MORNING REPORT

OR V
Wednesday, July 13th 2016

Patient 1

Name
: Mr. M. Rizky
weight: 26 kg

Age
: 15 YO
High: 120 cm

Diagnose : Intrcranial tumor

Procedure : Craniotomy + removal tumor

Anemnesa
Chief complaint : Patient came with decreased consciousness
Allergy (-) Asthma (-) hypertension of record (-)
Physical examination
Airways
: Clear ,mallampati 1
Breathing : RR 22 x/minute Ves (+/+) Rh (-/-), Wh (-/-)
Circulation : HR 86 x/minute BP :- Cor : BJ 1 > BJ 2, Reguler
Brain : E4 M6 V5 GCS :15
Lokalis State
:
Lab ( 11/07/2016) : Hb (11,9), Ht (34), Trom (141) , ureum (80), na (130) billirubin (9,31)
Rontgen(18/06/2016): normality visible of COR and Pulmo
Conclusion
Impress
: ASA 3 with decreased consciousness.
Plan
: General Anesthetic

Patient 2

Name
: Mr. Syahril H
weight: 76 kg

Age
: 33 YO
High: 168 cm

Diagnose : Wound Dehsiscence ar. Temporal

Procedure : Wound debridement + to close defect post craniotomi

Anemnesa
Chief complaint : white discharge from the wound
Allergy (-) Asthma (-) hypertension of record (-)
Physical examination
Airways
: Clear ,mallampati 1
Breathing : RR 22 x/minute Ves (+/+) Rh (-/-), Wh (-/-)
Circulation : HR 82 x/minute BP : 130/ 80 Cor : BJ 1 > BJ 2 Reguler
Brain : GCS : 15
Lokalis State
: ar temporal dextra
Lab ( 11/07/2016) : Leukosit(12,0)
Rontgen (12-07-2016): normality visible of COR and Pulmo
CT-scan(11-07-1016)
Conclusion
Impress
: ASA 3 with history of decreased consciousness + Leucositosis(12,0)
Plan
: General Anesthetic