Morning Report

Saturday,,March 24th 2012

A

25-year-old male was transferred to the ER of AA Hospital on March 12th 2012 following an electrical injury

. Gurgling (-) CLEAR .BASIC LIFE SUPPORT in Unit Care (Cendrawasih I) AIRWAY Patient can talk spontaneously Stridor (-). Snoring (-)..

.BREATHING Breath spontaneously. rhonki (-) CLEAR • The reality: the patient hadn’t given O2 administration.. RR = 20 x/minutes. • He supposed to be given O2 10-12 Lpm via NRM  for keeping O2 saturation . respiratory sound was vesicular R=L. respiratory motion symmetrically.

warm acral. with the color was yellow and clear EXCELLENT . CRT<2 seconds Administration of IVFD RL 20 dpm • The evaluation: Urine output= 80 ml/h (BW= 55 kg). reguler (A.CIRCULATION Blood Pressure = 140/90 mmHg HR = 99 x/minutes. dorsum pedis).

pupils’ reflect of light (+/+)  Contralateral hemiparyse (-/-) EXPOSURE • prevent hipotermia.DISABILITY  GCS 15 (E4V5M6)  Pupils was isochor Ф 3 mm/3mm. • Exposure for other injuries that threaten patient’s life .

Chief complain: electrical injury in a hour b/t to the hospital The History • A hour b/t to the hospital. prolong contact was about  1-3 minutes. • The ground was on patient’s right foot which shown as flash burn. . Patient hold iron cylinder for building by hands while the iron was contacted with high-voltage current. the patient contacted with high-voltage current in occupational setting as builder.

. and then transferred to the ER of AA Hospital.• Afterward. but he was still alert. patient felt tetanic muscles for all of his body. • He was transferred to local health clinic and was given IVFD (the type wasn’t be known) and urine catheter. • Arrived at ER. the tetanic muscle was stop.

head injury.AB???Ketorolac??? • No other secondary injuries (ex: fall down. etc) were complained.• In ER ( 2-3 hours). . – From medical record: administration of IVFD RL 1 line 100 cc/h till the color urine was clear yellow.……. the patient told the color of his urine was chocolate at the first and became clear yellow. abdominal injury. chest injury..

hypertension. chronic of pulmonal disease): (-) History of epilepsy (-) History of DM (-) History of Tetanus immunization : wasn’t be known Family illness history: History of hypertention (-) History of asthma (-) History of epilepsy (-) History of DM (-) .Other Medical Histories: Cardiovascular disorder/disease (heart disease. hypercholestremia. stroke): (-) Respiratory disorder/disease (asthma.

   General state: poor Conciousness : CM Vital sign: ◦ ◦ ◦ ◦ BP: 140/90 mmHg HR: 99 x /minutes RR: 20 x/minutes Temp: 37.9 0C .

Burn wound (-) Neck Sign of cervical injury (-) Burn wound (-) . Head ◦ Eyes:  Sclera: jaundice (-)  Konjunctiva: anemis (-)  No visual impairment and sign of catarac (-) ◦ Ears: no hearing impairment ◦ Lesion (-).

rhonki (-) ◦ Burn wound (-)  Abdominal: Normal ◦ ◦ ◦ ◦ Ins: flat. Chest : Normal ◦ Cor: synus rhythm.. hematoma (-). respiratory sound was vesicular R=L. tenderness (-) Per: timphany . Burn wound (-) Aus: bowel sound (+) N. 6x/minute Pal: muscular rigidity (-). murmur (-) ◦ Lung: respiratory motion symmetrically.

 Extremitas : Localized  Genitaurinary: Normal ◦ Ins: hematoma (-). Burn wound (-) ◦ Pal: tenderness (-) . lesion (-).

axilla)  3rd grade-Burn wounds on hands  Entry wound  Pal :      Tenderness (+). non-pitting oedem (+) Signs of fracture or deformity (-) Sensoric (was difficult to measure cause pain of inflammation) Motoric (+.Right and left of Superior extremities (Regio antebrachii 1/3 distal and regio manus)  Ins:  Inflammation (+).  Burn wounds at joint areas (cubiti. was limited cause pain and inflammation) Distal vascular (difficult to measure cause inflammation) . muscle tetani (-).

Entry Wound .

Right and left of Inferior extremities  Ins:  Inflammation (+).  3rd grade-burn wounds at:  Regio femoris anterior sinistra 1/3 distal  Regio cruris posterior dextra et sinistra  Regio dorsum pedis dextra (ground wound) et sinistra  Pal :  tenderness (+). Motoric (+)  Distal vascular: A. muscle tetani (-). non-pitting udem (+)  Signs of fracture or deformity (-)  Sensoric (+). dorsum pedis (+) .

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Ground wound .

 Electrical burn injury of 15 % TBSA .

000 /µL .CBC (Complete Blood Count): WBC : 23.3 gr/dl Ht : 45.7 % PLT : 278.200 /µL Hb : 16.

0 g/dL (N=7 – 18) (N=0.4 mg/dL  D-BIL : 0.57 mg/dL  UREUM : 19.6 – 1.3 mg/dL  I-BIL : 2.1 mg/dL  AST : 172 IU/L  ALT : 40 IU/L  ALB : 4.Glucose: 206 mg/dl (N=70 – 125 ) Renal function  BUN : 9 mg/dL  CR-S : 0.25) (N ≤ 0.75) (N=14 – 50) (N=11 – 60) (N=3.3 mg/dL Hepar function  TBIL : 2.5 – 5) .0) (N ≤ 0.3) (N=20 – 40) (N ≤ 1.

92 mmol/L (N= 3.= 106. Electrolites ◦ Na+ = 136.3 mmol/L (N=98-106) .4 mmol/L (N=135-145) ◦ K+ = 3.5-5) ◦ Cl.

03 Blood = (+3) Keton = (-) Nitrit = (-) .URINALYSIS  Color: chocolate  Turbidity : cloudy          Protein = (+1) Glucose = (-) Bilirubin = (-) Uroblinogen = N pH = 5 BJ = 1.

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compartment syndrome. cataract. and arterial blood gas ATS + prophylactic administration of high-dose penicilin Burn wounds care with moist dressing or using MEBO Follow up for other advanced complications (arrythmia. etc) Co” for plastic surgeon .5-1 ml/kg/h EKG monitoring Check for serum myoglobin. creatine kinase.       Urine (clear yellow) maintain a urine output of 0. septic.

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