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  • Morning Report Combutio

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    Anonymous 0SYzMqje2
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    Patient JY, a 3-year old male, was admitted to the hospital after falling into a pail of hot water. Upon examination, he had second degree burns covering 8% of his body surface area, including his buttocks, genitalia, and scrotum. Treatment included antibiotics, debridement of burned tissue, silver nitrate dressings, and fluid resuscitation based on his weight and extent of burns. His vital signs and initial lab work were stable. The working diagnosis was second degree burns over 8% of his body.

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    morning report combutio

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    Patient JY, a 3-year old male, was admitted to the hospital after falling into a pail of hot water. Upon examination, he had second degree burns covering 8% of his body surface area, including his buttocks, genitalia, and scrotum. Treatment included antibiotics, debridement of burned tissue, silver nitrate dressings, and fluid resuscitation based on his weight and extent of burns. His vital signs and initial lab work were stable. The working diagnosis was second degree burns over 8% of his body.

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    4 views12 pages

    Morning Report Combutio

    Uploaded by

    Anonymous 0SYzMqje2
    Patient JY, a 3-year old male, was admitted to the hospital after falling into a pail of hot water. Upon examination, he had second degree burns covering 8% of his body surface area, including his buttocks, genitalia, and scrotum. Treatment included antibiotics, debridement of burned tissue, silver nitrate dressings, and fluid resuscitation based on his weight and extent of burns. His vital signs and initial lab work were stable. The working diagnosis was second degree burns over 8% of his body.

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    © All Rights Reserved
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    of 12

    June 28th 2011

    Putri Ingen Setiasih


    Ucky Saura
    Agrita Eka W

    IDENTITY
    Patient JY, male, 3 years old, came to AA
    hospital on June 28th 2011

    CHIEF COMPLAIN:
    Fallen down in pail contain hot water.

    Present Illness History


    Patient fallen down in pail contain hot water

    about 1 hour before admitted to the hospital.


    Patient was fall to a sitting position.
    The hot water, contact with his skin at bottom
    and genitalia area.

    General condition
    Conciousness
    Vital sign :

    HR
    RR
    T

    : 130 x/i
    : 26x/i
    : 37,3 C

    : severe illness.
    : composmentis

    Head and neck


    Chest
    Abdomen
    Genitalia
    Extremity

    :
    :
    :
    :
    :

    normally
    normally
    normally
    Status Lokalis
    normally

    Local Status
    Genitalia :
    ins : Bulae (+), eritema (+), pain (+)
    Grade II
    at gluteal, perineum, scrotum and genitalia.

    Injury Area = 2,5% + 2,5 % + 1 % + 1 % + 1 % = 8 %

    Working diagnose
    Combutio Grade II about 8 %

    Supporting
    examination
    Rutine Laboratorium
    Blood rutin
    Hb
    : 12,6 gr/dl
    WBC
    : 13.800/mm3
    Trombosit : 235.000/l
    Ht
    : 37,4 %

    Treatment
    ATS
    Ceftriaxone inj.
    Debridement
    Nitras argenti 0,5 % compress

    Maintenance Fluid
    4 ml x KgBB X injury area %
    4 x 12Kg x 8 % = 384 cc/24 h
    First 8 h = 192 cc
    Next 16 h = 192 cc

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