Morning Report

Saturday, Juli 11th, 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
( Jaga
dr. Raja Raharja M
( Jaga
dr. Andri Feisal
dr. Bobby
( Jaga
dr. Herdi Gunanta
( Jaga
dr. Syahmardani Ibnu
I.

II.

Patient Identity
Name
Age
Sex
Address
Fathers phone
Body weight
MR
Came at

( Jaga 1 )
2)
3)
( Jaga 4 )
4)
5)
( Jaga 5 )

:
:
:
:

Umar Al Kadri
4 year old
Boy
Jantho Makmur, Aceh Besar
: 081360455568
: 15 Kg
: 1-05-01-25
: 10:50 WIB

Time Response

Date/h
our
patient
came
to ER

Examina
tion
hour

11 Juli
2015
10.50
AM

11.00 AM

Laborator
y
Examinati
on

Radiology
Examinati
on

Sen
d

Res
ult

Sen
d

Res
ult

11.1
0
AM

01.1
0
PM

11.4
0
AM

01.3
0
PM

Hour
of
Diagn
ostics

Date/h
our
patient
out
from
ER

DPJP

11.00
AM

11 juli
2015
09.00
PM

dr.Syam
sul Rizal
Sp.BP

III.

Chief Complaint:
flame burn injury

IV.

Present illness history

Patient came to Zainoel Abidin Emergency Room with a chief complaint flame
burn since 2 hours ago. The patients mother was burn garbage suddenly the
fire burning his clothes. History of decrease of consciousness (-), vomiting (-).

V.

Physical examination

Primary Survey :
A: Clear, sound (+)
B: Spontaneous, RR : 22 breaths/mnt
C: Pulse : 100 beats/mnt, Blood pressure : 120/80 mmHg
D: GCS E4 M6 V5 (15)
E:

N
o

Region

Look

Pain

Percent
age

Head

Red and
whitish

Hipoastesi
a

Thorax

Red and
whitish

Anestesia

Upper arm (left)

Whitish

Anestesia

forearm(left)

Whitish

Hipoastesi
a

Total

27 %

Secondary Survey

N
o

Region

Look

Pain

Percent
age

Head

Red and
whitish

Hipoastesi
a

Thorax

Red and
whitish

Anestesia

Upper arm (left)

Whitish

Anestesia

forearm(left)

Whitish

Hipoastesi
a

Total

27 %

VI.

Assessment:
Flame burn width 27 % grade IIa-IIb

VII.

Management
Stop oral Intake
Fluid maintenances (Baxter formula)
4 cc x Kg BW x width of burn
4 x 15 kg x 27 = 1620 cc
for the first 6 hours : 810 cc
for the next 16 hours :810 cc
Inj. Ceftriaxone 750 mg
Inj. Metamizol sodium 200 mg
Tetagam 250 IU
Urinary catheter
Laboratory examination
Radiology examination

Time

urine

Time

Urine

15:00

15 cc

20:00

18 cc

16:00

12 cc

21:00

20 cc

17:00

10 cc

22:00

17 cc

18:00

14 cc

23:00

15 cc

19:00

13 cc

VIII.

IX.

Laboratory result
Hemoglobin
:
White blood count
:
Platelet
:
Hematocrite
:
CT
:
BT
:
Potassium
:
Sodium
Chloride
:
Blood Glucose ad random :

12,2 gr/dl
9.200/ul
301.000 /ul
36%
8/ minute
32minute
3.6 meq/L
: 137 meq/L
102 meq/L
164 mg/dl

Diagnose :
Flame burn width 27 % grade IIa-IIb

X.

Consult to Plastic Surgery division:

Debridement Emergency
Hospitalize

XI.

Intraoperative
Performed debridement
Dressing with silversulfadiazine

Post Operative Diagnosed

Flame burn width 27 % grade IIa-Iib (ICD 10 CM .T30)

XII.
XIII.

Follow up

Date
13/7/ 2015
POD 2

S
(-)

O
Pulse: 90 beats/minute
RR: 20 breaths/ minute
GCS: 15 (E4 M6 V5) ; 15

A
Mild Head Injury
(ICD-10-CM S09.8) +
Close fracture
depressed at the right
temporoparietal
region (ICD 10 CM
SO2)

P
Diet 450 KKal
Fluid
maintenances
(Baxter formula)
4 cc x Kg BW x
width of burn
4 x 15 kg x 27
= 1620 cc
for the first 6
hours : 810 cc
for the next 16
hours :810 cc
Inj. Ceftriaxone
750 mg
Inj. Metamizol
sodium 200 mg