CASE REPORT

Wednesday, July 2nd 2014

Team On Duty:

I.

Dr. Hendra Kastiaji

Dr. Joko Siswanto
Dr. Ifradin Pinim
Dr. Tommy Rivelino
Dr. Muharyansyah
Dr. Andri Mulia
Dr. Jauhari Deslo
Dr. Arfan
Dr. M. Saidi
Dr. Adang Sunandar

Patient identity
Name
Age
Sex
Address
MR
Phone
Time Arrived

: M.Ahyani Yusuf
: 12 years old
: Boy
: Ds.Aleu Keumeneng, Kec.Wolya Barat Kab. Aceh
Barat
: 100 93 56
: 081375019019
: 11.01 AM

II.

Chief complaint
Penetration injury at the left chest

III.

Presenting history
The patient referred From Distric hospital Meulaboh to Zainoel Abidin
emergency room with a chief complaint penetration injury at the left chest
since 12 hours ago. Initially, the patient was played with his friend and
suddenly his friend accidentally shoot him with air riffle. There was no
history of dyspnoe (-).

IV.

Physical Examination
Primary Survey
A
: Clear
B
: Spontaneous, 22 breaths/min
Thorax
examination
Inspection

Right hemithorax

Left hemithorax

Enter wound (+) about 3 cm from linea parasternal left

hemithorax as high as 2nd rib, Symmetrical, trachea
medial, JVP normal

Palpation

Stem fremitus (N)

Stem fremitus (N)

Percussion

Sonor

Sonor

Auscultation

Vesicular

C
D

: Pulse: 78 beats/min
: GCS 15 = E4 M6 V5 .

Vesicular

Secondary survey : there was no trauma at the other part of body

V.

Assessment
Penetration injury at the left hemithorax

VI.

Management
IVFD NaCl 0,9% 20 drips/minute
Ceftriaxone inj 1 gr
Ketorolac inj 10 mg
Tetagam 250 iu
Laboratory examination
Radiology examination

VII.

Laboratory result
Haemoglobin
WBC
Platelet
CT/BT
Ht

:
:
:
:
:

12,1 gr/dl
11.600 /ul
342.000/ul
7/2
40 %

VIII. Radiology result

Thorax AP/Lateral
There was foreign body at the left hemithorax at the 3 thrib parasternal
IX.

Diagnose
Foreign of body at the left hemithorax due to air riffle bullet penetration

X.

Consult to TCV Surgery division:

Remove foreign body at the left hemithorax urgency

XI.

Operation Report
Patient in supine position with general anesthesia
Aseptic and Antiseptic procedure.
Perfomed incision at the 3th rib, layer by layer until fascia and muscle
There was haematoma, performed release of the tissue
Found bleeding out from partial rupture of the brachiocephalica artery
and vein
Performed repair of the brachiocephalica artery and vein
Performed fluoroscopy to determine the position of the foreign
bodyforeign of body at the left hemitorax at the left lung upper lobular
Bleeding control
Wound operation close layer by layer with primary suture
Performed one tube drain 20fr at the left ICS 6

XII.

Post operative diagnose :

1. Foreign of body at the left hemithorax due to air riffle bullet penetration
(ICD 10 CM S05.4)
2. Partial rupture of the brachiocephalica artery and vein (ICD 10 CM
I82.29)

XIII. Follow Up
Date
S
4-07Pain
2014
(-)
POD II

O
General condition: good
HR: 80 beats/minute
RR: 20 beats/minute
Localize state :
At the thorax region
Inspection : Symmetrical,
Palpation:
Sterm
fremitus
dextra = sinistra
Percussion: sonor/sonor

A
1.Foreign of
body at the left
hemithorax due
to air riffle bullet
penetration (ICD
10 CM S05.4)
2.Partial rupture
of
the
brachiocephalica
artery and vein
(ICD 10 CM
I82.29)

P
IVFD RL20 drip/minute
Ceftriaxone inj 1gr/12
hour
Ketorolac inj 10mg/8
hour