Case Combustio Grade IIB
-
Upload
triono-assamsul -
Category
Documents
-
view
27 -
download
0
Transcript of 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
-
5/24/2018 Case Combustio Grade IIB
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
-
5/24/2018 Case Combustio Grade IIB
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'
-
5/24/2018 Case Combustio Grade IIB
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 #$$
Bl%%d e&a'inati%n (
Haemolobin :5.2 dl
Haematocyte : 1" G
eucocyte :9.#00 mm?
!hombocyte :B.000 mm?
/%6 : B.5
*odium : 125 m@l
%otassium :1.# m@l
3eum :1" mdl
'eatinin : 0." mdl
-
5/24/2018 Case Combustio Grade IIB
5/16
aeces :
'olouconsistency : yelloishli@uid
*lime : >
ytocyte%- : =
eucocyte : 2=#
Amylum : =
Amoeba : =
/aco,hae : =
-
5/24/2018 Case Combustio Grade IIB
6/16
-aso,hil : 0
osino,hil : 0
*ta8 : 0
*emen : 5B
im,hocyte : ?0
/onocyte : 10
N" ( 'iel%cyte #*+ t%&ic ,ranula -
th!e"ruary #$$
%latelet : #9.000 mm?
*odium : 12B m@l
%otassium : ?.5 m@l
aeces :
'oloconsistency : een li@uid
*lime : >
ytocyte%- : =
eucocyte : =
Amylum : =
Amoeba : =
/aco,hae : =
-
5/24/2018 Case Combustio Grade IIB
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 #$$
-
5/24/2018 Case Combustio Grade IIB
8/16
Hemolobin : 15. dl
euocyte : 11.200 mm?
%latelet : B.000 mm?
*odium : 1?0 m@l
%otassium : #.5 m@l
Random %lasma &lucose : 112 mdl
#$ 2e"ruary #$$
Hemolobin : 11.0 dl
euocyte : .?00 mm?
%latelet : 2.000 mm?
#st !e"ruary #$$
Hemolobin : 10. dl
euocyte : 5.#00 mm?
%latelet : 5".000 mm?
-
5/24/2018 Case Combustio Grade IIB
9/16
-
5/24/2018 Case Combustio Grade IIB
10/16
!O44O5 UP
-
5/24/2018 Case Combustio Grade IIB
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
-
5/24/2018 Case Combustio Grade IIB
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 (=)
%ecussion : !ym,anic
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
-
5/24/2018 Case Combustio Grade IIB
13/16
*lime : >
eucocyte : 2=#
#th!e"ruary #$$
Hemolobin : 11. dl
%latelet : 22.000 mm?
)th!e"ruary #$$
Hemolobin : 10." dl
Haematocyte : ?1
euocyte : 20.200 mm?
%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
-
5/24/2018 Case Combustio Grade IIB
14/16
Haematocyte : #? G
3 2e"ruary #$$
Hemolobin : 15. dl
euocyte : 11.200 mm?
%latelet : B.000 mm?
#$ 2e"ruary #$$
Hemolobin : 11.0 dl
euocyte : .?00 mm?
%latelet : 2.000 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 #$$
ecotomy
6I. P%st %7erati%n
%ost=o,eati$e Dianosis : 'ombustio ade II>*e,sis>se$ee dehidation
%ost=o,eati$e Instuction :
'ontol $ital sin e$ey hou
-
5/24/2018 Case Combustio Grade IIB
15/16
astin 8o 2 days
In8use R:A 1- 1:1 1000 cc 2# h
!hea,ies:
&astidin ?70+5 cc
/eto8usin 27100 m
oaes ?70+5 cc
3se a Doe cathete and o88 in the 5th day
'hane the $eband in the #thday
-athin the ,atient once a day
-unaine a8te tae a bath
3se 2 ? mnt
Heat lam,
'hec Hb+ euocyte+ !hombocyte+ Random %lasma &lucose+ a+
,ost o,eati$e.
6II. Pr%,n%sis
uo ad$itam : dubia ad bonam
uo ad8unctionam : dubia ad malam
-
5/24/2018 Case Combustio Grade IIB
16/16
DISCUSSION
!his ,atient ha$e dianosed combutio based on :
om Heteoanamnesis : ,atient had a bunin ound caused by an accidental hot
ate s,lashed on his abdomen to ,at o8 his loe
limbic.
om ,hysical e7amination a Abdomen:
Ins,ection : lat
%al,ation : Distention (=)+ mass (=)+ de8ence muscula (=)
%ecussion : !ym,anic
Auscultation : -oel sound (>) inceasin
!he teatment in this ,atient as:
!e"ruary 3th #$$
ecotomy
%onosis :
@uo ad $itam dubia ad -onam+ @uo ad unctionam dubia ad /alam