Morning Report

4th December 2015

Identity

• Name : Mr. IL• Sex : Male• Age : 25 years old• Religion : Christian • Job : Farmer

Anamnese• Chief Complain :

Burn wound by gas lamp• Present Complain:

Patient came into the emergency unit cause of burn wound by a gas lamp in his house 6 hours before he came to hospital. Burn wound can seen in his face, right and left arm and front side of body. Founding large number of bubble skin which contains fluid in his face, both arms and front side body.

Secondary Survey GCS : E4V5M6 Vital signs

Blood presure: 130/100 Heart rate : 88x/m RR: 24x/m

Head Hair : Black, Allopesia (-), burning hair Eyes : Hematom : -/-

Conjungtiva : Anemis (-/-)Sclera : Icterik (-/-)pupil : isokor, pupil reflects +/+Ears : otorhea (-)

Nose : Blackish nastril with burning hair of nose Mouth : dry mouth Neck : Limphonodes (-)

PULMOInspeksi : Chest expansion symetric, venous

dilatation (-)Palpasi : Vocal fremitus (d=s), mass (-), krepitasi (-)Perkusi: sonor (+/+)Auscultasi : Vesiculer (+/+) , Ronchi (-/-),

Wheezing (-/-) COR

S1/2 single, murmur (-), gallop (-)

• ABDOMEN– Inspection : mass (-), scar (-), wound (+)– Auscultation : peristaltics normal– Palpation : tenderness pain (-) , mass (-) – Percusion : timpany sound (+)