Bahan tentamen 3 2

(1)

Thoracic Wall, Lung, Heart

Road to Tentamen 3.2 chest complaints ^.^

(2)

Thorax. Breast. Pleura.

(3)

• Rib fractures

-1st_{rib: plexus brachialis & a/v.}

subclavia,

• Flail chest

- >2 ribs, gerak nafas paradoksal

• Supernumery ribs

-pada cervical (bisa nyebabin sindrom Horner) &/ lumbar

• Sternal fracture

-jarang, biasanya dislokasi manubrio sternalis. Kalopun iya jadi comminuted

• Medial sternotomy

-CABG/ambil tumor lobus sup pulmo

• Sternal biopsy

• Thoracotomy

-anterior: H-shaped @ perichondrium -posterior: SIC 5-7 posterolateral

(4)

• Paralysis diafragma  paradoksal

• Pectus Excavatum

• Pectus Carinatum

• Barrel Chest

• Thoracic Outlet Syndrome

-Gangguan vaskuler/ neurologis di apertura thoracica superior:

biasanya obstruksi di pangkal leher, manifestasi di upper limb.

MEDIASTINUM

• Superior

---angulus sternalis--VT4-5

• Inferior:

ant, med, inf

• Mediastinoscopy

(5)

(6)

(7)

• Polymastia

• Polythelia (mammary ridge)

• Amastia

• Gynecomastia

• Ca Mammae

-Metastasis

Dari plexus lymphaticus subareolaris

Lat & center: lnn. axillaris

Med:  lnn. parasternalis / ke mammae sebelahnya

Inf :  lnn. abdominalis - Mastectomy

simple: dr spatium retromammaria

radical: + m. pectoralis, fat, fascia, lnn. - Lumpectomy (BST)

• INNERVASI: n. intercostalis 4-6

• VASKULARISASI: a. thoracica interna & lateralis, a. intercostalis posterior

(8)

• Pleuritis

-Pleural rub, adhesion

-Referred pain: bahu atas

• Pleural effusion

• Hydrothorax

• Hemothorax: injury a.

intercostalis, a. thoracica interna

• Pyothorax

• Chylothorax : ruptur ductus thoracicus

Mx:

*Thoracoscopy

*Thoracocentesis: SIC 9 MAL saat ekspirasi, jarum ke atas

*Chest Tube+WSD: SIC 5/6 MAL,

ke recessus costodiaphragmatica

3. PLEURA

Recessus

Costodiaphragmatica Recessus Costomediastinalis

(C3-C5) (N. spinalis)

(9)

Pneumothorax

-Open

-Tension

• Sebab:

-Fistula bronchopulmonar

-Injury pleura cervicalis (sering pada anak2), luka tembak

• Akibat kronik:

spontaneous secondary atelectasis,

mediastinal shift

• Mx:

-Needle thoracostomy: SIC 2 MCL

-Chest tube: SIC 5/6 MAL

(10)

(11)

PULMO

• Vaskularisasi

-Nutrisi: a. bronchiales -Respirasi: a. pulmonalis • Innervasi

Plexus pulmonalis: -Simpatis: VT1-5

(Efek: bronchodilatasi, vasokontriksi, mucus)

-Parasimpatis: N. vagus • Lymphatic drainage

-lnn. bronchopulmonalis

(hilar nodes)

-lnn. tracheobronchialis

(di bifurcatio trachea, ada yg sup & inf )

-lnn. axillaris (u/ yg pleural adhesion)

• Bronchus: principalis – lobaris - segmentalis

VT5

VT6

je pol _{telu juk}

DEXTER Eparterial (1) Hiparterial (2)

SINISTER

(12)

• Pneumonia (>> lobus inferior)

-Bronchopneumonia (parsial) -Lobar pneumonia

• TB

- >> di apex: tuberkel, kaverna

• Bronchitis kronis

• Emfisema

-Di distalnya bronchiolus terminal -Barrel chest

• Bronchiectasis (>> lobus inferior)

dilatasi bronchus abnormal permanen krn inflamasi & nekrosis

(13)

• Pneumonectomy

• Lobectomy

• Segmentectomy

(hayo apa aja segmennya? :DD)

• Ca Pulmo

bisa ganggu n. phrenicus paralysis hemidiafragma  paradoks

Kalo Ca pulmo apical ganggu n. laryngealis recurrent  paralysis vocal cord  serak

Metas limfogen ke hilar nodes, lnn. supraclavicular (sentinel)

Metas hematogen ke brain, bone, liver • Bronchoscopy:

liat carina, pada metas Ca pulmo ke lnn. tracheobronchialis, carina tampak

distorted, widened posteriorly, & immobile

• Corpus alienum: - >> bronchus dexter

• Atelectasis (kolaps)

-Primer (sejak lahir), sekunder -Obstructive, non-obstructive

-Segmental atelectasis: krn obstruksi di bronchus segmentalis

• Emboli pulmo (di a. pulmonalis) - Komplikasi: ARDS, cor pulmonale, lung infarct

VT5

VT6

je pol _{telu juk}

(14)

Pericardium. Cor.

(15)

1. PERICARDIUM

• Fibrosum, Serosum (parietal & visceral)

• Sinus obliquus pericardii

• Sinus transversus pericardii

-Penting u/ ligasi great arteries pas surgery, misal: CABG

• Innervasi: n. phrenicus (C3-C5) rr. pericardiaci

• Vaskularisasi: a./v. pericardiacophrenica (cabang a. thoracica interna)

• Pericarditis

• Pericardial friction rub

-auskultasi di LSL upper ribs (apex-sternum)

• Pericardial effusion (inflammatory & non-)

• Cardiac tamponade

-Tanda: Beck’s triad (hipotensi, JVD, suara jantung terendam) + pulsus paradoksus

-Hemopericardium: dari bekas MI

(16)

Mx Cardiac Tamponade

:

• Pericardiocentesis

Di are area of peri ardium

-SIC 5/6 LSL  incisura cardiaca

-angulus infrasternalis (arah post-sup)  ati2 kena a./v. thoracica interna

• u/ acute cardiac tamponade krn hemopericardium:

(17)

2. COR

•-a. coronaria Vaskularisasi • Innervasi Intrinsik:

SAN, AVN, Berkas His, Crus dexter-sinister, Purkinje

Ekstrinsik:

Plexus cardiacus;

- Simpatis:

*ganglion cervicale sup, med, inf

*Rr. mediastinales (cabang ganglion paravertebralis I-V)

(Efek: kronotropik +, inotropik +, dromotropik +, vasodilatasi a. coronaria)

-Parasimpatis: N. vagus

• Skeleton Cordis: annulus fibrosus, trigonum

(18)

EMBRIOLOGI

Cor: dulunya tubulus cordis

1. Ventrikel primordial 2. Bulbus cordis

3. Truncus arteriosus

4. Sinus venosus  sinus venarum

5. Atrium primordial  auricula

4&5 dipisahin crista terminalis (dlm) dan sulcus terminalis (luar)

- Septum primum

- Septum secundum  limbus - Foramen ovale  Fossa ovalis (krn pas lahir: P kiri > kanan)

ASD

= Left to right shunt

(acyanosis)  RAH, RVH, TPD

-Lama2 bisa right to left shunt

(19)

EMBRIOLOGI

Septum interventrikular:

• Pars membranacea (sup) defek >> disini

• Pars muscularis (inf)

VSD

•

Left to right shunt

(acyanosis) >>  bising

• Lama2 darah ke RV  

hipertensi pulmonal 

tekanan di RV  > LV  jadi

right to left shunt (cyanosis) = Eise e ger’s syndrome

•  Heart Failure

(20)

(21)

EMBRIOLOGI

• Truncus arteriosus  truncus pulmonalis dan aortae

Truncus Arteriosus

(22)

TGA

• Dari pulmo ke pulmo, dari sistemik ke sistemik  lethal

• Bisa hidup kalo ada shunt, biasanya ASD atau PDA

•

Cyanosis

(23)

EMBRIOLOGI

• Ductus arteriosus  lig. arteriosum (Bottali)

PDA

• Left to right shunt

(

acyanosis

)

• Continous murmur

(24)

Coarctatio Aorta

Aorta narrowing, biasanya deket ductus arteriosus

• Tipe preductal /

penyempitan isthmus aortae

Pertahanin PDA u/ min. sirkulasi ke distal

•Tipe postductal / discrete -Darah susah ngalir ke distal

 dialihin ke a. subclavia 

a. thoracica interna & a. intercostalis gede

Aneurysm of Asc. Aorta

• Biasanya di distal aortae ascendens (ga tertutup

pericardium), krn tekanan 

(25)

(26)

(27)

(28)

Murmur

• Sistolik:

-Stenosis aortae / TP

-Insufisiensi mitral / tricuspid

• Diaistolik:

-Insufisiensi aortae / TP -Stenosis mitral / tricuspid

Valvular Heart Disease

Mx: Valvuloplasty,

(29)

SAN, & AVN Myocard Infarct: krn obstruksi akibat emboli/atherosclerosis di LAD (>>), RCA

(>), dan LCX.

Angina Pectoris:

• Nyeri deep sternum-medial lengan,

transient, membaik dengan istirahat (beda dgn MI)

• Tx: nitrogliserin sublingual

Cardiac Arrhythmia

• Heart block (RCA)

(30)

Cardiac Referred Pain

visceral afferent berjalan bersama simpatis ke ganglion sensoris T1-T5.

Anginal pain

Substernal-left pectoral-left shoulder-left upper limb (med). medial cutaneous nerve of the arm.

lateral cutaneous branches of the 2nd and 3rd intercostal nerves. commisural ke kanan.

(31)

• Angiography

• (Percutaneous Transluminal) Coronary Angioplasty

• Pake kateter dari a. femoralis

•Balon diinflasi * +thrombokinase

(32)

CABG

Diambil dari

• v. saphena magna / a. radialis, krn:

-diameter oke -mudah didiseksi

-min. katup & percabangan

• a. thoracica interna