MI/F/3yo

Chief Complaint : Shortness of breath

it had been sufferred by the patient since 1 week
before admitted to Haji Adam Malik Hospital.
The complaint become greater in this 2 days,
history of coughing (+) since 2 months, history
of fever (+) since 2 months, history of decrease
of body weight (+) 2kg in last month, history of
night sweating (+) history of contact with a TB
patient was denied, fever (+), history of eat 6
months medication (-), history of trauma.

Present State:
Sens: CM
BP: 120/80 mmHg
Pulse: Complaint
breath

Shortness

of

it had been sufferred by the patient

since 1 week before admitted to Haji
Adam Malik Hospital. The complaint
become greater in this 2 days,
history of coughing (+) since 2
months, history of fever (+) since 2

Generalized State:

Head: no abnormality
Neck: e Complaint : Shortness of breath
it had been sufferred by the patient since
1 week before admitted to Haji Adam
Malik Hospital. The complaint become
greater in this 2 days, history of coughing
(+) since 2 months, history of fever (+)
since 2 months, history of decrease of
body weight (+) 2kg in last month, history
of night sweating (+) history nlargement

Localized State

Thorax:
I : Symmetrical
P : tactile Fremitus equal on both hemi thorax
enlargement of lymph node at regio (R)
axilla size 2x1cm
P : Dullness on (R) hemithorax
A : Vesiculair decreased o/t (R) Hemithorax

Radiologic Finding:
Thorax Ap Erect : Homogenous Cloud o/t (R)
Hemithorax

Laboratory Finding:
Hb/Ht/Leu/Trom: 11,4 / 35,30 / 12,33 / 399

Na/K/Cl

: 137 / 3,5 / 114

Ur/Cr

: 25,9 / 0,2

RBS

: 100

Treatment at the Emergency Room:

-O2 Face Mask 5l/i
-IVFD Crystalloid
-Inj. Antibiotic
-Inj. Analgetic
-Patient was prepared for Emergency Thoracic
Tube Insertion + WSD

At the Operating Theatre

- Patient in supine position, general anesthesia, aseptic
and antiseptic procedure, drapping procedure was
performed
- Injection of lidocaine 2% rumboidly at linea axillaris
anterior and Inter Costa Space V
- Incision was made transversely, cutis, subcutis,fascia
was opened sharply, muscle, and pleura parietal was
opened bluntly.

At the Operating Theatre

- Identification of tract using index finger, mass (-)
- Insertion of Thoracic Tube 20 Fr to cranioposterolateral
and connected to a WSD bottle
- Came out initial 150 cc purulent fluid, sample was
taken for microbiological culture and sensitivity test,
fungi test, direct TB test, and sitologi examination
- Undulation (-), expiratory bubble (-)
- The tube then fixated with silk material

- Operation was done