MORNING REPORT

IDENTITY

Name : Mrs. M
Age : 53 years old
Sex : Female
Address : Laeya Village
DPJP : dr. Saktrio D Subarno, Sp.BP-RE
Admission : 8 September 6th 2018
 HISTORY TAKING

Chief complain : Burn Injury

Anamnesis :
Since about 1 hours before admitted to hospital due to scalded
MOT :
the patient wants to cook and wants to replace the gas stove. then the stove gas is exposed to
fire so that the fire affects the patient's body and face.
HOT :

Syncope (-), Nausea (-), Vomiting (-)

History of drug used (-), alcohol (-), narcotic (-)

History of bleeding (-)

History of Medication (-)

 PRIMARY SURVEY

A • Clear

B • RR : 28x/minutes

C • HR : 98x/minutes, reguler BP 120/80

D • GCS : E4M6V5 (15), pupil isokor,

2mm/2mm

E • Temperature : 36,6˚C,
SECONDARY SURVEY

General State
Moderate Illness, Composmentis

Malnutrition State
 Status Present

Head : Within Normal Limit

Face : Localized
Eye : Within Normal Limit
Nose : Within Normal Limit
Ear : Within Normal Limit
Neck : Localized
Chest : Localized
Abdomen : Within Normal Limit
Upper Limb : Localized
Lower Limb : Localized
 Localized State
Facialis Region
• Eritheme(+), Bulla (-), Necrosis(-), Combutio
Inspection grade IIA 1%

Palpation • Tenderness (+)

Cervikalis Region
• Eritheme(+), Bulla (+), Necrosis(-), Combutio
Inspection grade IIAB 1%

Palpation • Tenderness (+)

Upper Extremity sinistraRegion
• Eritheme(+), Bulla (+), Necrosis(-), Combutio
Inspection grade IIAB 3%

Palpation • Tenderness (+)

Upper Extremity dextraRegion

• Eritheme(+), Bulla (+), Necrosis(-), Combutio
Inspection grade IIAB 4%

Palpation • Tenderness (+)

Lower Extremity sinistraRegion
• Eritheme(+), Bulla (+), Necrosis(-), Combutio
Inspection grade IIAB 1%

Palpation • Tenderness (+)

Upper Extremity dextraRegion

• Eritheme(+), Bulla (+), Necrosis(-), Combutio
Inspection grade IIAB 1%

Palpation • Tenderness (+)

Clinical Finding
Clinical Finding
 Combutio grade IIAB 11 % e.c. Fire
DIAGNOSE
Injury
 Pharmacology
- IVFD (Baxter)
- Antibiotic (Cefotaxime)
Management
Non-Pharmacology
• Compress with Gauze NaCl 0.9%
• High Protein Soft diet