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, Fadilah, Siti A
Resume
Operation : 1
Inpatient : 0 Outpatient : 0
Consultant incharge
Primary Survey
Airway : clear Breathing : spontaneous, slightly tachypnea (RR = 24x/menit) Circulation : Strong pulse (86x/mnt), Blood pressure of 130/70 mmHg CRT <2 . Normal skin color , Good skin turgor Disability . response Alert , Pupils isokor (+ / +) .GCS E4V5M6 Exposure , Lesion on the abdomen (+)
Secondary Survey
Head: Normocephal Eyes: Conjungtiva anemic (- / -), sclera jaundice (- / -) ENT: Secretions (-), tracheal deviation (-)
Thorax Inspection : Lesion (-) Palpation : Tenderness (+) at the right inferior thorax Percussion : dullness at left inferior thorax Auscultation : decrease vesicular sound at left inferior thorax Heart : no gallop, no murmur Abdomen Inspection : exoriation, flat Auscultation : normal bowel sound Palpation: no muscular rigidity, no pain Percussion: timpany
Local status
Laboratory results
Planning
Plan WSD 34.91 Thoracentesis Informed consent O2 Nasal canul 3-4 l/mnt IV line Analgetic Antibiotic
Operation report
semi-supine patient position a and antisepsis operation and
the surrounding area infiltration anesthesia with lidocaine 2 percent in ICS 6 aspiration: serohemoragic discharge incision on ICS 6, No. 28Fr chest tube inserted, the initial discharge serohemoragic 150 cc, with undulations, no initials bubble fixation chest tube, and connected with a bottle of WSD operation is complete
Atelectasis:inferior lobe
ribs 9th Blunt abdominal trauma with stable haemodinamic and no peritonitis Atelectasis left inferior lobe Next treatment Chest fisotherapy Inhalation Analgetic Antibiotic
Condition today
Good condition
Abcd
Thank you