No. Name : Ch. T Sex : Male

Age : 14 years old No. Reg : 627529

Chief complaint : Dyspnea

Case : The condition had been apparent for 1 hour before the patient was delivered to the hospital. There were no events of vomitting and unconsciousness.

Mechanism of injury

: He was walking suddenly stabbed by unknown people. Next mechanism was unknown

Sustained injury : ThoraxSymptom & sign : DyspneaExamination : Physical examination, Laboratory examination, Chest X-

ray

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Primary SurveyPrimary Survey

A: Clear

B: RR: 28x/minutes, spontaneous, asymmetric, thoraco abdominal type

C: BP : 120/80 mmHg, HR : 88x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal Ø 3/3mm , LR +/+

E: T (ax) : 36,7 oC

Secondary SurveySecondary SurveyThorax :I : Seen no symmetric right and left. Skin color same with its vicinityP : Tenderness (+), vocal fremitus decreased at left hemithorax, sub cutis emphysema (+)P: Hyper sonor at left hemithoraxA: Decreased breathing sound at left thorax

Right Thorax posterior :I : Seen lacerated wound size 1x0,5 cm. Hematome (-), udem (-)P : Tenderness (+)

Left Thorax posterior :I : Seen lacerated wound size 2x0,5 cm. Hematome (-), udem (-)P : Tenderness (+)

Laboratory ResultLaboratory ResultWBC : 19,12 x 103 / μL

RBC : 4,72 x 106 / μL

HGB : 13,2 g/dL

HCT : 37,6 %

PLT : 309 x 103/ μL

CT / BT : 6‘30”/3’00”

Blood Sugar : 119 mg/dl

Ureum : 16 mg/dl

Creatinin : 0,7 mg/dl

GOT / GPT : 26/14 μ/L

Chest X-Ray

WORKING DIAGNOSIS : - Vulnus ictum penetrants at thorax posterior- Left simple pneumothorax

MANAGEMENT : O2 IVFD Medicaments Report to senior thorax vascular advice : Chest tube + WSD & debridement