EMERGENCY CASE REPORTS

Saturday, October 2nd , 2010

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
 Saturday, October 2nd 2010

Ambulation : 2 Patient

Hospitalized : 10 patients

Observation : 2 patient
Operated : 5 patient
Death : - patient

Total : 12 patients
No. 1
Name : Ch. A Sex : Male
Age : 5 years old No. Reg : 44 31 06

Chief complaint : Electrical burn injury

History taking : Suffered since 3 days before admitted to the hospital
due to electrical shock. History loss of consciousness
(-) , vomiting (-). Prior medical care at Angkatan Laut
Hospital
Mechanism of : He was playing near relay station of high electrical
injury strained, suddenly he entered to the relay station and
touched something. Next mechanism was unclear
Injury sustain : Fore hand, hand, lumbal, thigh, perineum
Ssymptom & sign : Pain, wound
Examination : Physical examination, laboratory examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 18 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/70 mmHg, HR : 80 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5 / 2,5 mm , LR +/+

E: T (ax) : 36,8 oC
Secondary Survey

Right antebrachii region :

I : Seen burn wound grade IIa IIb 3 %
P : Tenderness (+)

Left antebrachii and palmar region :

I : Seen burn wound grade IIa IIb 1 %,
seen lacerated wound has been stitched
size 3 cm, seen lacerated wound has been
stitched size 3 cm at palmar region
P : Tenderness (+)
Secondary Survey

Right lumbal region :

I : Seen burn wound grade IIa IIb 6 %
P : Tenderness (+)

Left femur and perineum region :

I : Seen burn wound grade IIa IIb 6 %,
P : Tenderness (+)
 Laboratory Result
WBC : 9,6 x 103 / L Na : 136

RBC : 5,11 x 106 / L Kalium : 4,4

HGB : 13,2 g/dL n klorida : 108

HCT : 38,6 %

PLT : 326 x103/ L

CT / BT : 700 / 200

Blood Sugar : 123 mg/dl

Ureum : 15 mg/dl

Creatinin : 0,4 mg/dl

GOT / GPT : 46/ 39 /L

 Urinalisa
Warna : kuning Sedimen leukosit : 0 1

Ph : 7,0 Sedimen eritrosit : 0 - 1

Bj : 1,01 Sedimen epitel :2

Protein : -

Glukose : -

Bilirubin : -

Urobilinogen : -

Blood : -

Leukosit : -
ECG
WORKING DIAGNOSIS : Electrical burn injury grade IIa IIb 16 %

MANAGEMENT : IVFD
Medicaments
wound care
Report to senior plastic surgeon
advice : conservative
PROGNOSIS : good
FOLLOW UP : Vital sign wound healing