You are on page 1of 17

M/M/23 yo

78.96.17
Chief Complaint: Swollen on the neck
It has been suffered by patient since 5 days
before admitted to Adam Malik Hospital. It
growth up slowly, first it come on the neck then
spread to the chest. Initially, patient was fallen
from a tree as high as 4 meters with the face
down and neck hit the wood. It followed by
hoarse and coughing of blood (+) since 5 days
ago.
Dyspnoe (-), Fever (-) , nausea and vomit (-),
micturition (+) normally, defecation (+) normally.
Patient was referred from district hospital.
Present State:
• Awareness : Alert
• BP : 130/70 mmHg
• HR : 98 beats/minute
• RR : 20 times/minute
• Temp : 37,20 C
• VAS :3
Generalized State:
Head : no abnormality was found
Neck : in localized state
Chest : in localized state
Abdomen : no abnormality was found
Genitalia : male, no abnormality
Extremities : no abnormality was found
Localized state
Neck :
I : symmetric, swollen (+), lymphnode enlargement (-),
hematoma (+)
P : crepitation (+), tracheal deviation (-)

Chest:
I : Symmetric, lag of breath movement (-).
P : Crepitation (+), resonance on both hemithorax.
P : Tactile premitus equal
A : Vesicular on both hemithorax
Localized state
Clinical picture
Chest X -Ray
Laboratorium Finding
Hb/Ht/Leu/Tro : 15,6/48/16.200/205.000
Random Blood Glucose : 112
Nasotrakeoscopy
CT Scan Neck
CT Scan Neck
CT Scan Neck
CT Scan Neck
Neck CT Scan
Working Diagnose:
Blunt neck injury zone II + Emfisema Subcutis + Susp.
Pneumomediastinum
Management at Emergency Room :
IVFD Cristaloid  NaCl 20gtt/i
• Inj. Cefriaxone 1 gr/12 Hours
• Inj. Ketorolac 30 mg/8 Hours
• Inj. Ranitidin 50mg/ 12 Hours

Plan:
• Bronchoscopy
• Chest X-Ray