Emergency Report

Wednesday, April 30
th
, 2014
dr. Windy Juliandra
Attendings On Duty
Pediatric surgery: dr. Suharyo, Sp.B, SpBA
Digestive surgery: dr. A. Hamid Rochanan, Sp.B-KBD
Orthopaedic surgery: dr. AJ Didy Surachman, SpOT
Plastic surgery: dr. Harun Adam, SpBP-RE, MARS
Neuro surgery: dr. Agus Yunianto, SpBS
Oncology surgery: dr. Kristina Maria S, SpB(K)Onk
Thorax CV Surgery: dr. Arif W. TAufiq, SpBV
Urology surgery: dr. Nugroho B. Utomo, SpU
Patients Distribution
Outpatient: -
Inpatient: -
Operation: 1


Patient that had been performed
Surgery

Name Age Sex Diagnosis Treatment
Mr. YW 59 - Suspect
Malignant Pleural
effusion at left
hemithorax
- Myoma Uteri.
Chest Tube
Insertion + WSD
CC : Shortness of breath

HT :
2 weeks prior to admission, patient
complained shortness of breath. The complaint
felt became worst. The complaint reduced when
the patient in sitting position. There was no
fever. No history of heart disease. The patient
had history of soft tissue sarcoma surgery in
2010 at left inguinal in Gatot Subroto Hospital,
and history of Myoma Uterine.
Physical Examination
General State
Alert
BP : 130/70 mmHg Pulse : 98x/mnt
RR : 32x/mnt Temp : 36,7
0
C
Conjunctiva anemic (+), sclera wasnt icteric

Local State :
At thorax region :
Asymetrical chest expansion, Right VBS > Left VBS, Rh (-/-), Wheezing (-/-).
At left hemithorax region : dullness on percusion.
At Lower Abdominal region : Mass (+) 15 x 15 x 10 cm in size, fixed, irregular border,
solid.
CHEST X- RAY
Laboratory Findings

Hb : 8,6 g/dL
Ht : 31 %
L : 23.800 /L
Platelet : 698.000 /L
Glucose ad random : 126
Na : 133
K : 3,7


D/ :
Suspect Malignant Pleural Effusion at left
hemithorax
Myoma Uteri

Th/ :
O
2
4 lpm
Antibiotic
Analgetic
R/ Insertion of Chest Tube + WSD
Intraoperative findings
Air bubble (-)
Undulation (+)
Initial pleural fluid : 500 cc, serous
Intraoperative bleeding : 5 cc
Intraoperative complication : none.
Intraoperative consultation : none
Histological examination : Pleural fluid
Post Insertion CTT X-Ray