PLASTIC

MF/KN
 I. Identity

 Name :hendrianto
 Sex : male
 Age : 16 yo
 Med.Rec : 1129361
Diagnosis : contracture digiti 1.2,3 manus dextra
 Pro : contracture release
 subjective
His finger 1.2.3 on right hand difficult to move since 12 years ago cause burns

 Allergy history (-)

 Coex history (-)
 History of asthma (-)
 Surgery history(-)
 History of hipertension (-)
 History of diabetes (-)
 objective

Sense : Compos mentis

BP :110/70
HR : 88x/menit
RR : 20x/menit
T : 36.5 ºC
SpO2 : 98%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
 Laboratorium
Laboratory test ( 09-07-19)
 Hb : 15,2
• Leucocyte : 9.990
• Trombocyte : 311.000
• Ht : 46
• Ur/Cr : 21/0,96
• Na/K/C : 144/4,2/10
• BSS : 78
 Assessment
ASA I Wrist Block
 Identity

 Name : achmad hudzaifah

 Sex : male
 Age : 2 yo
 Weight : 14kg
 Room : RBP
 Med.rec : 1040057
 Diagnosis : labiognasopalatoshchizis post labioplasty
+ palatoplasty
 Pro : palatoplasty repair
 subjective
Cleft lip surgery, still often comes out of food from the nose. Aterm, pervaginum, BBL
2900gr, VACTREL (-)

 Coex history (-)

 Allergy history (-)
 History of asthma (-)
 Surgery history (+)
 History of hipertension (-)
 History of diabetes (-)
 objective

Sense : compos mentis

BP : (-)
HR : 104x/menit
RR : 24x/menit
T : 36.5 ºC
SpO2 : 99%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
 Laboratorium
Laboratory test (18-09-19)
• Hb : 11,9
• Leucocyte : 7.940
• Trombocyte : 357.000
• Ht : 34
• DC : 0/4/46/40/10
Assessment
ASA 1 GA INK