IDENTITY

Name : Child K
Age : 12 years old
Sex : Female
Address : Wawonii
Admission : February, 11th
2017 (19.35 PM)
DPJP : dr. Syamsul Rijal,
Sp.B

HISTORY
Chief complain : dyspneu
TAKING
Anamnesis :
Patient was refferal from Dewi Sartika Hospital
with complaint dyspneu experienced since 13
days ago. Dyspney was felt continously and
increasingly so patient difficult to speak. In
addition, patient also complain of fever 3 weeks
earlier. Cough (+) with mucus and blood,
vomiting (+) contain mucus especially when
choughing. Decrease appetite (+). Bowel and
bladder smoothly.
History of complaint yellow on the eyes since the
last 3 weeks with tea-colored urine.
History of previous treatment at Dewi Sartika
 Head :

GENERAL Normal
STATE
Face:
General State :
Normal
Compos mentis,
Eye :
Severe ill,
Normal
Vital Sign :
BP: 120/80 mmHg Nose :
RR : 60 x/m Normal
HR : 140 x/m Ear :
T : 35,80c
Normal
 LOCALIS STATE

Thorax
INS : Subdiaphragma retraction(+),
PAL : fremitus vocal weakened,
tenderness (+)
PER : dim sound (+) as high as 2nd
and 3rd ICS
AUS : bronchovesicular, ronchi (+/+),
wheezing (-/-)
 LOCALIS STATE

Abdomen
INS : flat, follow the motion of breath,
scar (-), distended (-),
AUS : peristaltic (+) normally
PAL : tenderness at epigastric region
(+), hepatomegaly (-)
PER : tympani(+)
 Plan of Diagnostic

Counting blood cell

Chemical blood count
Xray thorax AP/Lat
Routine urine
 Diagnosis

Pleural effusion caused by

susp. Pnemonia +
hepatitis + sepsis
MANAGEMENT
O2
IVFD
Antibiotics
Consult to
pediatrician
Consult to general
surgery
 Thank You

BAGIAN ILMU
BEDAH
stavita Maria Bandong