CASE REPORT
A. Patient Identity
Name : TD
Gender : Female
Age : 11 years old
Address : Banjer lk 7
Occupation : -
Religion : Islam
CM : 49.40.94
Entry Date : March 07, 2017
B. Anamnesis
Main complaint : Tightness
History of The Disease Now :
The patient came with the main complaint of tightness, tightness felt since ± 1 week of
SMRS and aggravated since this morning. The patient also complained of sumer-sumer fever
felt since ± 1 week SMRS, fever down with fever-reducing drugs. The patient also
complained of a cough that was felt since ± 2 months of SMRS, a slimy cough, white color,
no blood. Patients experienced a decrease in appetite since ± 2 months of SMRS and weight
loss since ± 2 months of SMRS.
History of The Disease First
Previous history of pulmonary diseases : Bronchopneumonia and pleural effusion
sinistra.
, History of diseases of the heart, liver, kidneys refuted
Previous trauma history thoughtl
Previous operation history is refuted
History of drug allergies is refuted
Family History of Disease
The sufferer's father experienced the same symptoms and had died ± 9 years ago.
Social Life History
The history of contact with neighbors who are on medication is 6 months.
C. Physical Examination
General Circumstances : The patient appears to be moderately ill
Awareness / GCS : Compos mentis (E4V6M5)
Vital Signs : T : 100/60 mmHg
N : 123 x/min
RR : 48x/min
Temperature : 37.5oC(Axilla)
Generalist Status :
Head : Conjunctiva anemis (+), isocor round pupil, ɸ 3 mm left=right, RC+/+
normal.
Neck : Trachea central location, kgb enlargement (-)
Thorax :
Lung
Inspection : movement of the left chest wall left behind
, Palpation : stem fremitus left < right
Auscultation : bronchial breathing sounds, Rh +/+
Percussion : left hypersonor, right dim
Heart
No extra sounds
Abdomen : flat, normal bowel sound (+)
Superior extremities : no abnormalities
Ekstremitas inferior : no abnormalities
Skin
Normal (+) skin turgor
D. Occupational diagnosis
Bronchopneumonia dd pulmonary tuberculosis + sinistra pleural effusion
E. Management
- O2 1 lpm via nasal canal
- IVFD NaCl 0.45 % in D5% 21 gtt/m
- Cefotaxime 3x1 gr iv
- Gentamicin 1x100 mg iv
- Dexamethasone 3x3.5 mg iv
- Surgical cosul :
Left thoracosynthesis plan : if serous fluid comes out continue to check the
analysis of pleural fluid + culture, If the fluid is turbid plan install WSD.
F. Supporting checks
A. Patient Identity
Name : TD
Gender : Female
Age : 11 years old
Address : Banjer lk 7
Occupation : -
Religion : Islam
CM : 49.40.94
Entry Date : March 07, 2017
B. Anamnesis
Main complaint : Tightness
History of The Disease Now :
The patient came with the main complaint of tightness, tightness felt since ± 1 week of
SMRS and aggravated since this morning. The patient also complained of sumer-sumer fever
felt since ± 1 week SMRS, fever down with fever-reducing drugs. The patient also
complained of a cough that was felt since ± 2 months of SMRS, a slimy cough, white color,
no blood. Patients experienced a decrease in appetite since ± 2 months of SMRS and weight
loss since ± 2 months of SMRS.
History of The Disease First
Previous history of pulmonary diseases : Bronchopneumonia and pleural effusion
sinistra.
, History of diseases of the heart, liver, kidneys refuted
Previous trauma history thoughtl
Previous operation history is refuted
History of drug allergies is refuted
Family History of Disease
The sufferer's father experienced the same symptoms and had died ± 9 years ago.
Social Life History
The history of contact with neighbors who are on medication is 6 months.
C. Physical Examination
General Circumstances : The patient appears to be moderately ill
Awareness / GCS : Compos mentis (E4V6M5)
Vital Signs : T : 100/60 mmHg
N : 123 x/min
RR : 48x/min
Temperature : 37.5oC(Axilla)
Generalist Status :
Head : Conjunctiva anemis (+), isocor round pupil, ɸ 3 mm left=right, RC+/+
normal.
Neck : Trachea central location, kgb enlargement (-)
Thorax :
Lung
Inspection : movement of the left chest wall left behind
, Palpation : stem fremitus left < right
Auscultation : bronchial breathing sounds, Rh +/+
Percussion : left hypersonor, right dim
Heart
No extra sounds
Abdomen : flat, normal bowel sound (+)
Superior extremities : no abnormalities
Ekstremitas inferior : no abnormalities
Skin
Normal (+) skin turgor
D. Occupational diagnosis
Bronchopneumonia dd pulmonary tuberculosis + sinistra pleural effusion
E. Management
- O2 1 lpm via nasal canal
- IVFD NaCl 0.45 % in D5% 21 gtt/m
- Cefotaxime 3x1 gr iv
- Gentamicin 1x100 mg iv
- Dexamethasone 3x3.5 mg iv
- Surgical cosul :
Left thoracosynthesis plan : if serous fluid comes out continue to check the
analysis of pleural fluid + culture, If the fluid is turbid plan install WSD.
F. Supporting checks
