By:Truely Panca 1015005Jason Alim1015074Renaldi1015175Tendi Robby0815147

Tutor:Eduard P Simamora, dr., Sp.BA

DEPARTEMENT OF SURGERYFACULTY OF MEDICINEMARANATHA CHRISTIAN UNIVERSITYIMMANUEL HOSPITALBANDUNG2015

Name: HAge: 5 years oldSex: MaleNationality: IndonesianAdmission Date and Time: June 8th 2015, 13.05Examination Date and Time: June 22nd 2015, 09.30 Hospital Discharge Date: June 22nd 2015

Patients Identity

History was taken heteroanamnesis from Parents on : June 22nd 2015

A 5 years old boy patient was admitted to Immanuel Hospital with general appearance: moderate, conscious, compos mentis, no cyanotic, no anemic, and no icteric appearance.

History Taking

Chief complain: burns

The patient was admitted with the face, volar side both upper extremities, lower legs and feet burns after struck by fire from the gas that leaked from one of the house in the residence.

The burn incident was happened 20 minutes ago when the patient was playing with his friend in a stall. All parts of body that exposed by the fire become redness accompanied by blisters. History Taking

The wounds were very painful on first inspection. The patient didnt feel difficult to breathe, loss of consciousness, not complained of dizziness, nausea and vomiting.

History Taking

Medication: noneFamilly history: there is no family historyAllergic History: the patient has no allergic historyImmunization History: basic immunization is complete

History Taking

General Appearance: ModerateConsciousness: Compos MentisGCS: 15Height: 98 cmWeight: 15 kgsNutritional Status: Z-score -2 SD 0 SD (good)Vital SignsBlood Pressure: 100/70 mmHgPulse: 120 x/mRespiration: 24 x/mTemperature: 36,80COxygen Saturation: 98%

Physical Examination

Head: there is no deformity Eyes: anemic conjunctiva (+) , icteric sclera (-)Nose: deformity (-), secret (-)Neck: no lymph node enlargementChest: shape and movement are simetric on both sides Cor: normal heart sound, regular, murmuric sound (-) Pulmo: VBS +/+ , Rh -/- , Wh -/-Abdomen: convex, normal bowel sound, tympanic, no tenderness on palpationSkin: sensory (+)

Physical Examination

Head and Neck: 3%Right upper extremity: 1.5 %Left upper extremity: 1.5 %Right lower extremity: 7 %Left lower extremity: 7 %Total: 20%

Localize status

Laboratory Findings

ExaminationValue UnitNormal RangeHematology 10/06/2015Hemoglobin13.3g/dL10.7 15.6Hematocrit40.3%31 43Leucocyte17.89103/mm34.00 13.50Trombocyte352103/mm3150 450Eritrocyte5.1juta/mm33.8 5.8MC ValueMCV78fL77 95MCH26pg/mL25 33MCHC33g/dL32 36

Laboratory Findings

ExaminationValue UnitNormal RangeHematology 16/06/2015Hemoglobin11.6g/dL10.7 15.6Hematocrit35.3%31 43Leucocyte21.08103/mm34.00 13.50Trombocyte582103/mm3150 450Eritrocyte4.5juta/mm33.8 5.8MC ValueMCV78fL77 95MCH26pg/mL25 33MCHC33g/dL32 36Differential Count

Basofil0.0%0.0 1.0Eosinofil1.0%1.0 5.0Neutrofil Stab0%3.0 5.0Neutrofil Segment60.0%25.0 60.0Limfosit25.0%25.0 40.0Monosit14.0%2.0 10.0Random plasma glucose93Mg/dL60 100

Laboratory Findings

Hematology 22/06/2015ExaminationValue UnitNormal RangeHemoglobin9.4g/dL10.7 15.6Hematocrit29.5%31 43Leucocyte15.50103/mm34.00 13.50Trombocyte490103/mm3150 450Eritrocyte3.7juta/mm33.8 5.8MC ValueMCV80fL77 95MCH25pg/mL25 33MCHC32g/dL32 36

Differential CountBasofil0.3%0.0 1.0Eosinofil2.1%1.0 5.0Neutrofil Stab0%3.0 5.0Neutrofil Segment58.6%25.0 60.0Limfosit27.2%25.0 40.0Monosit11.8%2.0 10.0

A 5 years old boy patient was admitted to Immanuel Hospital with chief complain: burns

History taking using heteroanamnesis, the patient was admitted with the face, volar side both upper extremities, lower legs and feet burns after struck by fire from the leaked gas.

The burn incident was happened 20 minutes ago before hospitalized.

The wound become redness accompanied by blisters and very painful on first inspection. Resume

Dyspnea (-), loss of consciousness (-), dizziness (-), nausea (-) and vomiting (-).

Medication: -Familly history: -Allergic History: -Immunization History: complete

Resume

Laboratory Findings :10/06/15:Hematology: leukocytosis

16/06/15:Hematology: leukocytosis

22/06/15:Hematology: leukocytosis and anemia

Resume

Localize statusHead: 3%Right upper extremity: 1.5 %Left upper extremity: 1.5 %Right lower extremity: 7 %Left lower extremity: 7 %Total: 20%

Resume

Pre Operation Diagnosis: Combustio 20 % grade 2Post Operation Diagnosis: Combustio 20 % grade 2Duration : 30 minutesOperation: the patient had a necrotomy on 9th June 2015

Surgery Report

Surgery Approach: NecrotomySurgery managementmedication (post operation): Infusion RL 1500 / 24 hrCeftriaxone 2 x 1 gRantin 3 x 1 ccNovalgin 3 x 0,5 ccVip Albumin 2 x 1 caps

Management

Prognosis

Quo ad vitam: dubia ad bonamQuo ad functionam: dubia ad bonamQuo ad sanationam : dubia ad bonam

The patient is diagnosed as combustio 20 % grade 2 because of the following condition:

Based on heteroanamnesis, the patient struck by fire from the leaked gas (thermal injury). The area surface are the face, volar side both upper extremities, lower legs and feet burns. The condition still in the acute phase burns, so its necessary to check primary survey of the patient (at emergency).

From general examination we can rule out . The vital sign pulse pressure: 100/70 mmHg, pulse 100 x/ minute, respiration 24 x/ minute, temperature 36,8oC and oxygen saturation is 98%, it means the patient in stable condition (without sign of cardiovascular and respiratory distress or the presence of inhalation injury, normal breathing and no eschar on neck that may obstruct breathing)Discussion

On the body was found burns in faces (3%), Right upper extremity (1,5%), left upper extremity (1,5%), right lower extremity (7%), Left lower extremity (7%). Size of burns was determined by the diagram form Lund and Browder. The total of burns were 20% with a depth of stage II.Discussion

Laboratory finding, the increase of leukocytes caused by an inflammatory reaction in the acute phase of burns. Management has done were:Hospitalization with isolation roomsMaintenance from fluid infusion of Ringer laktat 1500 cc/ 24 hour with monitoring intake and output of the patient.Wound care for reepiteliasization and to prevent evaporation Physiotherapy for the treatment of contractures

Discussion

Medical therapy :Ceftriaxone 1 gr drip in NS 100 cc every 12 hourRantin IV 1 cc /8 hourVip albumin 2x1 caps p.o Novalgin 3 x 1 cc.

Discussion

Necrotomy already done on 22nd June 2015.

The management of the patient was correct and appropriate with the procedure. The prognosis of these patient is bonam because the current condition is not life threatening, healing can occur spontaneously and already have adequate medical therapy for burns.Discussion

THANK YOU

*