No.

Name : Mr. P Sex : Male

Age : 52 years old No. Reg : 667069

Chief complaint : Pain at left hemithorax

History taking : The condition had been apparent since 1 hours before
admitted to the hospital due to fell down from his roof.
History loss of consciousness (-), vomit (-). Prior
medical care at Daya Hospital.
Mechanism of : He was climbing his roof, suddenly he slipped and fell
injury down as far as 3 m with his left chest bumped to piece of
bamboo.
Injury sustain : Left hemithorax
Symptom & sign : Pain, dyspneu
Examination : Physical examination, laboratory examination, Chest X-
Ray
PHYSICAL EXAMINATION
Primary Survey
A: Patent

B: RR : 32x/minutes, spontaneous, asymmetric, thoraco

abdominal type

C: BP : 130/70 mmHg, HR :98 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5mm/2,5mm , LR +/+

E: T (ax) : 36,6 oC
Secondary Survey
Thorax :
I : Seen bruised wound at left hemithorax, edema
(-), movement of left hemithorax less than right
P : Tenderness (+), Crepitating (+) at lateral of left hemithorax, stem
fremitus left less than right hemithorax
P : Hipersonor at left hemithorax, sonor at right hemithorax
A : Right hemithorax : vesiculer
Left hemithorax : breath sound away
 Laboratory Result
WBC : 4,9 x 103 / L

RBC : 3,87 x 106 / L

HGB : 11,6 g/dL

HCT : 36,7 %

PLT : 159x103/ L

CT / BT : 730 / 300

Blood Sugar : 162 mg/dl

Ureum : 20 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 55/24 /L

Chest AP
X-Ray
WORKING DIAGNOSIS : Fracture at VII, VIII posteriorLeft rib
Pneumothorax at left hemithorax

MANAGEMENT : O2
IVFD
Medicaments
Report to Senior Thoraxvasculer Surgeon,
Advice : Immediate Chest tube
 Operating Procedure
Patient laid supine under GA
Disinfection and drapping procedure
Identificated axillaris media line and ICS 6 at left
hemithorax
Local anesthetic infiltrated on ICS 6 at left hemithorax
Incision on ICS 6, deepen until pleura aspirated
Inserted chest tube into chest cavity bubble (+)
fixation
Close wound and operation finished
POST OP DIAGNOSIS : Fracture at VII, VIII posteriorLeft rib
Pneumothorax at left hemithorax

PROGNOSIS : Good

FOLLOW UP : Vital sign