Morning Report

Thursday, 1st August 2013 Muhammad Previo Hibatur Rahman

Robby (4 YO)
M: I : S: T: Got burned by fireworks Plantaris Pedis Dextra Pain Wound Toilet

History of Illness
Patient came to Pelabuhan Hospital with burned wound at his right foot. His foot got burned at his house when he plays fireworks, 1 day before admitted to the hospital.

HEAD TO TOE
Eyes +/+ Ear Neck Thorax Insp Pal Per Aus : pupil isocors 3mm/3 mm, centered, light reflex : Bruise (-), hematoma (-) : Bruise (-), hematoma (-) : : bruise (-), movement of chest wall symmetrical : crepitation (-) : sonor right = left : Basic breath sound vesicular right and left

 Abdomen : Ins : flat, bruise (-) Aus : bowel sound (+) 6x/min Pal : tenderness (-), muscular defense (-) Per : tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)

Localized Status
Plantar Pedis Dextra
Inspection : bruise (+), active bleeding (-), swelling (+) Palpation : crepitation (-), tenderness (+)

Diagnosis
Combustio Grade II et Plantar Pedis Dextra

Planning
Wound Toilet Give Analgetic Give Antibiotic

Before

After

THANK YOU