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CASE STUDY Presented by
นสพ.จิราพร ตั้งกฤษณขจร
นสพ.จุฑามาศ พงศช์า้งอยู ่นสพ.ณฐัณิชา กงัวลกิจ
นสพ.พรรณปพร ดิษบรรจง นสพ.พิมพป์ระพนัธ์ อุไรกลุ
นสพ.รัตนชาติ ศิรินิล
นสพ.วศินี ชาญพิชยั
นสพ.อคัรภา จุฬคุปต ์
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CASE
HN : 22052-57
Case : ผูป่้วยชายไทย อาย ุ18 ปี เช้ือชาติไทย สญัชาติไทย ศาสนาพทุธ
อาชีพนกัศึกษา ภูมิล าเนาจงัหวดัพิจิตร สิทธิโครงการนิสิต มศว
Chief Complaint : เจบ็หนา้อกดา้นขวา 2 วนั ก่อนมาโรงพยาบาล
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HISTORY
Present Illness :
- 2 วนัก่อนมาโรงพยาบาล ผูป่้วยมีอาการเจบ็หนา้อกดา้นขวาขณะอยูเ่ฉย ๆเจบ็
ตลอดเวลา เจบ็พอทนได ้ เจบ็มากข้ึนขณะหายใจเขา้ ไม่มีอาการหอบเหน่ือย ไม่มี
อาการแน่นหนา้อก สามารถท ากิจกรรมไดป้กติ แต่อาการปวดไม่ดีข้ึน จึงมา
โรงพยาบาล ศูนยก์ารแพทยฯ์
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HISTORY
Past History :
- 1 ปีก่อนมาโรงพยาบาล ผูป่้วยมีอาการเจบ็หนา้อกดา้นขวา เจบ็เสียดๆ ขณะ
นัง่เรียน เจบ็มากข้ึนเวลาหายใจเขา้ ไม่มีหอบเหน่ือย ไปพบแพทยไ์ดรั้บการวนิิจฉยั
เป็นกลา้มเน้ืออกัเสบ ไดย้าแกอ้กัเสบมากิน อาการดีข้ึน
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HISTORY
Past History :
- No known underlying disease
- No known food, drugs or chemical allergy
- No history of trauma or previous surgery
- No smoking/drinking
- No current medication
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HISTORY
Family History :
- No known genetic disease
- คนในครอบครัวไม่เคยมีอาการเหมือนผูป่้วย
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PHYSICAL EXAMINATION
Vital Signs : BT 36.5 oC HR 70 bpm RR 16/min BP 124/78 mmHg
General Appearance : A Thai male, good consciousness
HEENT : Not pale conjunctiva, anicteric sclera
Cardiovascular system : Full pulse, normal S1S2, no murmur
Respiratory System : Decreased breath sound at right lung, hyperresonant
on percussion at right lung, equal chest expansion, no crepitation.
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PHYSICAL EXAMINATION
Abdomen : No distension, no superficial vein dilatation, no visible
abdominal mass, normoactive bowel sound, soft, not tender, no guarding,
no rebound tenderness, liver and spleen can’t be palpated
Extremities : Full pulse, no rash, no petechiae, no pitting edema, capillary
refill < 2 sec
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PHYSICAL EXAMINATION
Nervous system :
- Mental status : good consciousness, E4M6V5
- Normal gait
- No neurological deficit
- Motor power grade V all extremities
- No sensory loss
- Deep tendon reflex grade 2+ all
- Normal cerebellar sign
- Stiff neck negative
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PROBLEM LIST
1. Pleuritic chest pain 2 days PTA
2. Decreased breath sound and hyperresonance on percussion at right lung
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DIFFERENTIAL DIAGNOSIS
• Spontaneous pneumothorax
• Spontaneous pneumomediastinum
• Costochondritis
• Pericarditis
• Myocardial infarction
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PROVISIONAL DIAGNOSIS
Spontaneous pneumothorax
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APPROACH FILM
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Diagnosis : Spontaneous pneumothorax
CONCLUSION
History : Pleuritis chest pain
Physical examination : Decreased breath sound and hyperresonance on
percussion at right lung
Chest X-ray : Visible visceral pleural line at right lung, absence of lung
marking lateral to pleural line
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PSP in CXR
ACCP 2001 : ระยะ (a)
• ≥ 3 cm = large pneumothorax
• < 3 cm = small pneumothorax
BTS 2010 : ระยะ (b)
• ≥ 2 cm = large pneumothorax
• < 2 cm = small pneumothorax
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PSP in CXR
Size of pneumothorax by Rhea Method:
Pneumothorax size (%)
= Average interpleural distance (cm)
= (A + B + C)/3
1 = 15%
2 = 20%
3 = 30%
4 = 40%
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MANAGEMENT
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TIPS : Tube Malposition
1. Intraparenchymal Tube Placement
2. Fissural Tube Placement
3. Chest Wall Tube Placement
4. Mediastinal Tube Placement
5. Abdominal Placement
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Intraparenchymal Tube Placement
• Occurs more likely in the presence of pleural adhesions or preexisting
pulmonary disease
• On CT, the tube is seen transvering the lung.
• Probably representing a haematoma due to lung laceration
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Fissural Tube Placement
• The probability is higher when using the lateral approach.
• Outlined by a residual pneumothorax.
• Located in the region of a fissure but without areas of an
intraparenchymal opacity around it.
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Chest Wall Tube Placement
• An unstable chest wall.
• A tube is positioned outside the parietal pleura.
• May cause bleeding from pectoralis major muscle and the breast.
• High insertion in the posterior chest wall has resulted in Horner’s
syndrome.
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Mediastinal Tube Placement
• Placing chest tubes far into the thorax can result in perforation of heart,
injuries to large vessels, perforation of the oesophagus, and nerve
injuries.
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Abdominal Placement
• Usually occurs when tube thoracostomy is performed too low.
• Injuries to the spleen, liver, and stomach.
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Case Progression
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0.6 cm subpleural bleb
at apical segment of RUL
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After Video-Assisted Thoracic
Surgery (VATS) with lung blebs
resection
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TAKE-HOME MESSAGE
• Signs of pneumothorax in CXR :
- visible visceral pleural line
- no lung markings are seen peripheral to this line
- the peripheral space is radiolucent compared to adjacent lung
- the lung may completely collapse
- subcutaneous emphysema and pneumomediastinum may also be present