Honi Noeem AlAstol

120071269

Anesthesia Case
Date of PreOp visit: 13-12-2012
Date of Surgery: 15-12-2012
Ward: Orthopedics

Personal Data
Amani Salim El-Masri, is a 14-year old female patient who is single. She
was admitted to the surgery department via Emergency Room on
Wednesday 12.12.2012.

Chief Complaint
Right lower leg pain and swelling for a few hours-duration.

History of Cheif Complaint:

This young lady was doing well till early morning of Wednesday had a
trauma by a a car causing her severe pain and swelling in her right
ankle.She was brought to ER in the hospital right away with x-rays
showing a fracture in the right medial malleolus. Cold bands where applied
with casting thereafter. She was admitted to Orthopedics department.
Surgery planned to go on Saturday in order to fix the fracture with
screws.No previous similar conditions happened to the lady.

Past Medical and Surgical/Anesthetic History

- There is no chronic illnesses, HTN, DM or Asthma
- No history of surgeries or exposure to
anesthetics. - No previous similar conditions

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Drug and Allergy History

- She doesn't take any drug regularly.
- She hasn't taking aspirin recently. She has no food or drug allergy.

Social History
- This young female is single studying in school
- She lives with her family in a well ventilated house, 1st floor made of
concrete.
- No pets at home.
- No history of recent traveling.
- No smoking or alcohol history.

Family History
- No similar attacks in family.
- No history of malignant hyperthermia or allergy to anesthetics.
- No consanguinity between her parents.
- No inherited conditions in her family.

Systemic Review
General: No fever, weight loss or anorexia
-Chest: No cough, dyspnea or hemoptysis. No wheezing or chest pain.
-CVS: No dyspnea, orthopnea or PND. No palpitations.
-GIT: No diarrhea, constipation or abdominal pain. No vomiting or
heartburn -Neurological System: Intact memory, no headaches, blurred
vision, tinnitus, abnormal hearing or seizures.
-Urological System: no dysuria, frequency or urgency. No incontinence.

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Physical Examination

General Examination
The patient is conscious, oriented and alert. She has normal BMI of 22 kg/
m2. Her vitals revealed a RR of 12 breaths/minute. BP of 120/80 mmHg.
Temperature of 37 C. And HR of 76 bpm.
No clubbing, cyanosis or tar staining. Normal JVP with no teeth
abnormalities.
No tonsillar enlargement or congestion.

Chest Examination:
Inspection: shows symmetrical chest moves with respiration. No skin rash
or deformities.
Palpation shows Normal chest expansion with symmetrical tactile
fremitus. Apex beat is in the 5th intercostal space midclavicular.
Percussion: normal resonant chest with no areas of dullness.
Auscultation: normal breath sounds, vesicular with no crackles or
wheezing.

Cardiovascular Examination
- Inspection: Reveals normal chest symmetry with no precordial bulge.
Apex beat was localized to 5th intercostal space midclavicular. No lower
limb edema
- PalpationNo palpable thrill or heaves.
- Auscultation reveals normal S1 and S2 with no murmurs or opening
snaps. No basal crackles.

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Investigations ordered
CBC:
Hb: 12.8
WBCs: 9.8
Hct: 38.4%
Plt: 390.000
FBS: 132 mg/dl
Urea 35 mg/dl
Creatinine: 0.5 mg/dl
CXR or ECG were not ordered.

ASA classification: 1
Premedications:
-NPO at midnight
-Dormicum( Midazolam) 5 mg IM on Call
- Cefazolin 1 g in OR.
-Electrolytes
Operation plan: soft tissue debridement, 2 screws fixation for right
medial malleulous.
Anesthetic Protocol: Under General Anesthesia.
Intubation: ETTA 7
Anesthetic Circuit: Semi-closed
IV cannula: 18 g left arm

Dose given: Cefazolin 1 g given

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Vitals during surgery:

BP: 120/80
SiO2: 99%
O2/N2O: 4/4
FiO2: 50%

Induction of Anesthesia used IV propofol 150 mg

with Fentanyl 100 mic. And Atracurarium 30 mg

Maintenance of Anesthesia: Halothane 1%

Termination of Anesthesia uses Oxygen/ atropine and Neostigmine.

At Recovery room : conscious, stable Vital signs. Clear wound, no
blood oozing.
Admission to surgery ward.

Hani Naeem AlAstal

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