Morning ReportSeptember 29th, 2015Dedi STuti Marinus L

DR. M. SUTOMO HOSPITAL

Patient Identity #1Name : Child. JAge : 5 year oldSex : MaleReligion : protestanAddress : Balai KaranganAdmission date : September 29th, 2015, Type of Payment : BPJSBody Weight : 15 kg

History of Present IllnessChief complain:Planning to remove internal fixation in the right elbowPresent illness history:A 5-yo-boy was brought to ER of M.Sutomo Hospital complaining of plan to remove internal fixation in the right elbow. Patient have no complain of fever, pain (+) and the patient complain to movement limitation to the right elbow.

Past Medical HistoryOn January 2015, the patient had accident with chair. The patient fall from the chair so the right hand got stuck by his own body.On April 2015 the patient got operation to repair the right elbow. But after operation the patient had complain with the right elbow. The right elbow could not to movement with normally. On June 2015 the patient got operation for the second time to repair operation again. And than the patient had not complain to the right elbow again.

General ExaminationVitals: T 36,1C, HR- 80 tpm , RR: 20 tpm, Growth: Weight- 15 kgGeneral: Patient is awakeHead: head symmetric; rash (-)Eyes: no icterus, no discharge, no conjunctivitis Neck: no lymphadenopathy, rash (-)CV: Reguler S1/S2, murmurs (-), gallop (-), capillary refill

Laboratory testBlood test (29-09-2015)Hb: 13,1 g/dlHT: 36 %Leukocyte: 10.200 /uLEritrosyt : 4,39 milionBT :3CT : 63

X-ray

DiagnosisWorking Dx:Union fractur supracondylar humerus dextra

TherapyER :IVF D5 NS 6 hour before operation 180 cc/6 hour is 30 dpm inj prophylaxis antibiotic with cefotaxime 2X500 mgFasting month 6 hour before operation Aff wire

Prognosis Ad vitam: bonamAd functionam: dubia ad bonamAd sanactionam: bonam

Morning ReportSeptember 29th,2015Anesthesi

Minar Nur CahyaniM. Luthfi TaufikDR. SUTOMO HOSPITAL

Allergic : Food (-), medicine (-), asthma (-)Medication : paracetamol syrup last Friday, September 25th 2015Past illness : elbow joint fracture at 8 months ago and undergone two surgeries to repair that joint at 5 and 3 months ago.Last meal : at 9 p.m. September 29th, 2015 and would be fasted for 6 hours before surgeryEnvironment : -

Physical ExaminationBreath: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

Physical ExaminationBladder: urination normal, no catheterized urine

Bowel: defecation normal, bowel normal 15x/min, abdomen tenderness (-)

Bone: ROM at elbow joint dextra is limited

Body Weight : 15 kgTempherature : 36,1 C

Diagnose pre surgery : Union Fracture supracondilar humerus dextra

Planning of Surgery:Operator : dr. Oktavianus, Sp. OTType of Surgery : Pro Aff wireTime of surgery: September 30th, 2015 at 2 pm

PS ASA status : 1, elective, Special condition pediatriPlanning of Anesthesi: General anesthesi, face mask

Pre SurgeryFasting 6 hours before surgeryIVFD D5 NS 30 dpm microFluid needs during fasting 6 hours : 2 x 15 x 6 = 180cc/6 hours = 30 dpmMaintenance : 1.000 + 250 = 1.250 cc/dayNa+ : 30-60 mEq/dayK+ : 15-45 mEq/day

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