Siti Rahma

SHORT CASE PLASTIC SURGERY

(TRAUMA)
 IDENTITY
Name : Mr. A

Age : 14 years old

Sex : Male

Address : Ranomeeto, Konsel

Admission : November, 04th 2019 (19.30 WITA)

DPJP : dr. Saktrio D. , Sp. BP-RE

 HISTORY TAKING
Chief complain : Burns at the neck and chest

Anamnesis : Since 1 hours ago after exposed hot water

Mechanism of trauma : The patient want to take a shower using hot water, after
returning home playing soccer. When walking to the bathroom, the patient slip and his
scalled by the hot water he is holding so that it his the neck, chest and both upper arms.

History of trauma :
There was no history of unconscious
There was no history of nausea and vomiting .
There was no history of bleeding nose and mouth
There was no history of treatment.
 PRIMARY SURVEY
A : Clear, cervical spine control done
B : RR: 20 x/min, spontaneous, symetric, thoracoabdominal type
C : HR: 80x/min, regular & strong
D : E4M6V3
E : 36.8℃/axillar
 SECONDARY
SURVEY
• Generalized state:
Composmentis, Mild illness, Well nourished
• Vital sign:
Blood presure: 110/70 mmHg
Hearth rate: 80 bpm, strong,reguler
Respiratory rate : 20 x/min,
spontaneous, regular,
thoracoabdominal type
Temperature: 36,8’C / axillary
 PHYSICAL
EXAMINATION
Localized State
1. Facial Coli Region
• Inspection : Crust (-), necrotic (-), hyperemis (+),
hematoma (-), swelling (-), bulla (-)
• Palpation : hyperestesia (+)
Epidermal burn injury 2%
2. Upper Ekstremitas Dekstra Region
• Inspection : Crust (-), necrotic (-), hyperemis (+),
hematoma (-), swelling (-), bulla (-)
• Palpation : hyperestesia (+)
Epidermal burn injury 1%
 PHYSICAL
EXAMINATION
Localized State
3. Upper Ekstremitas Sinistra Region
• Inspection : Crust (-), necrotic (-), hyperemis (+),
hematoma (-), swelling (-), bulla (-)
• Palpation : hyperestesia (+)
Epidermal burn injury 2%
2. Thorako abdominal Region
• Inspection : Crust (-), necrotic (-), hyperemis (+),
hematoma (-), swelling (-), bulla (-)
• Palpation : hyperestesia (+)
Superficial dermal burn injury 9%
PLAN OF DIAGNOSTIC

 Laboratorium
(Routin Blood Test)
 LABORATORY FINDINGS
Hematology Result Unit Normal
Hemoglobin 15.2 g/dl 12.0 – 16.0
Leukosit 12.60 10^3/uL 4.0-10.0
Eritrosit 5.81 10^6/uL 4.0-6.0
Trombosit 301 10^3/uL 150 - 450

Nilai
CT 8’30”
BT 2’30”
 DIAGNOSE

Superficial Dermal Burn

Injury 14 % ec heat
water
 Farmacology

• IVFD
MANAGEMENT • Antibiotic injection
• Analgetic injection
• PPI injection
• Topical anti microba

Consult To General Surgeon