Eko Chesa S.

, Fadilah, Siti A

Resume
Operation : 1
Inpatient : 0 Outpatient : 0

Consultant incharge

Mr. S, Male, 60 years old

The main complaint pain during deep breathing and slight shortness of breath since he fell 5 days ago
History of present illness 5 days ago 5 days before entering the hospital patients fell from a height of 3 meters + while fixing tiles. The patient fell to the ground with his back first. When the patient fell scratched tile in the abdomen. After falling patient can stand alone. Since that day, pain during deep breathing at right thorax and slight shortness of breath, was taken to a general hospital bekasi examination chest film, in care given oxygen and medication injection, treated for 5 days and still no improvement, then the family chose to be referred to hospital gatot subroto History of past illnes : diabetes, allergic and hypertension is undeniable,

Primary Survey
Airway : clear Breathing : spontaneous, slightly tachypnea (RR = 24x/menit) Circulation : Strong pulse (86x/mnt), Blood pressure of 130/70 mmHg CRT <2 . Normal skin color , Good skin turgor Disability . response Alert , Pupils isokor (+ / +) .GCS E4V5M6 Exposure , Lesion on the abdomen (+)

Secondary Survey
Head: Normocephal Eyes: Conjungtiva anemic (- / -), sclera jaundice (- / -) ENT: Secretions (-), tracheal deviation (-)

Chest: see the local status

Abdomen: see the slocal tatus Backs: not found abnormalities

Genitalia: not found abnormalities

Extremities: warm, edema (-)

Thorax Inspection : Lesion (-) Palpation : Tenderness (+) at the right inferior thorax Percussion : dullness at left inferior thorax Auscultation : decrease vesicular sound at left inferior thorax Heart : no gallop, no murmur Abdomen Inspection : exoriation, flat Auscultation : normal bowel sound Palpation: no muscular rigidity, no pain Percussion: timpany

Local status

Laboratory results

Chest X-Ray, RSUD Bekasi

Diagnosis Pre WSD

Blunt thoracic trauma with wiht hematothorax S27.1Traumatic

haemothorax and fractures of the left ribs 9th S22.3Fracture of rib

Blunt abdominal trauma with stable haemodinamic and no

peritonitis S30.1Contusion of abdominal wall

Planning
Plan WSD 34.91 Thoracentesis Informed consent O2 Nasal canul 3-4 l/mnt IV line Analgetic Antibiotic

Operation report
semi-supine patient position a and antisepsis operation and

the surrounding area infiltration anesthesia with lidocaine 2 percent in ICS 6 aspiration: serohemoragic discharge incision on ICS 6, No. 28Fr chest tube inserted, the initial discharge serohemoragic 150 cc, with undulations, no initials bubble fixation chest tube, and connected with a bottle of WSD operation is complete
Atelectasis:inferior lobe

Diagnosis post WSD

Blunt thoracic trauma with wiht hematothorax and fractures of the left

ribs 9th Blunt abdominal trauma with stable haemodinamic and no peritonitis Atelectasis left inferior lobe Next treatment Chest fisotherapy Inhalation Analgetic Antibiotic

Condition today
Good condition
Abcd

Thank you