case combustio grade iib

5/24/2018 Case Combustio Grade IIB

1/16

CASE PRESENTATION

COMBUSTIO GRADE II

by:

Ichsan J. Juanda (0210029)

Dian Desianti (0110050)

Roni Halomoan (0110119)

Anes Imanuella !oemon (00101"#)

I$an %. & (9910019)

'ounselo:

duad %. *imamoa+ d.*,.-A()

D%AR!/! *3R&R4

/DI'A A'3!4 /ARAA!HA 'HRI*!IA 3I6R*I!4

I//A3 H*%I!A

-AD3&

2010


2/16

I. Patients Identity

ame : A. /. R

Ae : 1 yea 5 months old

*e7 : /ale

Reliion : /oslem

ationality : Indonesian

Admission Date : ebuay 11nd 2010

7amination Date : ebuay 22nd2010

II. Present Medical Status

a. Histoy o8 %esent Illness

Histoy as taen by Heteoanamnesis 8om the ,atient;s mothe and

medical ecod: ebuay 22nd2010 until e7amination date.

/ain com,laint : -un . %atient has a had time eatin+ $omitin. oods :-east mil and steam ice.

" days be8oe he as admissteed to the hos,ital+ he had a 8e$e+

es,ecially at niht. iht seats =+ con$ulsion =+ tem,eatue asn;t

measued.

5 days be8oe he as admisteed to the hos,ital+ he had a eddish lesion

in his eas. It as teated ith $iohydocot tice a day. ? days aain+ it

e=a,,eas. !his medication as i$en by a eneal ,actitione

1


3/16

aeces : small amounts+ yelloish+ li@uid consistency+ slime >+

8e@uency moe than nomal limits (57day)

3ine : small amounts+ yelloish+ 8e@uency deceases.

Histoy o8 diseases : =

Alleic histoy : !hee is no alleic histoy.

-lood disode : !hee is no blood disode histoy.

b. %hysical 7amination

&eneal A,,eaance : /odeate illness

'onsciousness : 'om,os mentis

%ulse : 120 7minute+ eula+ ston+ e@ual

Res,iation : 2B 7minute

!em,eatue : ?"+#o'


4/16

ec : o lym,h node enlaement+ mass (=)

'hest : *ha,e and mo$ement ae symmetic in both sides+

etaction (=)

Heat : omal heat sound+ eula+ shu88le (=)

un : 6-* >>+ ales (=)+ heein (=)

Abdomen :

Ins,ection : 'on$e7

%al,ation : Distention (>)+ mass (=)+ de8ence

muscula (=)

%ecussion : !ym,anic

Auscultation :-oel sound (>)

Anus=Rectum :Anus (>)+ 8istula (>)

Inuinal and &enital : lat

7temities : 'yanosis (=)+ edema (=)+ 'R! E 2F

!he iht le as had to be staihten

euoloy : o neuoloical de8icits and nomal

e8le7es

c. aboatoy indins

th!e"ruary #$$

Bl%%d e&a'inati%n (

Haemolobin :5.2 dl

Haematocyte : 1" G

eucocyte :9.#00 mm?

!hombocyte :B.000 mm?

/%6 : B.5

*odium : 125 m@l

%otassium :1.# m@l

3eum :1" mdl

'eatinin : 0." mdl


5/16

aeces :

'olouconsistency : yelloishli@uid

*lime : >

ytocyte%- : =

eucocyte : 2=#

Amylum : =

Amoeba : =

/aco,hae : =


6/16

-aso,hil : 0

osino,hil : 0

*ta8 : 0

*emen : 5B

im,hocyte : ?0

/onocyte : 10

N" ( 'iel%cyte #*+ t%&ic ,ranula -

th!e"ruary #$$

%latelet : #9.000 mm?

*odium : 12B m@l

%otassium : ?.5 m@l

aeces :

'oloconsistency : een li@uid

*lime : >

ytocyte%- : =

eucocyte : =

Amylum : =

Amoeba : =

/aco,hae : =


7/16

0th!e"ruary #$$

Hemolobin : 9+" dl

Haematocyte : 29 G

euocyte : 11.900 mm?

%latelet : 120.000 mm?

/%6 : 10.#

*odium : 1?? m@l

%otassium : #.0 m@l

Di88eential count :

-aso,hil : 0

osino,hil : 0

*ta8 : 0

*emen : #?

im,hocyte : #

/onocyte : 9

b : mielocyte : 2G

1 2e"ruary #$$

Hemolobin : 1?. dl

Haematocyte : #? G

euocyte : 10.B00 mm?

%latelet : 121.000 mm? *odium : 1?# m@l

%otassium : #.? m@l

-leedin time : ? minutes

'lottin time : B minutes

3 2e"ruary #$$


8/16

Hemolobin : 15. dl


%latelet : B.000 mm?

*odium : 1?0 m@l

%otassium : #.5 m@l

Random %lasma &lucose : 112 mdl

#$ 2e"ruary #$$

Hemolobin : 11.0 dl

euocyte : .?00 mm?


#st !e"ruary #$$

Hemolobin : 10. dl

euocyte : 5.#00 mm?

%latelet : 5".000 mm?


9/16


10/16

!O44O5 UP


11/16

Date ollo 3, Ad$ice

22012010 D: Ileus,aalitic

lectolyte imbalance

Adhesion

In8use R 1000 cc 2# h

astin

'hec Hb+ Ht+ !c+ a+ +

3eum+ 'eatinin

%ediaticianad$ice:

!omit ?72 m I6

In8useincease to 1500 cc

2# h

ab :

Hemolobin : 1#+5 dl

euocyte : 1B.B00 mm?

%latelet :95B.000 mm?

Random %lasma &lucose : 11" mdl

*odium : 1??m@l%otassium : #m@l

3eum :1? mdl

'eatinin : 0+5 mdl

/eto8usin 27100 m

/eo8en 27500 m

%ulse ade@uate

Abdomen: con$e7+ distention (>)+ boel sound

(>) nomal

In8use R 1000 cc 2#

h8olloed by A #-

1000 cc 2# h

Aminosteil G 250 cc

2# h

2?012010 latus (>) %e,tisol

Abdomen: distention (>)+ boel sound (>)

nomal

%ediatician ad$ice:

'hec6ea+ a+ + albumin+

lobulin

astin

&! o.12

2#012010 Abdomen: distention (>)+ stool (>)+ latus (>) In8us 20 cc 2# Cam

25012010 %ulse ade@uate+ 8latus (>)+ abdomen distention(>)

Hemolobin : 1?+" dl

Ht : #? G

euocyte : 11.#00 mm?

%latelet : 5"9.000 mm?

*odium : 12 m@l

%otassium : #+? m@l

Albumin : ?+?

&lobulin : ?+0

Di88eential count : -aso,hil : 0+?

osino,hil : ?+2

-and : 0

'hane $eband

'ontinue thea,y

%ediatician ad$ice:

astin

Daue &!

In8use Aminosteil 200

cc 2# Cam

A #- 1000 cc 2#

Cam


12/16

-and : 0

III. Resu'e

1 yeas 5 months old ,atient+ male+ as bon on Auust Bth200B.

*ince a month ao the ,atient had a bun ound and diaheae !he 8eces

had small amount+ li@uid consistency+ uine had small amounts+ 8e@uency

deceases.

Histoy o8 diseases: " days be8oe he as admissteed to the

hos,ital+ he had a 8e$e+ es,ecially at niht. iht seats =+ con$ulsion =+

tem,eatue asn;t measued. 5 days be8oe he as admisteed to the

hos,ital+ he had a eddish lesion in his eas. It as teated ith $iohydocot

tice a day. ? days aain+ it e=a,,eas. !his medication as i$en by a

eneal ,actitione

!hee no alleic histoy and blood disode

%hysical 7amination

utitional *tatus : /odeate

Abdomen :

Ins,ection : 'on$e7

%al,ation : Distention (>)+ mass (=)+ de8ence muscula (=)


Auscultation : -oel sound (=)

aboatoy indins

th!e"ruary #$$

Bl%%d e&a'inati%n (

Haemolobin :5.2 dl

Haematocyte : 1" G

aeces :

'olouconsistency : yelloishli@uid


13/16

*lime : >

eucocyte : 2=#

#th!e"ruary #$$

Hemolobin : 11. dl


)th!e"ruary #$$

Hemolobin : 10." dl

Haematocyte : ?1


%latelet : 5?.000 mm?

Di88eential count :

-aso,hil : 0

osino,hil : 0

*ta8 : 0

*emen : 5B

im,hocyte : ?0

/onocyte : 10

N" ( 'iel%cyte #*+ t%&ic ,ranula -

th!e"ruary #$$

%latelet : #9.000 mm?

aeces :

'oloconsistency : een li@uid

*lime : >

N" ( Candida -

1 2e"ruary #$$

Hemolobin : 1?. dl


14/16

Haematocyte : #? G

3 2e"ruary #$$

Hemolobin : 15. dl


%latelet : B.000 mm?

#$ 2e"ruary #$$

Hemolobin : 11.0 dl

euocyte : .?00 mm?


#st !e"ruary #$$

Hemolobin : 10. dl

euocyte : 5.#00 mm?

%latelet : 5".000 mm?

I6. Dia,n%sis

3nd!e"ruary #$$

%e=o,eati$e Dianosis:

'ombustio ade II>*e,sis>se$ee dehidation

6. Sur,ical Thera7y

!e"ruary 3th #$$

ecotomy

6I. P%st %7erati%n

%ost=o,eati$e Dianosis : 'ombustio ade II>*e,sis>se$ee dehidation

%ost=o,eati$e Instuction :

'ontol $ital sin e$ey hou


15/16

astin 8o 2 days

In8use R:A 1- 1:1 1000 cc 2# h

!hea,ies:

&astidin ?70+5 cc

/eto8usin 27100 m

oaes ?70+5 cc

3se a Doe cathete and o88 in the 5th day

'hane the $eband in the #thday

-athin the ,atient once a day

-unaine a8te tae a bath

3se 2 ? mnt

Heat lam,

'hec Hb+ euocyte+ !hombocyte+ Random %lasma &lucose+ a+

,ost o,eati$e.

6II. Pr%,n%sis

uo ad$itam : dubia ad bonam

uo ad8unctionam : dubia ad malam


16/16

DISCUSSION

!his ,atient ha$e dianosed combutio based on :

om Heteoanamnesis : ,atient had a bunin ound caused by an accidental hot

ate s,lashed on his abdomen to ,at o8 his loe

limbic.

om ,hysical e7amination a Abdomen:

Ins,ection : lat

%al,ation : Distention (=)+ mass (=)+ de8ence muscula (=)


Auscultation : -oel sound (>) inceasin

!he teatment in this ,atient as:

!e"ruary 3th #$$

ecotomy

%onosis :

@uo ad $itam dubia ad -onam+ @uo ad unctionam dubia ad /alam

case combustio grade iib

Documents