lung cancer, pleural effusion, dry pleurisy & pneumothorax
TRANSCRIPT
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KURSK STATE MEDICALKURSK STATE MEDICAL
UNIVERSITYUNIVERSITY
Department ofDepartment of
propaedeutics of innerpropaedeutics of innerdiseasesdiseasesNeoplasm of the lung.Neoplasm of the lung.
Pleual e!us"on. D#Pleual e!us"on. D#pleu"s#.pleu"s#.
Pneumothoa$.Pneumothoa$.
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Lung carcinomaLung carcinoma
Is the most common malignantIs the most common malignant
neoplasm in men throughout the world,neoplasm in men throughout the world,
22ndnd in women in women (breast cancer frst).(breast cancer frst). It constitutes 16% of all malignantIt constitutes 16% of all malignant
tumors and accounts for 28% of alltumors and accounts for 28% of all
cancer deaths (35% in men and 1% incancer deaths (35% in men and 1% inwomen!"women!"
#he pea$ incidence 5565 &ears old"#he pea$ incidence 5565 &ears old"
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'rimar& lung carcinoma is a maor'rimar& lung carcinoma is a maor
health pro)lem with a generall& grimhealth pro)lem with a generall& grim
prognosisprognosis 2*% of all lung cancer patients ha+e2*% of all lung cancer patients ha+e
local disease (5 &ears sur+i+al 3*%local disease (5 &ears sur+i+al 3*%
for males, 5*% for females!for males, 5*% for females! 25% disease spread to regional25% disease spread to regional
l&mph nodesl&mph nodes
55% distant metastasis55% distant metastasis
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EtiologyEtiologyof lung cancer is multifactorialof lung cancer is multifactorial
Risk factorsRisk factors #o)acco smo$ing"#o)acco smo$ing"
tmospheric pollution ()en-p&rene,tmospheric pollution ()en-p&rene,
arsenious o.ide, nic$el!"arsenious o.ide, nic$el!" /ccupational factors (radioacti+e materials,/ccupational factors (radioacti+e materials,
as)estos, nic$el, chromiumcontaining iron!"as)estos, nic$el, chromiumcontaining iron!"
0.isting lung damage /'D, lung )rosis"0.isting lung damage /'D, lung )rosis"
enetic factors (loss of D4 seuences ofenetic factors (loss of D4 seuences of
the short arm of chromosome 3 or 11!"the short arm of chromosome 3 or 11!"
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lassication according to thelassication according to the
histolog&histolog& uamous cell carcinomauamous cell carcinoma
(epidermoid!3*35%"(epidermoid!3*35%"
denocarcinoma 3*35%"denocarcinoma 3*35%"
7arge cell carcinoma 152*%"7arge cell carcinoma 152*%"
mall cell (oat cell! carcinoma 2*mall cell (oat cell! carcinoma 2*
25%"25%"
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lassication according to thelassication according to the
locationlocation entrall& located (endo)ronchial growth!entrall& located (endo)ronchial growth!
suamous cell carcinoma,suamous cell carcinoma,
small cell carcinoma (9*%!small cell carcinoma (9*%! 'eripherall& located (with pleural'eripherall& located (with pleural
in+ol+ement!in+ol+ement!
adenocarcinoma,adenocarcinoma, large cell carcinoma (3*%!"large cell carcinoma (3*%!"
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taging classicationtaging classication
tages (*, I, II, III a, III ), I:!"tages (*, I, II, III a, III ), I:!"
tage grouping according to the #4;tage grouping according to the #4;
classicationclassication
# primar& tumor (
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#0 >/?'I4#0 >/?'I4tage *tage * # is# is 4*4* ;/;/
tage Itage I #1#1#2#2
4/4/4*4*
;/;/;/;/
tage IItage II #1#1
#2#2
4141
4141
;/;/
;/;/
tage IIIatage IIIa #3#3
#3#3
#1 #3#1 #3
4/4/
4141
4242
;/;/
;/;/
;/;/
tage III)tage III) n& #n& ##=#=
4343n& 4n& 4
;/;/;/;/
tage I:tage I: n& #n& # n& 4n& 4 ;1;1
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Main syndromesMain syndromes
/)structi+e atelectasis/)structi+e atelectasis
7ung tissue focal consolidation7ung tissue focal consolidation
7ung destruction7ung destruction
Into.icationInto.ication
'araneoplastic'araneoplastic Distant metastasisDistant metastasis
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SymptomsSymptoms
ough with sputum"ough with sputum"
@emopt&sis"@emopt&sis"
D&spnea"D&spnea"
'ain in the chest (when pleura is'ain in the chest (when pleura is
in+ol+ed!"in+ol+ed!"
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Endobronchial growth
ndobronchial growth
of the t morf the t mor
/cclusion of the/cclusion of the
)ronchus")ronchus"
&mptoms of&mptoms of
o)structi+eo)structi+e
atelectasis"atelectasis"
Displacement ofDisplacement of
mediastinum towardmediastinum toward
the aAected side"the aAected side"
Displacement of theDisplacement of the
trachea"trachea"
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Exobronchial growth of the t mor
xobronchial growth of the t mor
intrathorasic spreading of the tumorintrathorasic spreading of the tumor
ompression of the esophagus ompression of the esophagus d&sphagia"d&sphagia" ompression of the trachea ompression of the trachea stridor"stridor" >ecurrent lar&ngeal ner+e aAection>ecurrent lar&ngeal ner+e aAection
hoarsenesshoarseness"" Damage of the frenicus ner+e Damage of the frenicus ner+e ele+atedele+ated
diaphragm with parado.ical mo+ementsdiaphragm with parado.ical mo+ements(ele+ation in inspiration!"(ele+ation in inspiration!"
'ericardial and cardiac e.tension 'ericardial and cardiac e.tension tamponade, arrh&thmia, cardiac failure"tamponade, arrh&thmia, cardiac failure"
7&mphatic o)struction 7&mphatic o)struction pleural eAusion"pleural eAusion" ;etastasis to the ri)s ;etastasis to the ri)s spontaneous fractures"spontaneous fractures" ;etastasis to the l&mph nodes;etastasis to the l&mph nodes
(supracla+icular, infracla+icular, cer+ical!"(supracla+icular, infracla+icular, cer+ical!"
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intrathorasic spreading of theintrathorasic spreading of the
tumortumor
ompression of theompression of the
+ena ca+a superior+ena ca+a superior
toc$Bs collartoc$Bs collar(edema of the(edema of the
nec$!, c&anoticnec$!, c&anotic
face, dilated chestface, dilated chest
wall +eins"wall +eins" 'em)ertonBs sign'em)ertonBs sign
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intrathorasic spreading of theintrathorasic spreading of the
tumortumor
'ancoastBs s&ndrome superior'ancoastBs s&ndrome superior
sulcus tumorsulcus tumor(lung ape. carcinoma,(lung ape. carcinoma,
in+ol+ement of the 8#h1, 2 ner+es!in+ol+ement of the 8#h1, 2 ner+es! houlder and ulnar surface radiation houlder and ulnar surface radiation
pain (aAection of the )rachialpain (aAection of the )rachial
ple.us!, destruction of the 12ple.us!, destruction of the 12ndnd
ri)s"ri)s" 'ancoastBs s&ndrome often coe.ists'ancoastBs s&ndrome often coe.ists
with @ornerBs s&ndrome"with @ornerBs s&ndrome"
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intrathorasic spreading of theintrathorasic spreading of the
tumortumor
@ornerBs s&ndrome@ornerBs s&ndrome(damage of the(damage of the
&mpathetic&mpatheticcolumn #h1! column #h1!
ptosis,ptosis,
enophthalmus,enophthalmus,
miosis, anh&drosismiosis, anh&drosis(aAected side!(aAected side!
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Extrathoracic metastasisExtrathoracic metastasis CrainCrain neurologic neurologic
decits"decits"
ConesCones pain, pain,
pathological fractures"pathological fractures" Cone marrowCone marrow
c&topenia"c&topenia"
7i+er7i+er )iochemical )iochemical
d&sfunction, )iliar&d&sfunction, )iliar&
o)struction, pain"o)struction, pain"
7&mph nodes7&mph nodes
metastases"metastases"
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$eletal connecti+e tissue$eletal connecti+e tissue
s&ndromess&ndromes lu))inglu))ing
(3*% non small cell!"(3*% non small cell!"
@&pertrophic pulmonar&@&pertrophic pulmonar&osteoarthropath& osteoarthropath& ;ar& ;ar& Cum)ergerBs s&ndromeCum)ergerBs s&ndrome
(11*% adenocarcinoma!"(11*% adenocarcinoma!"
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4eurologic m&opathic4eurologic m&opathic
s&ndromess&ndromes 0aton 7am)ertBs s&ndrome0aton 7am)ertBs s&ndrome
>etinal )lindness>etinal )lindness
'eripheral neuropath&'eripheral neuropath&
u)acute cere)ellar degenerationu)acute cere)ellar degeneration
ortical degenerationortical degeneration 'ol&m&ositis'ol&m&ositis
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oagulation and throm)oticoagulation and throm)otic
and hematologic s&ndrome (1and hematologic s&ndrome (1
8%!8%! #rousseauBs s&ndrome migrator& +enous#rousseauBs s&ndrome migrator& +enous
throm)ophle)itis"throm)ophle)itis"
4on)acterial throm)otic endocarditis with4on)acterial throm)otic endocarditis witharterial em)oli"arterial em)oli" Disseminated intra+ascular coagulationDisseminated intra+ascular coagulation
with hemorrhage"with hemorrhage"
nemia"nemia" ranuloc&tosis"ranuloc&tosis" 7eucoer&thro)lastosis"7eucoer&thro)lastosis"
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utaneous manifestationutaneous manifestation
(1% or less!(1% or less! Dermatom&ositis"Dermatom&ositis"
canthosiscanthosisnigricans"nigricans"
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>enal manifestation (1% or>enal manifestation (1% or
less!less! 4ephrotic s&ndrome"4ephrotic s&ndrome"
lomerulonephritis"lomerulonephritis"
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Paraneoplastic syndromesParaneoplastic syndromes
&stemic&stemics&mptomss&mptoms
3*%E anore.ia,3*%E anore.ia,
weight lossweight loss
((cache.iacache.ia!,!, fe+er,fe+er,
suppressedsuppressed
immunit&"immunit&"
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Paraneoplastic syndromesParaneoplastic syndromes
0ndocrine F0ndocrine F
meta)olicmeta)olic
s&ndromess&ndromes12%E12%E
h&percalemia,h&percalemia,
h&pophsphatemia,h&pophsphatemia,
h&ponatremia,h&ponatremia,
ushingGs s&ndromeushingGs s&ndrome
,,
ectopicectopic
gonadotropin,gonadotropin,
h&pogl&cemiah&pogl&cemia
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InvestigationsInvestigations
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InvestigationsInvestigations
scintigraphyscintigraphy cintigraph&cintigraph&
with #cwith #c""
Defect of #cDefect of #caccumulation inaccumulation in
cancer regioncancer region
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InvestigationsInvestigations
computer tomographycomputer tomography
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InvestigationsInvestigations
ronchoscopyronchoscopy
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iopsyiopsy!bronchoscopy"!bronchoscopy"
needle aspiration" pleural"needle aspiration" pleural"
lymph node biopsy#lymph node biopsy#
7ag cell
cancer
adenocarcinoma
mallsellcancer
suamous
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$reatment$reatment
urger& resection"urger& resection"
>adiation therap&">adiation therap&"
hemotherap&"hemotherap&"
Immunotherap&"Immunotherap&"
7aser therap&"7aser therap&"
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Pleurisy with effusion%Pleurisy with effusion%
Etiology and pathogenesisEtiology and pathogenesis
'leural Huid accumulates when pleural Huid'leural Huid accumulates when pleural Huidformation e.ceeds pleural Huid a)sorption"formation e.ceeds pleural Huid a)sorption"
>easons>easons E$%ess pleual &u"' fomat"on(E$%ess pleual &u"' fomat"on(
1"1" from the parietal pleura"from the parietal pleura"
2"2" from the interstitial spaces of the lungs"from the interstitial spaces of the lungs"
3"3" from the peritoneal ca+it&"from the peritoneal ca+it&"
De%ease' &u"' emo)al *# the l#mphat"%s.De%ease' &u"' emo)al *# the l#mphat"%s.
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$he first step is to determine
he first step is to determine
whether the patient has a
hether the patient has a
trans dative or an ex dative eff sion%
rans dative or an ex dative eff sion%
AA tansu'atetansu'ate ++ the Huid that passes through athe Huid that passes through a
mem)rane (capillar& walls!"mem)rane (capillar& walls!"
AA tansu'at")etansu'at")epleural eAusion occurs whenpleural eAusion occurs when
s&stemic factors that inHuence the formation ands&stemic factors that inHuence the formation anda)sorption of pleural Huid are altered"a)sorption of pleural Huid are altered"
AnAne$u'atee$u'ate accumulation of Huid in a ca+it& or accumulation of Huid in a ca+it& or
matter that penetrates through +essel walls intomatter that penetrates through +essel walls into
adoining tissue or the production of pus oradoining tissue or the production of pus or
serum"serum"
AnAne$u'at")ee$u'at")epleural eAusion occurs when localpleural eAusion occurs when local
factors that inHuence the formation andfactors that inHuence the formation and
a)sorption of pleural Huid are altered"a)sorption of pleural Huid are altered"
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The lea'"ng %auses of e$u'at")e e!us"on(The lea'"ng %auses of e$u'at")e e!us"on(
Cacterial pneumonia (3**"*** per &ear!"Cacterial pneumonia (3**"*** per &ear!"
;alignanc& (2**"*** per &ear!";alignanc& (2**"*** per &ear!" :iral infection (1**"*** per &ear!":iral infection (1**"*** per &ear!"
'ulmonar& em)olism (95"*** per &ear!"'ulmonar& em)olism (95"*** per &ear!"
The lea'"ng %auses of tansu'at")eThe lea'"ng %auses of tansu'at")e
e!us"on(e!us"on(
7eft cardiac failure (5**"*** per &ear!"7eft cardiac failure (5**"*** per &ear!" irrhosis (5*"*** per &ear!"irrhosis (5*"*** per &ear!"
'ulmonar& em)olism (95"*** per &ear!"'ulmonar& em)olism (95"*** per &ear!"
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EtiologyEtiology$rans dative Ple ral Eff sion
rans dative Ple ral Eff sion
a" ongesti+e heart failurea" ongesti+e heart failure
)" 'ericardial diseases)" 'ericardial diseases
c" irrhosisc" irrhosis
d" 4ephrotic &ndromed" 4ephrotic &ndromee" uperior +ena ca+a o)structione" uperior +ena ca+a o)struction
f" ;&.edemaf" ;&.edema
g" ?rinothora.g" ?rinothora.
h" 'ulmonar& em)olih" 'ulmonar& em)oli I" 'eritoneal dial&sisI" 'eritoneal dial&sis
" ;eigBs s&ndrome" ;eigBs s&ndrome
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EtiologyEtiologyExEx dative Ple ral Eff siondative Ple ral Eff sion
Neoplast"% '"seasesNeoplast"% '"seases
;etastatic disease;etastatic disease
;esothelioma (primar& tumor from the;esothelioma (primar& tumor from themesothelial cells that line the pleural ca+ities!mesothelial cells that line the pleural ca+ities!
Infe%t"ous '"seasesInfe%t"ous '"seases( Cacterial, Jungal,( Cacterial, Jungal,#u)erculosis, :iral, 'arasitic#u)erculosis, :iral, 'arasitic!!
Pulmona# em*ol"smPulmona# em*ol"sm ,asto"ntest"nal '"seases,asto"ntest"nal '"seases(0sophageal(0sophageal
perforation, 'ancreatic disease, Intraa)dominalperforation, 'ancreatic disease, Intraa)dominal
a)scess, Diaphragmatic hernia, fter a)dominala)scess, Diaphragmatic hernia, fter a)dominalsurger&surger&!!
Collagen - )as%ula '"seasesCollagen - )as%ula '"seases(rheumatoid(rheumatoidpleuritis, &stemic lupus er&thematosus,pleuritis, &stemic lupus er&thematosus,KegenerBs granulomatosis!KegenerBs granulomatosis!
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EtiologyEtiology
ExEx dative Ple ral Eff siondative Ple ral Eff sion 'ostcardiac inur& s&ndrome'ostcardiac inur& s&ndrome
s)estos 0.posures)estos 0.posure
arcoidosisarcoidosis
?remia?remia
@emothora., h&lothora.@emothora., h&lothora.
Drugindused pleural diseaseDrugindused pleural disease
>adiation therap&>adiation therap&
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Main SyndromesMain Syndromes
ccumulation ofccumulation of
Huid in theHuid in the
pleural ca+it&pleural ca+it&
ompressi+eompressi+e
atelectasisatelectasis
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&linical Manifestations&linical Manifestations
&omplaints'omplaints' Je+er, chills (emp&ema of pleura!Je+er, chills (emp&ema of pleura! 'ain in the chest (increases in cough and deep'ain in the chest (increases in cough and deep
respiration!respiration!
D&spnea (respirator& insuLcienc& due toD&spnea (respirator& insuLcienc& due tocompression of the lung!compression of the lung!
ough dr& (reHe.ogenous!ough dr& (reHe.ogenous! In mediastinal pleuris&In mediastinal pleuris&
d&sphagia (compression of the esophagus!d&sphagia (compression of the esophagus! compression of the superior +ena ca+a (edemacompression of the superior +ena ca+a (edema
of the face, nec$ and the hands!of the face, nec$ and the hands! compression of the recurrent ner+ecompression of the recurrent ner+e
(hoarseness!(hoarseness!
eneral Into.ication (general wea$ness,eneral Into.ication (general wea$ness,o+ersweating, anore.ia!o+ersweating, anore.ia!
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(b)ective Examination(b)ective Examination
InspectionInspections&mmetr& of thes&mmetr& of thechestchest
#racheal#rachealdisplacement awa&displacement awa&from the Huidfrom the Huid7agging of the7agging of the
aAected sideaAected side'rotrusion of the'rotrusion of theintercostal spacesintercostal spaces
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(b)ective Examination(b)ective Examination
'alpation'alpation:ocal fremitus:ocal fremitus
IncreasedIncreasedo+er theo+er the
compressed lungcompressed lung
DiminishedDiminishedoror
not transmitted atnot transmitted atthe area of thethe area of theHuid accumulationHuid accumulation
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(b)ective Examination(b)ective Examination
'ercussion'ercussion
Dullness o+er the area of Huid"Dullness o+er the area of Huid" DamoiseauBs cur+e"DamoiseauBs cur+e" arlandBs trianglearlandBs triangleon the aAected side characteri-edon the aAected side characteri-ed
)& a dulled t&mpanic sound" It corresponds the lung)& a dulled t&mpanic sound" It corresponds the lungpressed )& the eAusion compression atelectasis"pressed )& the eAusion compression atelectasis"
>auchfussrocco triangle>auchfussrocco triangleis found on the health&is found on the health&side and is a $ind of e.tension of dullness determinedside and is a $ind of e.tension of dullness determinedon the aAected side" #he sides of the triangle areon the aAected side" #he sides of the triangle are
formed )& the diaphragm and the spine, while theformed )& the diaphragm and the spine, while thecontinued DamoiseauBs cur+e is the h&potenuse"continued DamoiseauBs cur+e is the h&potenuse"
)sence of the)sence of the#rau)eBs space#rau)eBs spacein the left sidedin the left sidedpleuritispleuritis
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(b)ective Examination(b)ective Examination
'ercussion'ercussion
arlandBstriangle
>auchfussrocco triangle(due todisplacement ofthemediastinum!
DamoiseauBs
ur+e
0Ausion
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(b)ective Examination(b)ective Examination
uscultationuscultation
In the region of accumulatedIn the region of accumulated
Huid Huid diminished +esiculardiminished +esicular
)reathing or not auscultated)reathing or not auscultated
)o+e the eAusion )o+e the eAusion )ronchial)ronchial
)reathing MechoN li$e)reathing MechoN li$e(compressi+e atelectasis!(compressi+e atelectasis!
Cronchophon& o+er theCronchophon& o+er the
eAusioneAusion is not determinedis not determined
(b) ti E i ti(b
) ti E i ti
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(b)ective Examination(b)ective Examination
ardio+ascular &stemardio+ascular &stem
Displacement of the heart )& theDisplacement of the heart )& the
eAusion onto the health& side"eAusion onto the health& side"
#ach&cardia"#ach&cardia" Deafened heart sounds"Deafened heart sounds"
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In)est"gat"onsIn)est"gat"ons
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In)est"gat"onsIn)est"gat"ons
Clood #estClood #est
7eu$oc&tosis7eu$oc&tosis mar$ed leu$oc&tosis mar$ed leu$oc&tosis
is characteristic of purulent pleuris&is characteristic of purulent pleuris& ometimeometime eosinophiliaeosinophilia
0> increased0> increased
#u)erculosis pleuris& is#u)erculosis pleuris& ischaracteri-ed )& lcharacteri-ed )& l&mphoc&tosis&mphoc&tosis
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DiagnosticsDiagnostics(pleural Huid!(pleural Huid!JeatureJeature #ransudati+e#ransudati+e 0.udati+e0.udati+e
ppearanceppearance lear, thin,lear, thin,nonclottingnonclotting
loud&,loud&,+iscous+iscous
7D@7D@ 4ormal4ormal IncreasedIncreased
'rotein'rotein O3*gPlO3*gPl Q3* gPlQ3* gPl
>elati+e densit&>elati+e densit& 1"**61"*121"**61"*12 1"*181"*221"*181"*22>i+altaBs reaction>i+altaBs reaction 4egati+e4egati+e 'ositi+e'ositi+e
KCKC )sent or few in)sent or few in
num)ernum)er7arge num)er, >C7arge num)er, >C
ma& presentma& present
JluidPserum 7D@JluidPserum 7D@ratioratio O*,6O*,6 Q*,6Q*,6
JluidPserum proteinJluidPserum protein
ratioratioO*,5O*,5 Q*,5Q*,5
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*ry Ple risy
ry Ple risy
omplaintsomplaints
'ain in the chest ( increased during'ain in the chest ( increased during
)reathing and coughing!)reathing and coughing! Dr& coughDr& cough
u)fe)rile temperature" eneralu)fe)rile temperature" eneral
wea$ness"wea$ness"
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(b)ective Examination(b)ective Examination
InspectionInspection
forced postureforced posture
(on the aAected(on the aAectedside or sitting!side or sitting!
supercialsupercial
respirationrespiration
unilateralunilateral
thoracic laggingthoracic lagging
(b) ti E i ti(b
)ective Examination
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(b)ective Examination(b)ective Examination
palpation and percussionpalpation and percussion
'ainful palpation of trape-oid and large'ainful palpation of trape-oid and large
thoracic muscles (thoracic muscles (tern)ergBs andtern)ergBs and
'ottengerBs signs!"'ottengerBs signs!" decreased mo)ilit& of the lung )order ondecreased mo)ilit& of the lung )order on
the aAected sidethe aAected side
(b) ti E i ti(b
)ective Examination
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(b)ective Examination(b)ective Examination
uscultationuscultation
pleural frictionpleural friction
ru)ru)
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InvestigationsInvestigations
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Pne mothorax
ne mothorax
'resence of gas in the pleural'resence of gas in the pleural
spacespace
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Pne mothorax
ne mothorax
11"" pontaneouspontaneouspneumothora. occurs withoutpneumothora. occurs withoutantecedent trauma to the thora.antecedent trauma to the thora.
""'rimar&'rimar&spontaneous occurs in anspontaneous occurs in an
indi+idual without underl&ing lung disease"indi+idual without underl&ing lung disease"
C"C"econdar&econdar& with underl&ing lung disease with underl&ing lung disease2"2"#raumatic#raumaticpneumothora. caused )&pneumothora. caused )&
penetrating or nonpenetrating chest inuriespenetrating or nonpenetrating chest inuries
3"3"#ension#ensionpneumothora. in which the pressurepneumothora. in which the pressure
in the pleural space is positi+e throughoutin the pleural space is positi+e throughout
the respirator& c&clethe respirator& c&cle
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omplaintsomplaints
'ain in the chest'ain in the chest
D&spneaD&spnea
Dr& coughDr& cough
'alpitation'alpitation
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&linical manifestations&linical manifestations
Inspection%Inspection%
as&mmetricalas&mmetrical
chest"chest"
Displacement ofDisplacement of
the trachea tothe trachea tothe opposite sidethe opposite side
lagging of thelagging of the
aAected sideaAected side
intercostalintercostalspaces arespaces are
increased andincreased and
smoothedsmoothed
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&linical manifestations%&linical manifestations%
Palpation%Palpation%
u)cutaneousu)cutaneous
emph&semaemph&sema (in(in
traumatictraumatic
pneumothora. !pneumothora. ! +ocal fremitus is+ocal fremitus is
decreased or a)sentdecreased or a)sent
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&linical manifestations%&linical manifestations%
Percussion%Percussion%
t&mpanic percussion soundt&mpanic percussion sound
shift of the mediastinum to the oppositeshift of the mediastinum to the opposite
sideside
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&linical manifestations%&linical manifestations%
auscultation%auscultation%
diminished +esiculardiminished +esicular
)reathing or a)sent)reathing or a)sent
onnection of theonnection of the
pleural ca+it& withpleural ca+it& with
)ronchus amphoric)ronchus amphoric
)reathing)reathing
In open pneumothora.In open pneumothora.
metallic )reathing metallic )reathing
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InvestigationsInvestigations
+,ray+,ray