parapneumonic syndrome.pptx

7/28/2019 PARAPNEUMONIC SYNDROME.pptx

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PARAPNEUMONIC

SYNDROME(Laporan Kasus)

Arismunandar H.P.U

0818011008

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1. ANAMNESIS

Identitas PasienNama : Tn. S

Umur : 60 tahun

Jenis Kelamin : Laki-laki Pekerjaan : Petani

Agama : Islam

Alamat : Punggur Tanggal Masuk : 19 Januari 2013,

pukul 18.00 WIB

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Keluhan Utama

Buang air besar cair sejak 1 hari SMRS

Keluhan Tambahan

Demam,batuk berdahak, pilek, sesak

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Riwayat Penyakit Sekarang Pasien datang ke IGD RSAY Metro dengan

keluhan buang air besar cair sejak 1 hariSMRS. Buang air besar sebanyak 5 kali

dengan konsistensi cair, ampas yang sedikitdan berlendir tanpa disertai darah. Pasien

juga mengeluh demam yang naik turun dandisertai dengan pilek, batuk berdahak dan

sesak serta dada terasa berat sejak 2 hariSMRS. Pasien juga mengaku tidak nafsumakan dan badan terasa lemas. Karenakhawatir akan kondisi dirinya, maka pasiendatang ke IGD RSAY Metro untuk berobat.

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Riwayat Penyakit Dahulu

Riwayat DM : disangkal

Riwayat hipertensi :

disangkal

Riwayat sakit jantung : disangkal

Riwayat minum OAT : disangkal

Pasien belum pernah mengalami sakit

seperti ini sebelumnya

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Riwayat Penyakit Keluarga

Riwayat penyakit serupa :

disangkal

Riwayat Hipertensi :disangkal

Riwayat DM : disangkal

Riwayat Jantung : disangkal

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PEMERIKSAAN FISIK Keadaan Umum : sakit berat,

compos mentis, gizi kurang

Tanda Vital Tekanan darah : 60/40 mmHg

Nadi : 124 x/menit

Pernapasan : 40 x/menit Suhu : 38,7 C

Saturasi O2 : 90 %

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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 (+).

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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 samadengan bagian kiri, saat dinamis, gerakan

dada kanan tertinggal dari kiri. Retraksiintercostal, dan subcostal ditemukan

Palpasi : Fremitus taktil kanan lebih lemah dari kiri

Perkusi : pekak/sonor

Auskultasi : ronki +/-, wheezing -/-

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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 -/-

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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

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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

Kultur darah (22-1-2013) : hasil

steril 12


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Foto Rontgen Thorax PA (23Januari 2013) :

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Kesan:

Efusi pleura

dextra

bronkopneumonia

kardiomegalidengan elongatio

aorta


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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

analisa dan 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

kokus gram positif.

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

Sel malignancy negative

Peradangan kronis supuratif (abses)

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Diagnosa kerja:

1.Pneumonia dengan efusi pleura dextra

(parapneumonic syndrome)

2.Diarrhea

3. 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

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PARAPNEUMONIC

SYNDROME

(Parapneumonic effusions and empyema)

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INTRODUCTION

Parapneumonic syndrome : Pneumonia symptoms with parapneumonic

effusion (exudative pleural effusion) that

results from pneumonia (CAP/NP) or lung

abses

Between 20% and 57% of the 1 million

patients hospitalized yearly in the U.S

with pneumonia, develop a PPE. Empyema is less common, occurring

in 5%10% of patients who experience

PPE 17


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Figure 1. Causes of empyema in 14 prior studies. Of the 1383

patients in the studies, 70% were parapneumonic. For the other

30% of patients, trauma was the cause of empyema in 7%,

empyema was postoperative in 6%, and prior tuberculosis was

the cause in 4%; 12% of cases were due to other causes.

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CLASSIFICATION

Clinical classificationof PPE : 1. uncomplicated parapneumonic

effusion (UPPE) 2. complicated parapneumonic effusion

(CPPE) 3. Empyema

Stages : 1. exudative 2. fibrinopurulent 3. final organizational

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CLINICAL PRESENTATION

Symptoms of pneumonia :

Fever, malaise, cough, dyspnea,

pleuritic chest pain

Eldery patients >> asymptomatic

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Pleural fluid analysis >>> to stage thePPE and guides initial management.

UPPEs : have a turbid appearance, witha pH >7.30, a glucose level >60 mg/dL,

an LDH level


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recommended that all patients withpneumonia be evaluated for thepresence of pleural fluid.

With the possible or definite presenceof pleural fluid noted on a chestradiograph, an ultrasound-guidedthoracentesis should be performed.

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

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Figure 3.A complex, septate pleural effusion

demonstrated by ultrasonography in a patient with

spontaneous hemorrhage into a pre-existing pleural

effusion. This precise pattern is typical of a complicatedparapneumoniceffusion as well. 24


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PATHOPHYSIOLOGY

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

after the onset of aspiration of bacteriainto the lung. 25


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MANAGEMENT

In general, early and appropriateantibiotic treatment will prevent the

development of a PPE and its

progression.

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MANAGEMENT Ant ib iot ic therapy: Early antibiotic therapy will prevent the development

of a PPE and its progression to a CPPE and empyema.

Pleural sp ace drainage :

Clinical factors that suggestpleural 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

drainage include an effusion involving >50% of the hemothorax

Stranding or septation noted on an ultrasound suggests the need for

pleural space drainage. Intrapleural f ibr inolyt ic s :fibrinolytic agents (urokinase and tissue

plasminogen activator) most effective in the early fibrinolytic stage in

avoiding the need for surgical drainage.

Surgery :pleural space drainage by tube thoracostomy has been

ineffective in controlling the pleural infection. (VATS).

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CONCLUSIONS1. Early antibiotic treatment usually prevents the development of a PPE and its

progression to 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 is highly likely that antibiotic treatment alone will be effective.

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


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TERIMA KASIH

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parapneumonic syndrome.pptx

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