MORNING REPORT

Wednesday, September 28 th 2016

Patient 4
Name
: Muzahri
weight: 73 kg
Age
: 40 YO
High: 170cm
Diagnose : multiple soft tissue tumor
Procedure : exsicion
Anemnesa
Chief complaint : massa left thigh
Allergy (-) Asthma (-) hypertension of record (-)
Physical examination
Airways : Clear ,mallampati 1
Breathing : RR 19 x/minute Ves (+/+) Rh (-/-), Wh (-/-)
Circulation
: HR 80 x/minute BP : 120/80 Cor : BJ 1 > BJ 2 Reguler
Brain: GCS : 15
Lab ( 22/09/2016) : Hb (14,6), Ht (43), Trom (301) , Leu (5,7), Na (142), k (4,2), cl (103), GDS (-),
ct/bt (-), ur(27), cr (0,91)
Rontgen (22-09-2016):
Conclusion
Impress : ASA I uncomplicated airway
Plan
: general Anesthetic
Post op
: ward

Patient 5
Name
: Nurmawati yusuf
weight: 65 kg
Age
: 45 YO
High: 160cm
Diagnose : left breast tumor susp benign
Procedure : exsicion
Anemnesa
Chief complaint :
Allergy (-) Asthma (-) hypertension of record (-)
Physical examination
Airways : Clear ,mallampati 1
Breathing : RR 20 x/minute Ves (+/+) Rh (-/-), Wh (-/-)
Circulation
: HR 80 x/minute BP : 120/80 Cor : BJ 1 > BJ 2 Reguler
Brain: GCS : 15
Lab ( 13/09/2016) : Hb (10,2), Ht (32), Trom (232) , Leu (8,1), erit (3,8)
Conclusion
Impress : ASA I
Plan
: General Anesthetic
Post op
: ward