Patient identity

Name
: Zulhilmi
Age
: 28 year old
Sex
: Male
Address
: Ladang Tuha Pasie raja Aceh
Selatan
Phone
: 085213407256
MR
: 1-05-86-29
Came at
: 10:30 PM

Time Response

Date/hour
patient
came to
ER

Examinati
on hour

11 Juli
2015/
10.30 PM

10:40PM

Laboratory
Examination

Radiology
Examination

Send

Result

Send

Result

10 :50
PM

11:45
PM PM

Hour of
Diagnos
tics

Date/ho
ur
patient
out
from ER

DPJP

10: 40
PM AM

18/7/201
5
02:00PM
PM

Dr M
Jailani
SpBP

Chief complaint
flame burn injury
Patient illnes history
Patient came to Zainoel Abidin Emergency
Room with a chief complaint flame burn for
1 day. Initialy patient was sleeping and
when his house burning. History of
decrease of consciousness (-), vomiting (-).

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

Grade

Percentag
e

Head

IIB-III

Thorax

IIB-III

Abdomen

IIB-III

Upper extremity
(Both)

IIB-III

36

Lower extremity
(Both)

IIB-III

36

Total

IIB-III

95 %

Secondary survey
N
o

Region

Grade

Percentag
e

Head

IIB-III

Thorax

IIB-III

Abdomen

IIB-III

Upper extremity
(Both)

IIB-III

36

Lower extremity
(Both)

IIB-III

36

Total

IIB-III

95 %

Assessment:
Flame burn width 95 % grade IIB-III

Management
Stop oral Intake
Fluid resusitation
IVFD RL 2000 cc for 1 hour urine out
put 30 cc/hour
Inj. Ceftriaxone 750 mg
Inj. Metamizol sodium 200 mg
Tetagam 250 IU
Laboratory examination

Time

urine

Time

Urine

11:00 PM

30 cc

04:00 AM

40cc

12:00 PM

35 cc

05:00 AM

35 cc

01:00 AM

30 cc

06:00 AM

32 cc

02:00 AM

32 cc

07:00 AM

33 cc

03:00 AM

30 cc

08: 00 AM 32 cc

Laboratory result
Hemoglobin
: 22.0 gr/dl
White blood count
: 36.800/ul
Platelet
: 137.000 /ul
Hematocrite
: 64%
CT
: 7 minute
BT
: 2minute
Potassium
: 5.9 meq/L
Sodium
: 134 meq/L
Chloride
: 105 meq/L
Blood Glucose ad random : 125 mg/dl

Diagnose
Flame burn width 95 % grade IIB-III (ICD 10
CM T20.0)

Consult to Plastic surgery Division

Hospitalize at ICU
Observation airway
Debridemnent urgency
Dressing with silfersulfadiazine

Operative report
Performed debridement
Dressing with silfersulfadiazine

Post op dignose
Flame burn width 95 % grade IIB-III (ICD
10 CM T20.0)

Follow Up
Date

22/7/
2015
POD 2

(-)

O
BP: 130/90 mmHg
Pulse: 90 beats/minute
RR: 20 breaths/ minute
GCS: 15 (E4 M6 V5) ; 15
Urine 30 cc/hour

A
Flame burn
width 95 %
grade IIB-III (ICD
10 CM T20.0)

P
IVFD RL 20
drips/Minute
Inj Meropenem
1gr/12 hour
Inj ketorolac 30
mg/8 hours