Morning Report Burn Injury

8/13/2019 Morning Report Burn Injury

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Morning Report

By :

Febrian Putra0908113658

Burn injurySKDI: 4A


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Anamnesis:

Ms. N , 14 years old, Female, came to Arifin

Achmad General Hospital on October 19th,

2013

Chief Complain :

Her body blistered because of fire 2 hoursbefore admitted to hospital.


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PRIMARY SURVEY

ward


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Airway

Objective

airway obstruction(-)

AssesmentClear airway


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Breathing

Objective

Breathing spontaneously

RR : 20 x/mins

chest wall move symetrically

Assesment

Clear breathing


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Circulation

Objective

IVFD attached (1 line)

HR: 90x/ minutes, regularly

TD: 110/70 mmHg

CRT: < 2 second

warm extremity

Assesment

stable hemodynamic , clear circulation


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Disability

Objective

GCS 15

isokhor pupil, d : 3 mm. light reflect (+/+)motoric power : +

Assesmentclear mini neurologic assesment.


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Exposure

Objective

T : 36,5 0C

Visible burn injury on head-neck, both right

and left hand, and left leg.


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Head - Neck


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Right Hand


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Left Hand


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Assesment

hypothermia (-) fever (-)

burn injury grade II A 32 %


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SECONDARY SURVEYward


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Trauma Mechanism

2 hours before admitted to hospital, patient got burninjury because of fire from the stove . Patient wanted

to shut the fire off from the pan, but it attacked her

head-neck, both of her hands, and left leg.

Patient wore T-shirt and short pants when theincident happened. After that, patient flushed with

water by his family and took to hospital in 30 minutes


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Past Illness history

No past illness history related to patients complain.


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Physical examination

General condition: seemed mild illness

Conciousness: compos mentis

Vital sign: Blood pressure : 110/70 mmHg

HR: 90x / minutes

RR: 20x/ minutes

Temp : 36,5 0C


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Head and neck : Localized Status

Thorax : normal

Abdomen : normal Extremity : Localized Status Lymph node : normal Genitourinary : normal


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Localized Status

Inspection:

Burn injury on head-neck, both hand, and left leg of the patient .

The color of the wound is red and the edge is black.

Bula (+)

Palpation:

Tenderness on the wound (+).


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Head-Neck : 7%

Right Hand : 10%

Left Hand : 5%

Left Leg : 10% +

32 %


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Working diagnosis

Burn injury grade II A 32% caused by fire


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Further examination

- Blood electrolyte, and albumin


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Laboratorium result

Wbc: 7200 /ul

Hb : 13,4 g/dl

Ht : 42,4 %

Plt: 234000 /ul

Na: 141,1 mmol/l

K: 3,56 mmol/l

Cl: 109,9 mmol/l

Alb : 3,5 g/dl


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Definitive Diagnosis

Burn injury grade II A 32% caused by fire


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Therapy Planning

Fluid therapy (Baxter):

Body weight 45 kg

10 x 45 x 4 = 1800 mlIVFD RL

Day 1 : 1800 ml in first 8 hours

1800 ml in next 16 hourDay 2 : 1800 ml for second day


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Ceftriaxone 2x1 inj

Ketorolac 3x1 inj

Hospitalized Pro debridement


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Thank you

Morning Report Burn Injury

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