuda triangle
Left atrium
Left Ventricle
Right Ventricle
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Thoracic and Pulmonary Vessels
Aorta
Caudal Vena Cava Cranial pulmonary
vessels Proximal third rib
Caudal pulmonaryvessels 9thrib where crosses
Veins are ventral andcentral
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The most common abnormalitie
in the thoracic cavity are:
Pneumothorax (Air)
Hydrothorax (Fluid)
Hemothorax (Blood) Chylothorax (Chyle)
Pyothorax (Pus)
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pneumothorax
Pneumothorax refers to the loss of negative
pressure in the thoracic cavity when air gains
entrance to the thorax. Most common causes:
Fractured Ribs Gunshot Wounds (See Photo)
Iatrogenic-thoracocenthesis-biopsy
Ruptured Lung
Ruptured Emphysematous Bulla Ruptured Parasitic Nodule
Ruptured Esophagus or Diaphragm.
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PNEUMOTHORAX
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PNEUMOPERITONEUM DUE TO PERFORATED PEPTIC
ULCER The CXR shows free air under the right hemidiaphragm, in addition to
features of hyperinflation. The possibilities include perforated peptic ulcer or GI
malignancy, recent laparoscopy/laparotomy, and peritoneal dialysis. It is important
to do an erect CXR for the free air to rise to the top of the abdomen. For patients
with a nasogastric tube in place, instillation of 200 ml of free air before the CXR mayaid the diagnosis
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MEDIASTINAL EMPHYSEMA (PNEUMOMEDIASTINUM)
The CXR shows free air in the mediastinum and subcutaneous tissues of
the neck (Fig. 16.2). The mediastinal air could have come from disruption of
the integrity of the lung, major airways, or the esophagus. A history of
trauma (e.g. motor vehicle accident with blunt injury to the anterior chest
wall by the steering wheel) or iatrogenic instrumentation (e.g. recentendoscopy) is important. Descending infections by gas-producing
organisms from the oral cavity and neck can cause severe mediastinitis
and result in a similar appearance.
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KELAINAN PLEURA
1. Penebalan pleura: e.c peradangan pleuritis
r.o : garis opaq linier
2. Schwarte:
- penebalan pleura yg tdk teratur +
perlekatan
- kalsifikasi pleura
r.o : opaq kehitaman
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3. Efusi pleura
Sedikit :
+/- 100 cc sudut costophrenicus tumpul (normal
lancip)
Banyak :Posisi PA berdiri : tampak kesuraman homogen
makin banyak membentuk garis lengkung lateral lebih
tinggi.
Masif :
seluruh hemithorax opaq homogen Posisi AP bagian
bawah dekat diafragma lebih suram
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4. Tumor pleura:
Jinak :
fibroma (batas jelas, costae intack) /
lipoma
Ganas :mesothelioma
Pl iti
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Pleuritis
Pleuritis can occur alone or in combination with pneumonia.
According to exudate: Fibrinous
Purulent (suppurative)
Empyema
Granulomatous
Chronic pleuritis typically results in pleural adhesions.
Etiology:
Most cases are infectious, although isolation is not alwayspossible.
Fibrinous pleuritis characterized by extensive deposition of
fibrin on pleural membrane
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Opacified HemithoraxThree Causes
Atelectasis
Pleural effusion
Pneumonia
Recognizing the Causes of an
Opacified Hemithorax
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Atelectasis
Opacified hemithorax from volume loss
Shift of heart and mediastinal structures
towardopacified hemithorax
Normally there are 2-10 cc of fluid in
the pleural space
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Atelectasis of right lungshift of the mediastinal structures
TOWARD the side of opacification
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Pleural Effusion
Opacified hemithorax from largeeffusion
Shift of heart and mediastinal
structures awayfrom side of opacifiedhemithorax
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Large right pleural effusion - shift of the mediastinal structures
AWAY from the side of opacification
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Pleural Effusions
Four Reliable Signs of CHF
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Pneumonia
Opacified hemithorax
No shift
Air bronchograms
The CXR shows opacities with air bronchograms involving both lung
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The CXR shows opacities with air bronchograms involving both lungfields. This is typical of severe pneumonia as evidenced by multilobar
involvement. Typical organisms include Streptococcus pneumoniae, Legionella,
and gram negatives l ike Klebsiella and Pseudomonas aeroginosa
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Pneumonia of LULno shift of the mediastinal
structures to either side; multiple air bronchograms
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Common Alveolar Lung Diseases
Pneumonia Pulmonary edema
Pulmonary hemorrhage
Aspiration
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Pulmonary edema
This disease is
fluffy and indistinctin its margins, it is
confluent and
tends to be
homogeneous. In
both upper lobes,
you can see airbronchograms.
This is an alveolar
(airspace) disease,
in this case
pulmonary edema
on a non-cardiogenic basis.
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Aspiration pneumoniaat both bases
Airspace Disease
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The CXR shows bilateral upper lobe infiltrates with cavities,
suggestive of active pulmonary tuberculosis. In general, thin-
walled cavities (5 mm) tend to be infective and
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The CXR of COPD typically demonstrates evidence of air trapping The signs
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The CXR of COPD typically demonstrates evidence of air trapping. The signs
are horizontality of the ribs, hyperinflated lungs (normally the right sixth rib
bisects the right hemidiaphragm), hyperlucent lung fields, bilateral symmetrical
attenuated pulmonary vasculature, long tubular heart, scalloping and flattening
o f t h e d i a p h r a g m
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DIAGNOSA BANDING PPOK
Asma Bronkiale
Gagal jantung kronis Bronkiektasis
Sindroma obstruksi pasca TB
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Fibrosis & kalsifikasi
BULA PARU
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BULA PARU
The CXR shows bilateral infiltrates and air bronchograms with
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The CXR shows bilateral infiltrates and air bronchograms with
a perihilar distribution. The heart size is normal. There are no
Kerley B lines or evidence of upper lobe venous diversion. All
these are typical features of PCP. PCP is the most common
life-threatening opportunistic infection in HIV disease.
There is a homogeneous density in the right upper zone and
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There is a homogeneous density in the right upper zone and
elevation of the transverse fissure. Instead of the transverse
fissure being straight, there is a bulge at the
medial end (Fig. 30.2), giving it an inverted S shape.
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KEGANASAN
Categorization
Parenchymal cancers
Leiomyomas, fibromas, chondromas
Bronchogenic lung cancer
Squamous cell (epidermoid)
Adenocarcinoma
Large cell carcinoma
Small (oat) cell
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Nodule (benign vs malignant)
Age (malignancy increases with patient age) Increases with malignancy
Size (size increases with malignancy)
85% of lesions > 3 cm are malignant
Calcification (lung cancer rarely calcify)
Benign pattern of ca++ rules out malignancy
Growth rate (stability of size over 2 year period
reliably excludes malignancy)
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MEDIASTINUM COMPARTEMEN
Anterior: posterior to sternumanterior
cardiac and tracheal borders
Posterior: posterior to a line 1cm dorsal to
anterior edge of vertebral bodies
Middle: between the two
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Diseases with Multiple Lung Nodules
Metastases Multiple AVMs
Rheumatoid nodules
Wegeners Granulomatosis
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Disease with Multiple CysticStructures
Cystic fibrosis
Bronchiectasis
Tuberculosis
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Cystic Fibrosis- interstitial
Middl di ti
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Middle mediastinum
Metastases to middle mediastinal nodes
Most metastases arise from intrathoracic
tumors, primarily lung
Extrathoracic- include genito-
urinary,melanoma, head and neck
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Posterior mediastinum
Neurogenic tumors
Tumors of esophagus
Primary and secondary tumors of the spine
M th i i
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Myasthenia gravis
Myasthenia gravis is associated with
thymoma
Th
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Thymoma
Older patients
Rarely before 20 y
20-50% asymptomatic
Symptoms: cough,dyspnea, hoarseness,
chest pain
Myasthenia gravis SVC syndrome
A thymic mass
Homogeneous soft-tissue
density
Oval, round, lobulated Sharply demarcated
Rarely cystic
Enhanceshomogeneously
May contain calcium
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The mass (red arrow)
silhouettes the right
heart border which isto say there is no
longer an edge of the
right heart seen. That
means the mass is (a)
touching the right
heart border (the massis anterior) and (b) the
mass is the same
density as the heart
(fluid or soft tissue
density). The mass is
athymoma.
Where in the chest is this mass?
Using the Silhouette Sign
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Lymphoma - CT
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Lymphoma CT
Nodes greater than 1cm in diameter - enlarged on CT , MRI
Multiple nodes smaller than 1cm suspicious
Enlarged nodes- discrete or fuse to form a single larger mass
Minor enhancement
Low density areas
Calcifications prior to therapy rare
commoner in more aggressive subtypes
seen occasionally following therapy
Carcinoma mass abo e right hil m
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Carcinoma mass above right hilum
E l d hil (b h i i )
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Enlarged hilum (bronchogenic carcinoma)
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Pancoast (superior sulcus) tumor
Bronchogenic tumor in the lung apex
Usually squamous cell type
Presents with:
Apical radiodensity
Horners syndrome
Thoracic outlet syndrome
Rib or vertebral destruction
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Pancoast tumor
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Tb paru lama & massa mediastnum
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Tb paru lama & massa mediastnum
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metastase
- Milier
- Coin lesion
- Coarse nodular
- Golf ball
- Lymphangitic spread
- Pleural effusion / ateletase
Coin lesion
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Coin lesion
Multiple pulmonary nodules and masses.
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p p y
You should think of pulmonary metastasis when you
see this presentation; although this case was due to a
less likely possibility, sarcoidosis
multiple malignant masses
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multiple malignant masses
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Pulmonary metastase
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Pulmonary metastase
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Peribronchial cuffing
Four Reliable Signs of CHF
Fluid in the
walls of the
bronchi make
them visible
and produce
numerous
doughnut
densities
throughout
the periphery
of the lung.