Case Report
Hydropneumothorax
Dextra
By : dr. Annisa Aryani Tarigan
Preceptor : dr. Reno Yovial
PATIENT IDENTITY
Name : Ali Wardana
Medical record number : 00952700
Gender : male
Age : 45 years
Religion : Islam
Address : Jl. Harapan Mulia VI No 14 B
Marital status : Married
Hospital admission : 27 May 2021
HISTORY
Chief complain:
• Cough 1 month before hospital admission
Current medical history:
• The patient came with a complaint of
cough with phlegm since 1 month,
without shortness of breath.
• Fever (-) nausea vomiting (-) diarrhea (-)
• Patient contact with possible/confirmed
covid is denied.
• History of DM Type 2(+)
PHYSICAL EXAMINATION
VITAL SIGN
■ General Condition : Moderate Pain
■ Awareness : E4V5M6 /
composmentis
■ Blood pressure : 129/90 mmHg
■ Pulse : 116 x/min
■ Respiration : 22 x/min
■ Temperature : 36 °C
PHYSICAL EXAMINATION
General examination
• Eyes : Anemia -/-, jaundice -/-, pupillary reflex +/+ isokor, palpebral edema -/-,
sunken eye -/-
• ENT
• Ears: secretions -/-
• Nose: secretions (-), nasal mucosa intact / intact
• Lips: angular stomatitis (-), ulcers (-), dry mucosa (-)
• Tongue: dry tongue mucosa (-)
• Throat: T1/T1 tonsils, hyperemic pharynx (-)
• Neck : JVP + 0 cmH2O, normal thyroid gland, enlarged lymph nodes (-)
PHYSICAL EXAMINATION
General examination
• Thorax : Symmetrical static and dynamic
• Cor
• Inspection : No pulsation of ictus cordis is seen
• Palpation : Iktus cordis not palpable
• Percussion : Right border of right PSL Left border of left MCL
• Auscultation: single S1S2, regular, murmur (-)
• Pulmo
• Inspection: Symmetrical, chest wall retraction (-)
• Palpation: asymmetrical vocal fremitus -/+, mass (-), crepitus (-), tenderness
(-)
• Percussion: Dull in the lower right lung field
• Auscultation: vesicular breath sounds, decreased right breath sounds
compared to the left, rhonchi (+/-) basal lung, wheezing (-/-)
PHYSICAL EXAMINATION
STATUS GENERALIS
Abdomen :
■ Inspection: Distension (-), ascites (-)
■ Auscultation: Bowel sounds (+)
■ Palpation: Liver not palpable, spleen not palpable, tenderness (-)
■ Percussion : Timpani
Extremities:
warm extremities(+). Edema (-)
DIAGNOSIS
Diagnosis : Hydro-pneumothorax Dextra
Planning :
- Consult to surgical department pro wsd
- Asering Infusion /12 hours
- Inj. ranitidine
- Check CBC, diff count, SGOT-SGPT, urea-
creatinine, electrolytes, Random blood sugar
level
Thorax
Thorax
HRCT Thorax
Thorax XRAY result: • The superior mediastinum shows no abnormalities
• Cor: CTR is difficult to assess, pushed to the • Good impression vascular structure
left, the aorta and mediastinum are normal • Fluid collection with air-fluid level in the lateral right pleural cavity
• Trachea in the middle accompanied by thickening of the visceral pleura compressing the
• Pulmo: right lung parenchyma, especially the middle and inferior lobes.
• normal left Hilus • Enlarged lymph nodes at level 4R and 7 with short axis <1 cm.
• Normal left bronchovascular pattern • Fibrosis in segments 3,5,10 right lung
• There is an infiltrate of the left lower field, • Nodules in segment 6
Sinus and diaphragm as well as upper to lower • Tree in bud in segment 5,6,10 left lung and 3 right lung
right hemithorax • Dilatation of segment 5 bronchus of our lungs
• Good skeleton and soft tissue • Visualized upper abdominal organs show no abnormalities
• Intact bones
Conclusion :
Left bronchopneumonia DD/active pulmonary TB Conclusion:
Massive right pleural effusion Right empyema dd/ localized hydropneumothorax
Tree in buds of both lungs with ronchiectasis and pulmonary nodules
suggestive of pulmonary tuberculosis with tuberculoma
Mediastinal lymphadenopathy
EXAMINATION RESULT NORMAL EXAMINATION RESULT NORMAL
RANGE RANGE
Complete hematology
Retikulosit
Hemoglobin 11.6 g/dL 13.2 – 17.3
Absolut 37 25-75
Leukosit 4.61 103/ul 3.8-10.6
Persen 0.94 % 0.50-2.00
Differential count
MCV 84 fL 80-100
basophl 0 % 0-1
MCH 29 Pg 26-34
Eusinofil 1 % 2-4
MCHC 35 g/dl 32-36
Neutrofil band 3 % 3-5
SGOT 12 U/L 10-34
Neutrofil segmen 58 % 50-70
SGPT 12 U/L 9-43
Limfosit 22 % 25-40
Ureum 23 Mg/dl 10-50
Monosit 16 % 2-8
Neutrofil limfosit 2.77 <=3.13 Creatinine 0.9 Mg/dl <1.4
ratio Natrium 136 Meq/L 135-147
LED 105 Mm 0-10 kalium 4.1 Meq/L 3.5-5.0
Hematokrit 33 % 40-52
Chloride 102 meq/L 94-111
Trombosit 445 103/ul 150-440
RBG 462 Mg/dl 70-200
Erytrosit 3.94 10 ul
3/
4.40-5.90
CRP quantitative 126.9 Mg/L <6
EXAMINATION RESULT NORMAL RANGE
Chemical
Haemostasis
Bleeding time 1.30 Menit 1.00-3.00
Clotting time 4.00 menit 4.00-6.00
Serology
Hepatitis (qualitative) (-) negatif (-) negatif
DIABETES
Glukosa jam 05.00 281 mg/dl
Glukosa jam 11.00 384 mg/dl
Glukosa jam 17.00 379 mg/dl
Glukosa jam 23.00 226 mg/dl
Rapid test antigen SARS COV 2 negatif negatif
Follow-Up 04/06/2021 — 18.00
S: A:
Right chest pain, weakness and cough - Hydropneumothorax dextra dd
(+) pyopneumothorax dextra ec
pulmonary TB.
O: - Type II DM with Hypoglycemia.
General condition : Moderate pain P:
consciousness: CM - Asering /12 hours
BP 120/87 - Ranitidine 2x50mg IV
HR 100 - Chest Tube
RR 23 - GeneXpert and sputum.
Temp : 37
Lungs: decreased vesicular / +
rhonki -/-, wheezing -/-
Follow-Up 05/06/2021 — 17.00
S: A:
Pain in the WSDs site. - Pyopneumothorax dextra ec
pulmonary TB dd mixed infection DM
O: type II
General condition : Moderate pain P:
consciousness: CM - Asering /12 jam
BP 105/72 - Ranitidine 2x50mg IV
HR 99 - Levofloxacin 1x750mg IV
RR 20 - Clindamycin 3x300mg PO
T : 36.8 - GeneXpert and sputum
Lungs: decreased vesicular / +
rhonki -/-, wheezing -/-
WSD right undulation (+)
bubbles (-)
Follow-Up 06/06/2021 —
S: A:
Feeling shortness of breath. Pain on - Pyopneumothorax dextra ec
wsd site pulmonary TB dd mixed infection DM
type II
O:
General condition : Moderate pain P:
consciousness: CM - Asering /12 jam
BP 109/82 - Ranitidine 2x50mg IV
HR 78 - Levofloxacin 1x750mg IV
RR 21 - Clindamycin 3x300mg PO
T : 36.2 - GenXpert and sputum
Lungs: decreased vesicular / +
rhonki -/-, wheezing -/-
WSD right undulation (+)
bubbles (-)
Follow-Up 07/06/2021 —
S: A:
Feeling less short of breath, cough (+) - Pyopneumothorax dextra ec
fever (-) pulmonary TB dd mixed infection DM
type II
O:
General condition : Moderate pain P:
consciousness: CM - Ranitidine 2x50mg IV
BP 100/82 - Levofloxacin 1x750mg IV
HR 80 - Clindamycin 3x300mg PO
RR 20 - Mefenamic acid 500mg 3x1
T : 36.4 - GenXpert and sputum --> no sample
- Chest XRAY 09/06/21.
Lungs: decreased vesicular / +
rhonki -/-, wheezing -/-
WSD right undulation (+)
bubbles (-)
Follow-Up 08/06/2021 —
S: A:
Non productive cough - Pyopneumothorax dextra ec TB paru
dd mixed infection DM tipe II
O:
General condition : Moderate pain P:
consciousness: CM - Ranitidine 2x50mg IV
BP 104/82 - Levofloxacin 1x750mg IV
HR 98 - Clindamycin 3x300mg PO
RR 18 - Mefenamic acid 500mg 3x1
T : 36 - Rifampisin 1x600mg morning
- INH 1x300mg morning
Lungs: decreased vesicular / + - Pirazinamid 1x500mg noon
rhonki -/-, wheezing -/- - Etambutol 1x1000mg night.
WSD right undulation (+) - Chest XRAY09/06/21.
bubbles (-)
Follow-Up 10/06/2021 —
A:
S:- - Pyopneumothorax dextra ec TB paru
dd mixed infection DM tipe II
O:
P:
KU : Moderate Pain - Ranitidine 2x50mg IV
Kes : CM - Levofloxacin 1x750mg IV
TD 110/80 - Clindamycin 3x300mg PO
HR 90 - Asam mefenamat 500mg 3x1
RR 18 - Rifampisin 1x600mg morning
S : 36.3 - INH 1x300mg morning
- Pirazinamid 1x500mg noon
Lungs: decreased vesicular / + - Etambutol 1x1000mg night.
rhonki -/-, wheezing -/- - AFF WSD
WSD right undulation (+) - Outpatient 11/06/21
bubbles (-) - Consult to Internist
11 Juni 2021
PEMERIKSAAN HASIL SATUAN
KIMIA KLINIK
DIABETES
Glukosa jam 05.00 326 mg/dl
Glukosa jam 11.00 315 mg/dl
Glukosa jam 17.00 419 mg/dl
Glukosa jam 23.00 139 mg/dl
Disease theory
INTRODUCTION
Hydropneumothorax can occur as a complication of invasive
procedures such as post transbronchial biopsy, chest tube
placement, or thoracocentesis.
Hydropneumothorax is a condition Other etiologies include post-
in which there is air and fluid in the traumatic thorax, secondary to
pleural cavity which causes the lung pneumonectomy, infection,
tissue to collapse. pulmonary infarction, cystic lung
disease, and obstructive
pulmonary disease.
LUNG ANATOMY
Definition of Hydrop-
neumothorax
Hydropneumothorax is a condition in which there is
air and fluid in the pleural cavity which causes the
lung tissue to collapse. This fluid may also be
accompanied by pus (empyema) and this is called a
pyopneumothorax. While the pneumothorax itself is a
condition, in which there is only air in the pleural
cavity which also causes lung tissue collapse. In other
words, hydropneumothorax is a combination of
pleural effusion and pneumothorax.
EPIDEMOLOGI
Pneumothorax is more common in the right hemithorax than the left
hemithorax. Bilateral pneumothorax accounts for 2% of all spontaneous
pneumothorax.
There is no record of the incidence
and prevalence of
hydropneumothorax, but the The incidence and prevalence of
incidence and prevalence of ventilal pneumothorax is 3 —
pneumothorax ranges from 2.4 to 5% of spontaneous
17.8 per 100,000 population per pneumothorax. The probability
year. According to Barrie et al, the of recurrence of pneumothorax
sex ratio of men compared to according to James and Studdy
women is 5:1. There are also is 20% for the second time, and
researchers who get 8:1. 50% for the third time.
CLASSIFICATION OF HYDROPNEUMOTORAX
1 Based on onset
2 Based on location
3 Based on lung parenchymal collapse
4 Based on fistula
CLASSIFICATION OF HYDROPNEUMOTORAX
1 Based on onset
• Primary spontaneous pneumothorax
• Secondary spontaneous pneumothorax
• Traumatic pneumothorax
• Artificial Pneumothorax
CLASSIFICATION OF HYDROPNEUMOTORAX
2 Based on location
• Parietal pneumothorax
• Mediastinal pneumothorax
• Basal pneumothorax
CLASSIFICATION OF HYDROPNEUMOTORAX
3 Based on lung parenchymal collapse
• Pneumotoraks totalis
• Pneumotoraks parsialis
CLASSIFICATION OF HYDROPNEUMOTORAX
4 Based on fistula
• Ventilal pneumothorax
• Open pneumothorax
• Closed pneumothorax
ETIOLOGY
Changes in pleural
permeability
Exudate
Contain protein
Pleural
effusion Increased pleural fluid
protein concentration
Transudate
Disrupted hydrostatic and
colloid osmotic capillary
pressure
PATHOPHYSIOLOGY
Pleural effusion
Fluid enters the cavity through the parietal pleura
Absorbed to circulation in the visceral pleura
It is also absorbed by the lymph nodes in the
parietal and visceral pleura.
Imbalance between formation and
reabsorption of pleural fluid
Pleural effusion.
PATHOPHYSIOLOGY
Pneumothorax
PNEUMOTHORAX
Closed Open
Pneumathorax Pneumathorax
The tearing of the
A B The tearing of the chest
visceral pleura so that wall and parietal pleura
inspired air from the so that there is a
alveolus will enter the connection between the
pleural cavity pleural cavity and the
outside world.
SYMPTOMS OF HYDROPNEUMOTHORAX
Common Symptoms :
Shortness of breath, cough, chest pain.
Physical examination:
decreased lung expansion, lagging chest
movement and decreased vocal fremitus,
dullness to percussion, decreased breath
sounds
INVESTIGATION
The chest X-ray combines the radiological features of pleural
effusion and pneumothorax, air-fluid level
INVESTIGATION
Hidropenumothorax Pleural effusion
INVESTIGATION
CT-Scan
Pleural Effusion differential diagnosis
Pleural Effusion differential diagnosis
Exudative Pleural Effusions
MANAGEMENT
Disease therapy WSD
1 2 3
Thoracocentesis
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