MORNING REPORT

Operating Theatre 5
Wednesday, November 16 2016
dr. Imai Sp. An
Patients 1
• Boy, RF , 9 y.o
• Weight 21 kg, Height : - cm
• Diagnose : Tumor cerebellum
• Procedure : Craniotomy removal tumor
• Anamnesis
- Complaints : Headache
- : HT (-), DM(+), Asma (-), Alergic (-)

• Physical examination
- Airway : Malampati (1) , denture (-) , obstruction (-), neck : normal
- Breathing : RR 21x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
- Circulation : BP 110/80 mmHg, HR:110 x/minute, cor: BJ 1 > BJ 2
- Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm
• Adjuvant examination
- Thorax AP (15/11/2016) : Look at : Cor and pulmo in normal limits

- Laboratorium (15/11/2016) : Hb (12,3), Ht (37), Eri (4,5), Trombo

(468), Leu (21,5) Na (140), K (3,4), Cl (104), Ur (36),
Cr (0,40) n KGDS (163), Alb(3,73) Glb (2,61)

• Conclusion : ASA III with Leukositosis (21,5) n increased intracranial pressure

chronic
• Planning : General Anesthesia
• Post Op : PICU/ICU Cardiac