AS/M/40yo

61.74.18
Chief Complaint: Shortness of breath

It has been suffered since 4 days before admitted to Adam Malik

Hospital. Initially the patient has been suffered ginggival abscess
since 7 days ago. The patient has underwent oral theraphy with
antibiotic during 2 days. 1 days after oral consumption patient was
in hospitalized in other hospital during 3 days. Patient was sent to
another hospital and underwent drainage of abcess on the
oropharingeal and tracheostomy was performed because the
abcess spread to the oepharingeal.
The patient sent again to adam malik hospital because the abcess
to spread to mediastinum, based on the clinical hystory and
additional examination.
fever (+), pain (+) intermittenly, history of past illness was unclear.
History of trauma (-).
Present State
Awareness : Somnolen
BP : 100/80 mmHg
HR : 100 x/min
T : 38.5°C
RR : 28x/min
Generalized state:
Head : no abnormalities was found
Neck : in localized state
Thorax : in localized state
Abdomen : no abnormalities was found
Extremities : no abnormalities was found
Localized State
Neck :
I : Dehiscence o/t tracheostomy wound,
hyperemic (+), pus(+), subcutis drain was
inserted
P : Fluctuation (+) around the
tracheostomy wound.
A : Snooring (+)
Thorax :
I : Symmetrical
P:
• Thorax :
Chest:
I : Symmetrical
P : Vocal fremitus decrease on the both
hemithorax
P : dullness on the both hemithorax
A : Vesicular sound was decrease on the both
hemithorax, ronchi (+) o/t both hemithorax
Laboratorium Finding
Hb / Ht / WBC / PLT : 11.3 /33/14.57/666
N/K/Cl : 130/3,6/99
Random blood glucose : 109

Agda :
Ph : 7.390
pCO2 : 27.0
pO2 : 208
HCO3 : 16.3
Total CO2 : 17.1
BE : -7.2
Saturasi : 98 %
Chest X-Ray october 18 th
Chest X-Ray october 21 st
Chest x-ray october 22 nd
Working Diagnose:
Abscess on the ginggival, oropharigeal and
mediastinum with post tracheostomy + sepsis +
pneumonia
Management at Emergency Room :
•IVFD Crystalloid 20
•Antibiotic Injection
•Analgetic injection
•Wound toilet
•Evacuation pus  came out pus 400 cc seropurulent
•Hospitalized
•Plan for sternotomy debridement and evacuation of
abscess urgency