Bahan tentamen 3 2

Road to
Tentamen 3.2
chest
complaints ^.^

:

Thoracic Wall, Lung, Heart

THORACIC WALL
Thorax. Breast. Pleura.

1. THORAX

• 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

• 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
• Mediastinal biopsy

2. BREAST
• 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

3. PLEURA
(N. spinalis)

(C3-C5)

Hilum, Lig.
pulmonale

Recessus

Costodiaphragmatica

• 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

Recessus
Costomediastinalis

ekspirasi, jarum ke atas

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

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
-u/ cegah atelectasis: Pleurodesis

LUNG

PULMO
• Vaskularisasi
-Nutrisi: a. bronchiales
-Respirasi: a. pulmonalis
• Innervasi
Plexus pulmonalis:
-Simpatis: VT1-5

DEXTER
Eparterial (1)
Hiparterial (2)

(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
SINISTER
je pol

telu juk

Hiparterial (2)

• 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

-Asthma

• 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

• 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
carina

• Bronchoscopy:

VT5

liat carina, pada metas Ca pulmo ke
lnn. tracheobronchialis, carina tampak
distorted, widened posteriorly, &
immobile

VT6

je pol

telu juk

HEART
Pericardium. Cor.

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
-Pneumopericardium: dari pneumothorax

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:
Thoracotomy untuk insisi
saccus pericardium + stasis of
hemorrhage

2. COR

• Vaskularisasi
-a. coronaria
• 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
fibrosum, tendo infundibuli

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
(cyanosis)

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
• VSD = kelainan kongenital
jantung paling sering (25%)

Right to left shunt (cyanosis)

EMBRIOLOGI
• Truncus arteriosus 
truncus pulmonalis dan
aortae

Truncus Arteriosus
Darah campur  cyanosis

TGA
• Dari pulmo ke pulmo, dari
sistemik ke sistemik  lethal
• Bisa hidup kalo ada shunt,
biasanya ASD atau PDA
• Cyanosis
• Kadang mengiringi isolated
dextrocardia

EMBRIOLOGI
• Ductus arteriosus  lig.
arteriosum (Bottali)

PDA
• Left to right shunt

(acyanosis)
• Continous murmur
(machine-like murmur)

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 
• Bisa menekan trachea dan
esofagus  chest pain sampe
punggung + susah nafas

VALVULAR HEART DISEASE

Murmur
• Sistolik:
-Stenosis aortae / TP
-Insufisiensi mitral / tricuspid
• Diaistolik:
-Insufisiensi aortae / TP
-Stenosis mitral / tricuspid

Valvular Heart Disease
Mx: Valvuloplasty,
-Artificial Prostheses
-Xenografted

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)
• Bundle branch block (LAD)
SAN, & AVN

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.
although usually referred to the left side, may be referred to the right side, both
sides, or the back

• Angiography
• (Percutaneous Transluminal)
Coronary Angioplasty
• Pake kateter dari a. femoralis
•Balon diinflasi
* +thrombokinase
* +blade-rotasi dengan laser
* +stent

CABG
Diambil dari
• v. saphena magna / a.
radialis, krn:
-diameter oke
-mudah didiseksi
-min. katup & percabangan
• a. thoracica interna
(anastomosis langsung)