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Umar Al Khadri
Umar Al Khadri
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.
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
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
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.
XI.
Intraoperative
Performed debridement
Dressing with silversulfadiazine
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