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Duty report

Thursday, March 23rd 2017

Surgical resident : Dennis W. Pratama,
M.D.
Surgical interns : Danny, Erni,

M.. M. SpB(K)Onk • TCV surgery : Andreas Andry Lensoen M. SpU . M. Agus Aulia. M. SpBS • Oncologic surgery : Taslim Mansjoer. D... SpBP-RE • Neurologic surgery : M. SpOT. SpBA • Digestive surgery : A. D. D. SpB(K)BD • Orthopedic surgery : Muljana Hasan.. M.. M. D. D. • Plastic &reconstructive surgery : Guntoro. M. D. Attending surgeons on-call • Pediatric surgery : Suharyo.. D. D. Zumaro.. SpB.. SpBTKV • Urologic surgery : Haryono.

Patients’ recapitulation Total Outpatient 0 Inpatients 2 Operation 0 Died 0 .

Mrs U. A 1 yo.Inpatients 1. Anemia due to Chronic Disease (Hb 6. and right lower extremity due to scalding . 54 yo. anterior trunk. PRC Tranfusion. Burn Injury gr IIA – IIB 18 % TBSA of head. Carcinoma of the left breast NST gr II on Neoadjuvant Chemotherapy. Girl.4)  Ward Admission. left upper extremity. 2.

A. right knee while her father was boiling water for making milk. History of Present Ilness Since two days ago. The hot water was poured over his body. left shoulder. left hand. Chief Complain Burn injury since two days ago.Girl. There was no gas explosion.o. No hoarseness after the incident. patient got burn injury by the boiling water on the face. 1 y. The patient was . chest.

No circular eschar on the chest. rhales -/-. no hoarseness. wheezing -/-. clear yellowish D: alert . 99% O2 saturation. warm extremities Urine production is currently 0. 30x / min. No increased work of breathing C: Heart Rate 124 x / minute. no burn on nose hair B: spontaneous.5cc / kg / h.Physical Examination Primary survey: A: clear. Vesicular sounds + / +.

E: Burns Grade 2A-B 18% F: Fluid Requirements Maintenance: D ¼ NS 37 cc / hour Drinking orally (Formula Milk free) Fluid titration as urine targets 1-2cc / kg / hour .

grade IIA-B – 7% Chest. BP: 130/80 mmHg. RR : 20 tpm. murmur (-). wheezing -/- • Abdomen : within normal limits • Extremity : CRT<2”. grade IIA-B – 8% Right Knee grade IIA – 2% . P: 76 tpm. warm • Local state : Face. T:36. grade IIA-B – 1% Left Shoulder + Hand. rhales -/-.8C • Eyes : no anaemic • Cor : 1st & 2nd heart sound normal.Physical Examination • CM. gallop (-) • Pulmo : vesicular sounds +/+.

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Laboratory findings • Complete Blood Count Hb 12.2 mmol/L /97 mmol/L .3 g/dL/ Ht 37( %) / WBC 15500) / Platelet Count 333.000/ UL • Electrolytes: Na/K/Cl 134 mmol/L/4.

left upper extremity. Guntoro. anterior trunk.D.Working Diagnosis • Burn Injury gr IIA – IIB 18 % TBSA of head. SpBP-RE(K)): • Maintenance intravenous fluid • Free drinking orally • Wound treatment with MEBO ointment • Antibiotic • Analgesic . M. and right lower extremity due to scalding • Plan (dr.

Today Condition .

It was a pleasure for me to serve These 2 clients during my watch .