PATIENT IDENTITY

Name : Ny. L
Age : 19 years old
Address : Ranomeeto
Admission : July 22st 2017
DPJP : dr. Saktrio
Darsono, Sp.BP-RE
 HISTORY TAKING
Main complain : Burns
Anamnesis :
Patient referrals from the Ranomeeto Primary Health
Care with complain burns hold body since 2 days ago
Mechanism of trauma : When the patient cooked the
water suddenly patient dropped and exposed hot water.
Hystory of treatment at Ranomeeto Primary Health Care :
IVFD RL, hystory of pregnancy was positive.
Physical examination
BP 110/90 mmHg

20x/min regular, spontaneous

thoracoabdominal type, symmetrical
RR

HR 78 x/min regular, strong

36,40 C (axillary) T
Generalized state
Normally

Normally

Normally

Normally

Normally

Normally
Next...
Eritema + Bulla At Right Mamaria Region
Eritema + Bulla At Right Pectoralis Region

Eritema + Bulla At Umbilikalis Region

Normally
Eritema + Bulla At Right Brachialis Region
Eritema At Right carpalis Region
Eritema At Right manus Region
Eritema + Bulla At left carpalis Region
Eritema + Bulla At left manus Region

Eritema + Bulla At Right Femoris Region

Eritema + Bulla At Left Femoris Region
 PLANNING

Complete Blood
Count

6
LABORATORY FINDINGS
WBC : 10,26 x 103/uL
HGB : 12,44 g/dL
Neut : 10,76%
 DIAGNOSE

Combutio grade
IIA 23% + G1P0A0
gr 13-14 week
 THERAPY

Fluid therapy
Antibiotic drugs
Analgesic drugs
H2-reseptor drugs
Consult Surgeon
Consult obgyn

10
 Thank You

BAGIAN ILMU BEDAH

Eka Ramadhani Darwanti