lung cancer, pleural effusion, dry pleurisy & pneumothorax

7/24/2019 Lung Cancer, Pleural Effusion, Dry Pleurisy & Pneumothorax

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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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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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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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scintigraphyscintigraphy cintigraph&cintigraph&

with #cwith #c""

Defect of #cDefect of #caccumulation inaccumulation in

cancer regioncancer region


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computer tomographycomputer tomography


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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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'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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'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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'ercussion'ercussion

arlandBstriangle

>auchfussrocco triangle(due todisplacement ofthemediastinum!

DamoiseauBs

ur+e

0Ausion


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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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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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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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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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uscultationuscultation

pleural frictionpleural friction

ru)ru)


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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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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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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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+,ray+,ray

lung cancer, pleural effusion, dry pleurisy & pneumothorax

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