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Name
: Mrs. C
BB: 60 kg
Age
: 55 years old
TB: 155 cm
th
Hypertension (+) controlled with amlodipin 1x5mg, DMII (-), allergy (-), asthma (-)
Physical examination
Airways
: Clear , Mallampati 1, Dentures (-)
Brain
: GCS : 15
Local state : a.r waist: inflamation signs (-), pain (+), limited ROM
Adjuvant examination
Lab (27/4/2016) : Hb (11,9 ) Ht(36) Leu(8,6) Trom(268) CT/BT (7/2) Ur/Cr(45/0,93) KGDS(107)
CXR
: Cor and Pulmo within normal limit
ECG (2/5/16)
: Normal ECG
Conclusion
ASA II with controlled hypertension + anemia (11,9)
Planning
: General anesthesia
MORNING REPORT
OR VIII
Wednesday, May 11th 2016
II
Name
: Mrs. N
BB: 70 kg
Age
: 61 years old
TB: 155 cm
Airways
: Clear , Mallampati 1, Dentures (-)
Brain
: GCS : 15
Lab (26/4/2016) : Hb (13,1 ) Ht(39) Leu(6,3) Trom(234) CT/BT (7/2) Ur/Cr(42/-) KGDP(100)
ECG (2/5/16)
: SR, HR 86 bpm, LAD
Conclusion
ASA II with hypertension gd 1
Planning
: General anesthesia
III
Name
: Mrs. K
BB: 50 kg
Age
: 58 years old
TB: 165 cm
th
Complain : low back pain and pain in legs since 3 months ago
Airways
: Clear, Mallampati 1, Dentures (-)
Brain
: GCS : 15
Local state : a.r thorax posterior: lump (+), pain (+), limited ROM
Adjuvant examination
PPLab (26/4/2016): Hb (12 ) Ht(36) Leu(12,2) Trom(338) CT/BT (7/2) Ur/Cr(26/0,71) KG2PP(97)
CXR
: Cor and Pulmo within normal limit
ECG
: SR, HR 97 bpm
Conclusion
ASA II with controlled hypertension +leucositosis (12200)
Planning
: General anesthesia
IV
Name
: Ms. R
BB: 75 kg
Age
: 16 years old
TB: 160 cm
th
Airways
: Clear, Mallampati 1, Dentures (-)
Brain
: GCS : 15
Lab (1/5/2016)
: Hb (12,5 ) Ht(38) Leu(9,9) Trom(424) CT/BT (7/2) Ur/Cr(15/0,40) KGDS(80)
CXR
: Cor and Pulmo within normal limit
Conclusion
ASA II with overweight (BMI 27)
Planning
: General anesthesia