Morning Report

September 29th, 2015

Dedi S
Tuti Marinus L

DR. M. SUTOMO HOSPITAL

Patient Identity #1

Name
: Child. J
Age
: 5 year old
Sex
: Male
Religion
: protestan
Address
: Balai Karangan
Admission date : September 29th, 2015,
Type of Payment : BPJS
Body Weight
: 15 kg

History of Present Illness

Chief complain:
Planning to remove internal fixation in the right
elbow

Present 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 History

On 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 Examination
1. Vitals: T 36,1C, HR- 80 tpm , RR: 20 tpm,
2. Growth: Weight- 15 kg
3. General: Patient is awake
4. Head: head symmetric; rash (-)
5. Eyes: no icterus, no discharge, no conjunctivitis
6. Neck: no lymphadenopathy, rash (-)
7. CV: Reguler S1/S2, murmurs (-), gallop (-), capillary refill <2
8. Resp: vesicular (+/+), wh (-/-), rhonci (-/-)
9. Abd: soft, nontender ; bowel sounds present; no masses.
10. Ext: warm, symmetric tone, edema (-/-)

Laboratory test
Blood test (29-09-2015)

Hb
HT
Leukocyte
Eritrosyt
BT
CT

: 13,1 g/dl
: 36 %
: 10.200 /uL
: 4,39 milion
:3
: 63

X-ray

Diagnosis
Working Dx:
Union fractur supracondylar humerus
dextra

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

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

Morning Report
September 29th,2015
Anesthesi
Minar Nur Cahyani
M. Luthfi Taufik

DR. SUTOMO HOSPITAL

 Allergic : Food (-), medicine (-), asthma (-)

Medication : paracetamol syrup last
Friday, September 25th 2015
Past 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 surgery
Environment : -

Physical Examination
Breath
:
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 <2sec
Brain : GCS 15 E4V5M6

Physical Examination
Bladder
:
urination
catheterized urine

normal,

no

Bowel : defecation normal, bowel normal

15x/min, abdomen tenderness (-)
Bone : ROM at elbow joint dextra is
limited
Body Weight : 15 kg
Tempherature : 36,1 C

 Diagnose pre surgery : Union Fracture

supracondilar humerus dextra
Planning of Surgery:
Operator : dr. Oktavianus, Sp. OT
Type of Surgery : Pro Aff wire
Time of surgery : September 30th,
2015 at 2 pm

 PS ASA status : 1, elective, Special

condition pediatri
Planning of Anesthesi: General
anesthesi, face mask

Pre Surgery
Fasting 6 hours before surgery
IVFD D5 NS 30 dpm micro
Fluid needs during fasting 6 hours : 2 x
15 x 6 = 180cc/6 hours = 30 dpm
Maintenance : 1.000 + 250 = 1.250
cc/day
Na+ : 30-60 mEq/day
K+ : 15-45 mEq/day