Morning Report

1st July 2011

Boy, Boby, Dina

Anamnesis
Patient U H, male, 24 years old, came
to AA hopistal on 1st July 2011

Chief Complain
Putrefied wound at left feet since 2
week ago

Present Illness History

Since 2 week ago, patient complained
her all left feet was wounded because of
snake bite when he went to work. The
bite left two hole wound in his left feet.
He loose his counciousness after the bite.
He was rushly taken to the clinic near
that area. In the clinic he was given an
injection and two pills after that he went
home. But in the afternoon he went to
Arifin achmad hospital because the
wound was still hurt

 At arifin achmad hospital he was given

anti snake venom serum, and other
medicine but he didnt know what its
name. He was treated in the hospital
for a week then he went home by his
own will. At home he change his own
bandage. The wound was getting
darker, painfull and give unpleasant
odor. No fever. A week later he go back
to arifin achmad hospital

Past Illness History

Never complain symptom like that
before
Never have diabetic melitus

Physical Examination
General condition
: looks moderate
illness
Consciousness
: Composmentis
Vital sign
BP
: 110/70 mmHg
HR
: 80 x/mnt
RR
: 18 x/mnt
Body Temp
: 36,5C

Head and neck

Chest
Abdomen
Extremity
Lymph
gland

:
:
:
:

Normally
Normally
Normally
Locally
: Normally

Locally Status

Locally Status
Regio cruris et pedis sinistra
Inspection:
looks oedem at cruris et pedis, colour is red,
skin looks shiny
Looks 2 necrotic wounds : one at proximal
cruris sinistra by size 3 cm x 2cm
One at distal cruris et pedis sinistra by size 10
cm x 6 cm

Palpation:
oedem ,warm, pain if get pushed, border is
clear, pus (+)

Working Diagnosis
Post snake bite infection

Suggestion Examination
thorax Xray

Blood routine

Hb: 13,9 g/dl

Ht : 38,8 %
Leukocyte : 16.400/ul
Platelet : 276.000/ul
Glukose : 192 mg%

Management
1. Analgetic
2. Antibiotic

Prognosis
Bonam