Y/L/14yo

79.64.24
Main Complaint: shortness of breath
It has been suffered since 1 month ago, worsened 7 days
before admission to Adam Malik Hospital. History of
coughing (+) since 2 month ago, bloody cough (-),
intermittent fever (+), sweating in the middle of the night
(+). History of TB drug comsumption (-). His bodyweight
was decrease in the last month. History of trauma (-).
Patient had been hospitalized for 3 days in district hospital.
Present state:
• Awareness : Alert
• BP : 110/70 mmHg
• HR : 127 x/I
• RR : 24 x/I
• T : 37.4 C
• VAS :4
• BW : 49
Generalized state:
Head : no abnormality was found
Neck : no abnormality was found
Chest : In localized state
Abdomen : no abnormality was found
Genital : Male, no abnormality was found
Extremities : no abnormality was found
Localized State:
Chest : I : symmetrical, lag of movement (-)
A : diminished sound of breath o/t
(L) hemithorax
P : tactile fremitus (L) increase
P : dullness (+) o/t (L) hemithorax
Laboratory finding
• Hb / Ht/ WBC / PLT : 12.8/34/ 8.620/381.000
• Random blood glucose : 92
Chest X Ray
• Working Diagnosis:
(L) Pleural Efusion + Susp Lung TB dd:Pneumonia
Management in Emergency Room :
• O2 with nasal canule 5 L/i
• IVFD RL = 1500 cc + ((49-20)x20 cc) / day
= 2,080 cc / day = 86 cc / hours
= 31.200 cc / mnt = 22 gtt/mnt (micro)
• Inj. Ceftriaxone 50 mg/kgbb/day.
= 50 x 49 kg = 2,450 mg/day
= 204 mg / 12 hours
• Inj. Paracetamol drip 15 mg/kgbb/p.r.n
= 15 x 49 kg = 735 mg/day
= 91 mg / 8 hours or p.r.n
• Prepare for chest tube insertion + WSD
At the operating theatre :
• Supine position, elevate and extend the (L) arm, aseptic,
antiseptic procedure was performed
• Infiltrating lidocaine 2% rhomboidly in ICS 5th just
anterior from midaxillary line projection
• Transverse incision, skin, subcutaneous were opened
sharply, fascia, muscle and pleura were opened bluntly
• Insert thoracic tube 24 Fr to cranioposterolateral for 6cm,
and was connected to a bottle of WSD, came out 400 cc
serous , expiratory bubble (-) , undulation (+) and
thoracic tube was fixed with silk material no 2.0 and
slipknot
• Operation was done
Chest X-Ray Post Chest Tube