COMBUTIO GRADE 2 + DM TIPE 2 DD/

STRESS HIPERGLIKEMI

By :
Elsa Aprilia, MD
Supervisor:
M. Diana Rahim, MD
PATIENT IDENTITY

Ms. IB /53 y.o/3040

June 23th, 2022
GP : Emilia, MD
HISTORY TAKING
The patient came with complaints of burns on the legs and
part of the abdomen since 2 weeks ago. Burns occurred due
to scalding hot water, at this time the patient complained of
pain.
.
History of drug use: Captopril
Past medical history: HT and DM
PHYSICAL EXAMINATION
General Condition: Moderately illness
Awareness: Conscious
GCS: 15
Blood Pressure: 130/94 mmHg
Pulse Rate: 92 x/minute
Respiratory Rate: 22 x/minute
Temperature: 36,5C
SpO2: 97 free air
Head
• Eyes: isochore, anemic conjunctiva -/- , icteric
sclera -/-
• Nose: septum deviation (-), secret (-)
• Ears: secret (-) , edema (-)
• Mouth: wet oral mucosa
Neck: lymph node enlargement (-)
Thorax: symmetrical chest movements
Cor: S1 S2 regular, gallop (-), murmur (-)
Pulmo: vesicular breath sounds , crackles (-/-), wheezing (-/-)
• Abdomen: flat, soepel, bowel sound (+) increase, epigastrium tenderness (+)
Liver: within normal limits
Spleen: within normal limits
• Extremities: warm, CRT <2 seconds, Edema (-)
• Skin: within normal limits, Burns in the thigh and calf region dextra and sinistra
SUPPORTING EXAMINATION
The Result of Laboratory Examination (June 23 22)
 Blood routine
- Hb : 8,8 gr/dL
- Leukocyte : 6.800/mm3
- Trombocyte : 353.000/mm3
- Ht : 31,2
- Erythrocyte : 4,42 millions/mm3
- GDS : 102 mg/dl
- Ureum : 30 mg/dl
- Creatinin : 0,87
- SGOT : 40
- SGPT : 26

 Immunology
Rapid antigen Covid-19 : Negative
DIAGNOSTIC
Combutio grade 2 20% ektremitas bawah + DM tpe 2 dd/stress
hiperglikemi
MANAGEMENT
• Ivfd RL 30 tpm
• Inj. Cefoperazone 2x1 iv
• Inj. Omeprazole 1x40 mg iv
• Ketoprofenn supp 3x1
• Kompres Nacl + Gentamisin