Morning report

Burn injury
By Ummatul Khairiyah 0908151679

Anamnesis
Mr. F , 25 years old, Male, came to Arifin Achmad General Hospital on October 5th, 2013 Chief Complain : His legs blistered because of fire 2 hours before admitted to hospital.

PRIMARY SURVEY
Inpatient room

Airway
Objective Gurgling (-) stridor (-) airway obstruction(-) Assesment Clear airway

Breathing
Objective Breathing spontaneously RR : 22x/minutes chest wall move symetrically Assesment Clear breathing

Circulation
Objective IVFD attached (1 line) HR: 90x/ minutes, regularly TD: 110/70 mmHg CRT: < 2 second warm extremity Assesment stable hemodynamic , clear circulation

Disability
Objective GCS 15 isokhor pupil, d : 3 mm. light reflect (+/+) motoric power : 5 5 5 5 Assesment clear mini neurologic assesment.

Exposure
Objective T : 37 C visible burn injury on both right and left leg.

 Assesment hypothermia (-) fever (-) burn injury grade II 36 %

SECONDARY SURVEY
di Bangsal

Trauma Mechanism
3 hours before admitted to hospital, patient got burn injury because of fire from the stove . Patient wanted to shut the fire off from the pan, but it attacked both of his legs Patient wore T-shirt and short pants when the incident happened. After that, patient flushed with water by his family and took to hospital in 20 minutes

Past Illness history

No past illness history related to patients complain.

Physical examination
General condition: seemed mild illness Conciusness: compos mentis Vital sign:
Blood pressure : 110/70 mmHg HR: 90x / minutes RR: 22x/ minutes Temp : 370C

Head and neck Thorax Abdomen Extremity Lymph node Genitourinary

: normal : normal : normal : localized status : normal : normal

Status Lokalis
Inspection: Seemed burn injury on both leg of the patient . The color of the wound is white and the edge is black. Bula (+) Palpation: tenderness on the wound (+). Left leg Right leg 18 % 18%

Working diagnosis
Burn injury grade II 36% cause by fire

Further examination
- Blood electrolyte, and albumin

Laboratorium result
Wbc: 7200 /ul Hb : 13,4 g/dl Ht : 42,4 % Plt: 234000 /ul

Na: 141,1 mmol/l K: 3,56 mmol/l Cl: 109,9 mmol/l Alb : 3,5 g/dl

Definitive Diagnosis
Burn injury grade II 36 % caused by fire

Therapy Planning
Fluid therapy (Baxter): Body weight 75 kg 10 x 75 x 4 = 3000 ml IVFD RL Day 1 : 1500 ml in first 8 hours 1500 ml in next 16 hour Day 2 : 1500 ml for second day

Ceftriaxone 2x1 inj Ketorolac 3x1 inj Hospitalized Pro debridement

Thank you