MS/F/10yo65.08.05

Main Complaint: shortness of breathIt has been suffered since 2 months before admission, getting worse 4 day before. Symptom worsen when patient lying down. Intermittent fever (+) for 3 months, sweating in the middle of the night (+), blood cough (-). Defecation and urinate still within normal limit. history of TB drug comsumption (+), only for 1 month and the patient stop taking drugs. History loss of weight (+) 10 kg in 6 months. History of family with same complaint (-).

Present state:• Awareness : Alert• BP : 130/80 mmHg • HR : 108 x/I• RR : 30 x/I• T : 37,8 C• VAS : 4

Generalized state:Head : no abnormalitites foundNeck : no abnormalities foundChest : in localized stateAbdomen : no abnormalities found Genital : female, no abnormalities foundExtremities : in localized state

Localized State:Chest : I : asymmetrical, lag of movement (+)

o/t (L) hemithorax, P : tactile fremitus right > left P : dullness o/t (L) hemithorax A : diminished sound of breath o/t (L)

hemithoraxLower Extremity

L : muscle hipotrophy, fat depletion F : NVD in normal limit M : muscle power 111/111 , DOF (-)

Enlargement lymph (+) o/t (L) supraclavicular

Laboratory finding• Hb / Leu / Ht / Trombo :7,3/99,34/24,20/431• U / Kr : 14,04/0,11 mg/dL• Na / K / Cl : 127/3,1/97 mEq/L• KGD : 45,45 mg/dL• Albumin : 1,8 g/dL• pH/pCO2/pO2/BE : 7.33/27/177/-10.8

4 Agustus 2015 4 Agustus 2015 post chest tube insertion + WSD at private hospital

8 Agustus 2015 post reposition chest tube + WSD at HAM hospital

• Working Diagnosis: (L) Massive pleural effusion d/t susp. pulmonary TB + Paraplegia d/t susp spondylitis TB + Susp. Sepsis + Malnutrition

Therapy in ER:• O2 with nasal canule 3L/i• IVFD Coloid fluid• Inj. Antibiotic• Inj. Analgetic• Reposition chest tube and connect to continues suction• Correcting Hb, albumin, respiratory acidosis and

hypoglikemic • Plan :– Chest CT-scan– Managing therapy with pediatric for nutrition and pulmonary

disease