PLASTIC

JY-DS-YD
 I. IDENTITY
 Name : Rahmat bin rasuwi
 Age : 35
 Gender : MALE
 Room : Rambang 2.1
 Med Rec : 1151623
 Diagnosis : Post reconstruction Maxilofacial
bone
 Pro : remove quick fix
II. SUBJECT
Pro removal implant post Wire and pen in
maxila 6/11/19
 History of congenital disease (-)
 History of coexisting (-)
 History of surgery (+) 1x :
 6/11/19 ORIF and Wire, GA, problem (-)
 Allergic history (-)
III. PHYSICAL EXAMINATION
 senses : compos mentis
 BP : 120/80 mmHg
 HR : 78 x/minute
 RR : 20 x/minute
 SpO2 : 99%
 Head : pale conjungtiva (-/-), jaundice (-/-),
Mallampati I, wire in maxila desktra
sinistra
 Neck : ROM normal, mass (-)
 Thorax :
cor : heart sound I & II reguler,
murmur (-), gallop (-)
Pulmo : Vesicular (+) normal, rales (-)
Wheezing (-)
 Abdomen : flat, tympani, Bowel sound normal
 Ekstremity : edema (-)
 Laboratory (17/12/19)
 HB : 14,3
 HT : 41
 WBC : 7800
 Platelet : 281000
 BSS : 75
 Natrium : 147
 Kalium : 3.9
 Ur/cr : 13/0.8
CT/BT : 9/2

Chest X ray 6/11/19 Normal

PHYSICAL STATES ASA I
GA TIVA
I. IDENTITY
 Name : M. Aristo
 Age : 11 years old
 Gender : MALE
 Room : Musi 1.2
 Med Rec : 1128044
 Diagnosis : Hipospadia type midhsaft
 Pro : Uretheroplasty
II. SUBJECT
 Opening of the urethra is underside of the
penis, no cough an flu
 VACTREL (-)
 History of surgery 4x :

Uretheroplasty juni 2019, with GA, problem

(-)
 Allergic history (-)
III. PHYSICAL EXAMINATION
 senses : compos mentis
 HR : 83x/minute
 RR : 20x/minute
 SpO2 : 99%
 Head : pale conjungtiva (-/-), jaundice (-/-)
 Neck : ROM normal, mass (-)
 Thorax : cor : heart sound I & II reguler,
murmur (-), gallop (-)
Pulmo : Vesicular (+) normal, rales (-)
Wheezing (-)
 Abdomen : flat, Bowel sound normal
 Genitalia: Penis opening ad below side
 Ekstremity : normal
 Laboratory 12/12/19)
 HB : 14,0
 HT : 41
 WBC : 9200
 Platelet : 445.000
 Natrium : 144
 Kalium : 4.0
 CT/BT : 9/2
PHYSICAL STATES ASA I
GA LMA
I. IDENTITY
 Name : Bambang
 Age : 12 years old
 Gender : MALE
 Room : lakitan 1.2
 Med Rec : 1068113
 Diagnosis : Hipospadia type distal
shaft
 Pro : Uretheroplasty
II. SUBJECT
 Opening of the urethra is underside of the
penis, no cough an flu
 VACTREL (-)
 History of surgery 3x :

Uretheroplasty juni 2019, with GA, problem

(-)
 Allergic history (-)
III. PHYSICAL EXAMINATION
 senses : compos mentis
 HR : 99x/minute
 RR : 20x/minute
 SpO2 : 99%
 Head : pale conjungtiva (-/-), jaundice (-/-)
 Neck : ROM normal, mass (-)
 Thorax : cor : heart sound I & II reguler,
murmur (-), gallop (-)
Pulmo : Vesicular (+) normal, rales (-)
Wheezing (-)
 Abdomen : flat, Bowel sound normal
 Genitalia: Penis opening ad below side
 Ekstremity : normal
 Laboratory 17/12/19)
 HB : 13,6
 HT : 39
 WBC : 8470
 Platelet : 358.000
 Natrium : 145
 Kalium : 4.2
 Ur/cr : 17 / 0.73
PHYSICAL STATES ASA I
GA LMA