CASE REPORT Thursday,April 3rd 2014 Team of duty: dr. Hendra Kastiaji dr. M. Nazir Tam unan dr.

!ynaldi Andriansya dr. Khali" dr. #umrahadi dr. $auhari dr. Muharriansyah I. Patient identity Name : %lli &itria A'e : 20 years (ld #e) : Male Address : *s +ampanah Teun'(h, Ke,. -ndrapuri, A,eh .esar M! : /0 01 00 2h(ne : 03124244/11/ 2atient ,ame at: 04.00 2M Chief complaint : *yspneu Present illness history: 2atient ,ame t( 5ain(el A idin emer'en,y r((m 6ith a ,hie7 ,(mplaint dyspneu sin,e 1 days a'(. -nitially she had dyspn(e a (ut 4 days and e,(me 6(rst 1 day. There are n( hist(ry (7 ,(u'h 7(r l(n' peri(d. Hist(ry (7 p(steri(r sta ilizati(n sur'ery due t( s,(li(sis 89: a (ut 1 m(nth a'(. Physical examination : Tra,hea in n(rmal limit -n,rease (7 $;2 8<: !i'ht haemith(ra) +e7t haemith(ra) -nspe,ti(n Asymmetri,al, 2alpati(n There 6as tra,hea n(t midline , $;2 6as in,rease, ,repitati(n 8<: 2er,uti(n dulness #(n(r Aus,ultati(n ;esi,uler de,rease ;esi,uler .l((d 2ressure : 130=30 mmH', 2ulse : 03 eats=min !espirati(n : #p(ntane(us, 23 reaths=min, Assesment: !i'ht pleural e77usi(n ana!ement : -;&* !+ 20 drips=min >)y'en 3 liters= 7a,emas" -nj. ?e7tria)(ne1 'r -nj. Ket(r(la, 30 m'

II . III.

IV.

V. VI.

 VII.

@rinary ?atheter +a (rat(ry e)aminati(n !adi(l('y e)aminati(n : 11,3 'r=dl : /,400 =ul : 113.000 =ul : 20 B : 3 min : 3 min : 12/ m'=dl

"a#oratory result H A.? 2latelets Ht ?T .T .l((d 'lu,(se ad rand(m

VIII.

Radiolo!y result Thora$ AP: the ri'ht ,(st(phreni,us 6as lunt !adi((paCue apearan,e at the ri'ht hemith(ra) there 6as s,(li(sis th(ra,( lum al There 6as p(steri(r sta ilizati(n implant 89: &ia!nosed !i'ht pleural e77usi(n Consult to T'V sur!ery di(ision 2er7(rmed A#* < < < < < Intraoperati(e report 2atient in semi7(6ler p(siti(n Asepti,, antisepti, pr(,edure and per7(rmed l(,al anesthesia -n,isi(n at linea mid a)illaris at inter ,(stae spa,e 1 -nserted ,hest tu e &! 23 pr(du,ti(n 400 ,, ser(us, undulati(n 89:. ?hest tu e 6as 7i)ated 6ith n(na s(ra le 1.0 Post Op &ia!nose !i'ht pleural e77usi(n )ollo* up # > *yspneu .2:140=30 8<: 2ulse : 143 eats=minute !!: (n Dentilat(r Temp : 34,3 0 ? +=# at ri'ht hemith(ra) A#* 89: 2r(du,ti(n 89: 300 ,, A !i'ht pleural e77usi(n l 2 -;&* !+ 20 drips=min >n Dentilat(r 8#: ?M; M(de &i >2100B >)y'en -nj. ?e7tria)(n 1 'r= 12 h(ur *rip 2ara,etam(l 1 'r= 3 h(ur &entanyl *( utamin 2r(p(7(l

%I. %II. VI.

VII. %IV. *ate 1<4<14 2>* -

;ent(lin ne ulizer