PARAPNEUMONIC SYNDROME.ppt

5/26/2018 PARAPNEUMONIC SYNDROME.ppt

1/28

PARAPNEUMONIC SYNDROME(Laporan Kasus)

Arismunandar H.P.U

0818011008

1


2/28

Identitas Pasien

Nama : Tn. S Umur : 60 tahun

Jenis Kelamin : Laki-laki

Pekerjaan : Petani

Agama : Islam

Alamat : Punggur

Tanggal Masuk : 19 Januari 2013, pukul 18.00WIB

2

1. ANAMNESIS


3/28

Keluhan Utama

Buang air besar cair sejak 1 hari SMRS

Keluhan Tambahan

Demam,batuk berdahak, pilek, sesak

3


4/28

Riwayat Penyakit Sekarang

Pasien datang ke IGD RSAY Metro dengan keluhan buang airbesar cair sejak 1 hari SMRS. Buang air besar sebanyak 5 kalidengan konsistensi cair, ampas yang sedikit dan berlendir tanpadisertai darah. Pasien juga mengeluh demam yang naik turunsejak 2 hari SMRS dan disertai dengan pilek dan batuk berdahak,dahak berwarna hijau tanpa disertai darah. Pasien juga

mengeluh sesak nafas dan dada terasa berat sejak 2 hari SMRS.Sesak nafas timbul saat istirahat dan tidak diperberat olehaktivitas. Pasien juga mengaku tidak nafsu makan dan badanterasa lemas. Karena khawatir akan kondisi dirinya, maka pasiendatang ke IGD RSAY Metro untuk berobat.

4


5/28

Riwayat Penyakit Dahulu

Riwayat kencing manis

: disangkal Riwayat darah tinggi

: disangkal

Riwayat sakit jantung

: disangkal

Riwayat minum OAT :disangkal

Pasien belum pernahmengalami sakit seperti inisebelumnya

5

RiwayatPenyakitKeluarga

Riwayat penyakit serupa: disangkal

Riwayat darah tinggi :disangkal

Riwayat kencing manis : disangkal


6/28

PEMERIKSAAN FISIK

Keadaan Umum : sakit berat, compos mentis,

gizi kurang (berat badan 45 kg,tinggi badan 1,67 m, BMI = 16,1)

Tanda Vital

Tekanan darah : 60/40 mmHg Nadi : 124 x/menit , cepat dan lemah

Pernapasan : 40 x/menit

Suhu : 38,7 C

Saturasi O2 : 90 %

6


7/28

Kepala : normochepal, simetris.

Mata : Conjungtiva anemis (-/-), sclera ikterik (-/-) Pupil isokor (3 mm/3mm), Reflek cahaya (+/+).

Hidung : Nafas cuping hidung (+), darah (-), secret (-).

Telinga : darah (-), secret (-).

Mulut : mukosa basah (+), sianosis (-), lidah kotor (-).

Leher : Simetris, limfonodi coli tidak membesar. Thorax : retraksi intercostal (+)

7


8/28

Jantung

Inspeksi : ictus cordis tidak tampak

Palpasi : ictus cordis tidak teraba

Perkusi : batas jantung dalam batasnormal

Auskultasi : BJ I-II intensitas normal,reguler, murmur (-), gallop (-)

Paru Inspeksi : Saat statis bagian dada kanan sama dengan

bagian kiri, saat dinamis, gerakan dada kanantertinggal dari kiri. Retraksi intercostal, dansubcostal ditemukan

Palpasi : Fremitus taktil kanan lebih lemah dari kiri Perkusi : pekak/sonor

Auskultasi : ronki +/-, wheezing -/-

8


9/28

Abdomen

Inspeksi : tampak datar, dinding

perut sejajar dengan dinding dada Auskultasi : bising usus (+)

Perkusi : Tympani

Palpasi : Supel, nyeri tekan (-), hepar/lien

tidak teraba Trunk

Inspeksi : Skoliosis (-), kifosis (-), lordosis (-)

Palpasi : Nyeri tekan (-), massa (-)

Perkusi : Nyeri ketok (-)

Ekstremitas :Oedem -/- Akral dingin -/-

9


10/28

PEMERIKSAAN PENUNJANG

Laboratorium (19 Januari 2013) :

DL :Hb : 9,5 g/dL

WBC : 34.600 /ul

RBC : 4,46 juta /ul

PLT : 437.000 /ul

GDS : 94 mg/dL

Ureum : 66,2 mg/dL

Kreatinin : 2,02 mg/dL

SGOT : 69,8 U/L

SGPT : 33,4 U/L

Albumin : 2,7 g/dL

Globulin : 1,74 g/dL

10


11/28

UL : leukosit 10/ul, eritrosit 30/uL, epitel ++

Feses lengkap :

macros : konsistensi lembek, lendir,darah negatif

micros : leukosit, eritrosit negatif

BTA sputum S-P-S : negatif-negatif-negatif

Kultur darah (22-1-2013) : hasil steril

11


12/28

Foto Rontgen Thorax PA (23 Januari 2013) :

12

Kesan: Efusi pleura dextra

bronkopneumonia

kardiomegalidengan elongatioaorta


13/28

USG Abdomen (21 Januari 2013) :

Complex pleural effusion supradiafragma dextra

Pielonefritis sinistra

Hepar,, lien, pancreas, vesica urinaria dalam batas normal

Dilakukan pungsi pleura pada tanggal 19 januari 2013, kemudian dilakukan analisadan sitologi cairan pleura, hasil :

Analisa cairan pleura (21-1-2013) :

Protein total serum : 5,76 g/dL, ratio 0,8

LDH serum : 291 U/L, ratio 3,2

Glukosa : 72 mg/dL

Pewarnaan BTA : negatif, pewarnaan gram : kokus gram positif

Sifat cairan pleura adalah eksudat dengan infeksi sekunder oleh kuman kokusgram positif.

Patologi anatomi cairan pleura (24-1-2013) :

Sel malignancy negative

Peradangan kronis supuratif (abses)

13


14/28

Diagnosa kerja:1.Pneumonia dengan efusi pleura dextra

(parapneumonic syndrome) 2. Syok sepsis

2.Diarrhea3. Malnutrisi underweight

5. PENATALAKSANAAN O2 2L/mnt IVFD RL guyur 1 liter maintenance 40 tetes/menit Levofloxacin 1 x 750 mg i.v

Ceftriaxone 2 x gr i.v Metronidazol 3 x 500 mg i.v Ranitidine 2 x 1 amp i.v Metoclopramid 2 x 1 amp i.v Diet : TKTP Nasi + ekstra telur 6. PROGNOSIS Ad vitam : dubia Ad sanam : dubia Ad fungsionam : dubia

14


15/28

15

PARAPNEUMONIC SYNDROME


16/28

Parapneumonic syndrome : Pneumonia symptoms with parapneumonic effusion

(exudative pleural effusion) that results frompneumonia (CAP/NP) or lung abses

Between 20% and 57% of the 1 million patientshospitalized yearly in the U.S with pneumonia,develop a PPE.

Empyema is less common, occurring

in 5%

10% of patients who experience PPE

16

INTRODUCTION


17/28

Figure 1. Causes of empyema in 14 prior studies. Of the 1383 patients inthe studies, 70% were parapneumonic. For the other 30% of patients,trauma was the cause of empyema in 7%, empyema was postoperativein 6%, and prior tuberculosis was the cause in 4%; 12% of cases weredue to other causes.

17


18/28

Clinical classificationof PPE :

1. uncomplicated parapneumonic effusion (UPPE) 2. complicated parapneumonic effusion (CPPE)

3. Empyema

Stages : 1. exudative

2. fibrinopurulent

3. final organizational

18

CLASSIFICATION


19/28

Symptoms of pneumonia :

Fever, malaise, cough, dyspnea, pleuritic chest pain

Eldery patients >> asymptomatic

19

CLINICAL PRESENTATION


20/28

Pleural fluid analysis >>> to stage the PPE and guidesinitial management.

UPPEs : have a turbid appearance, with a pH >7.30, aglucose level >60 mg/dL, an LDH level


21/28

21


22/28

recommended that all patients withpneumonia be evaluated for the

presence of pleural fluid.

With the possible or definite presence ofpleural fluid noted on a chest

radiograph, an ultrasound-guidedthoracentesis should be performed.

Ultrasonography can detect stranding or

septation in the fluid suggestive of aCPPE and can facilitate its drainage.

22


23/28

Figure 3. A complex, septate pleural effusion demonstrated byultrasonography in a patient with spontaneous hemorrhageinto a pre-existing pleural effusion. This precise pattern is

typical of a complicated parapneumoniceffusion as well.

23


24/28

Figure 2. The estimated time course ofuntreated or inappropriately treatedparapneumonic effusions. In general, anempyema will develop 46 weeks after

the onset of aspiration of bacteria into thelung.24

PATHOPHYSIOLOGY


25/28

In general, early and appropriate antibiotic treatmentwill prevent the development of a PPE and itsprogression.

25

MANAGEMENT


26/28

Antibiotic therapy : Early antibiotic therapy will prevent the development of aPPE and its progression to a CPPE and empyema.

Pleural space drainage :

Clinical factors that suggest pleural space drainage include :

prolonged pneumonia symptoms,

Comorbid disease,

failure to respond to antibiotic therapy, and

presence of anaerobic organisms .

Chest radiograph findings that suggest the need for pleural space drainageinclude an effusion involving >50% of the hemothorax

Stranding or septation noted on an ultrasound suggests the need for pleuralspace drainage.

Intrapleural fibrinolytics : fibrinolytic agents (urokinase and tissue plasminogenactivator) most effective in the early fibrinolytic stage in avoiding the need forsurgical drainage.

Surgery : pleural space drainage by tube thoracostomy has been ineffective incontrolling the pleural infection. (VATS).

26

MANAGEMENT


27/28

1. Early antibiotic treatment usually prevents the development of a PPE and its progressionto a complicated PPE and empyema.

2. Pleural fluid analysis provides diagnostic information and guides therapy.

3. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, >7.30), it ishighly likely that antibiotic treatment alone will be effective.

4. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH


28/28

28

TERIMA KASIH

Date post:	17-Oct-2015
Category:	Documents
Upload:	saga-sabara
View:	39 times
Download:	0 times

PARAPNEUMONIC SYNDROME.ppt

Documents