Patient Identity #1
Name
: Child. J
Age
: 5 year old
Sex
: Male
Religion
: protestan
Address
: Balai Karangan
Admission date : September 29th, 2015,
Type of Payment : BPJS
Body Weight
: 15 kg
General Examination
1. Vitals: T 36,1C, HR- 80 tpm , RR: 20 tpm,
2. Growth: Weight- 15 kg
3. General: Patient is awake
4. Head: head symmetric; rash (-)
5. Eyes: no icterus, no discharge, no conjunctivitis
6. Neck: no lymphadenopathy, rash (-)
7. CV: Reguler S1/S2, murmurs (-), gallop (-), capillary refill <2
8. Resp: vesicular (+/+), wh (-/-), rhonci (-/-)
9. Abd: soft, nontender ; bowel sounds present; no masses.
10. Ext: warm, symmetric tone, edema (-/-)
Laboratory test
Blood test (29-09-2015)
Hb
HT
Leukocyte
Eritrosyt
BT
CT
: 13,1 g/dl
: 36 %
: 10.200 /uL
: 4,39 milion
:3
: 63
X-ray
Diagnosis
Working Dx:
Union fractur supracondylar humerus
dextra
Therapy
ER :
IVF D5 NS 6 hour before operation
180 cc/6 hour is 30 dpm
inj prophylaxis antibiotic with
cefotaxime 2X500 mg
Fasting month 6 hour before
operation
Aff wire
Prognosis
Ad vitam
: bonam
Ad functionam : dubia ad bonam
Ad sanactionam : bonam
Morning Report
September 29th,2015
Anesthesi
Minar Nur Cahyani
M. Luthfi Taufik
Physical Examination
Breath
:
The airway is free, opening the mouth 4
fingers, mallampati I, false teeth (-), RR
28 x/min, regular, vesicular breath
sounds (+/+), Rhonki (-/-), Wheezing (-/-)
Blood :
HR 96 bpm, regular, strong in palpable,
perfusion dry-red-warm, CRT <2sec
Brain : GCS 15 E4V5M6
Physical Examination
Bladder
:
urination
catheterized urine
normal,
no
Pre Surgery
Fasting 6 hours before surgery
IVFD D5 NS 30 dpm micro
Fluid needs during fasting 6 hours : 2 x
15 x 6 = 180cc/6 hours = 30 dpm
Maintenance : 1.000 + 250 = 1.250
cc/day
Na+ : 30-60 mEq/day
K+ : 15-45 mEq/day