1. BURN Case Presentation
Block R
Magallanes, Vincent
Pasco, Bayani Jr.
Pambid, Karen
Pili, Stephanie
Raguindin, Peter Francis

2. Clinical Profile E.D. 40 / M, separated Tiaong, Quezon R-handed
Roman Catholic

3. History of Present Illness
DOI: April 2, 2010
TOI: 3 PM
POI: outside their home in Tiaong, Quezon
MOI: electrical burn

4. History of Present Illness
5 hours PTC
Patient was on the ground outside their house, fixing their antenna and accidentally touched a live wire.
Patient got electrocuted, immediately felt intense heat all over his body. He was found lying on the ground
(-) LOC, (+) numbness all over his body “nangingimi”
Patient was brought to a local hospital where he was hydrated with 2L of pNSS, given ATS/TeAna and 12L ECG was done. He was immediately referred to PGH for prompt management

5. Review of Systems (-) HA (-) nausea/vomiting (-) BOV (-) fever
(-) chest pain
(-) dyspnea
(-) cough and colds
(-) abdominal pain
(+) dark-colored urine
(-) melena/ hematochezia
(-) seizure

6. Past Medical History (-) HPN, DM, BA, PTB, allergies
(-) previous hospitalization/ surgery

7. Family Medical History
(+) HPN – mother
(-) DM, BA, PTB, allergies

8. Personal and Social History
Elementary graduate
Works as a welder
Separated with first wife to whom he had 7 children
Currently has a live-in partner
Smoker for 24 years, 3 sticks/day
Occasional alcoholic beverage drinker

9. Physical Examination Awake, conscious, coherent, NICRD
BP 100/60, HR 90, RR 20, T 37.3
HEENT: anicteric sclerae, pink conjunctivae, round pupils EBRTL, (-) NVE, (-) CLAD
CVS: Adynamic precordium, distinct heart sounds, NRRR, apex 5th ICS L MCL, (-) murmur

10. Physical Examination
Chest: Equal chest expansion, clear breath sounds, (-) crackles/ wheezes
Abdomen: flat, NABS, (-) tenderness
Extremities: PNB, FEP, (-) edema
Neuro:
E4V5M6, oriented to 3 spheres
CN intact, DTRs 2+ on all ext, (-) Babinski, supple neck
Motor Sensory
5/5

12. LUND and BROWDER CHART
AREA
Adult
TBSA
Head 7
Nech 2
Trunk ant 13 11
post
Buttocks R
2.5 L 1
Genitalia
Upper arm R 4
1.5
Lower arm R 3
0.5
Hand R
Thigh R
9.5 8
Leg R 5
Foot R
3.5
TOTAL
100 49

13. Assessment
Electrical Burn, 49% TBSA

14. Course ER: Primary Survey: Secondary Survey: Airway Breathing
Circulation
Disability
Exposure
Fluid Resuscitation
Secondary Survey:
history
Related trauma?

15. Laboratory Exams CBC Blood typing Na, K, Cl, BUN, Crea, Alb PT/PTT
Urinalysis with myoglobin
12-L ECG
CXR

16. LAB results CBC 4/2 4/3 Hgb 175 165 Hct 0.501 0.474 Wbc 26.30 2.48 Plt
317
254
Neut
0.892
0.452
Lymph
0.030
0.394
Mono
0.075
0.142
Eos
0.000
Baso
0.002
0.012
Blood
Chemistry
4/2
BUN
4.65
Crea
105
Alb 16 Na
141 K
3.1 Cl
106
PT/PTT
4/2
PT: 11.0 /13.0 / 0.76 / 1.25
PTT: 32.6 / 36.4

17. LAB Results U/A 12L ECG: RSR, NA, NsSTTwc CXR: NSCF
Light brown, turbid, pH 6.0, sg 1.030, few bacteria, (+) coarse granular cast 2-6/lpf, (+) amorphous urates +3/lpf
4/3 3:17 AM
Myoglobin positive
4/3 5: 21 PM
Myoglobin negative
12L ECG: RSR, NA, NsSTTwc
CXR: NSCF

18. PLAN Diet: NPO IVF: pLR @ 600cc/hr pLR @ 600cc/hr
Tx: Ceftazidime 2.5g IV q8
Amikacin 1.2g IV OD
MV w/ Zn 1 tab OD
Vit C 500mg/tab OD
Tramadol 50mg/cap, 1 cap TID
NGT open to drain
Monitor UO q1, should not be <100cc/hr
Monitor VS Q1