Plastic

JS/CT
 I. Identity

 Name : Cindai Arizona

 Sex : Female
 Age : 19 y.o
 Med.Rec : 1157527
 Room : Kelingi 2.1 – room 6
 Diagnosis : Skin Avultion digiti IV Manus Sinistra +
Anemia
 Pro : Groin Flop
 subjective
the patient loses the skin and tissue of the ring finger of the left hand while getting out of the car,
the finger wearing the ring is stuck, and the patient pulls it forcefully so that it erodes the tissue
on her finger

 Coex history : ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgical history ( - )
 History of diabetes ( - )
 Hypertension ( - )
 objective

o Sense : Compos mentis

o BP : 90/60 mmHg
o HR : 76x/menit
o RR : 20x/menit
o T : 36.3 ºC
o SpO2 : 99% with free air
 Head : Light Reflect ( + / +)
conjungtiva anemis(+/+) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
A/r Manus Sinistra Digiti IV = skin avulsi
 Laboratorium
Laboratory test ( 09/04/2019)

 Hb : 7.1
 Leucocyte : 6.590
 Trombocyte : 450.000
 Ht : 25
 Na/K : 145/4.6
 Ur/Cr : 15/0.62
 BT/CT : 2.0/11.0
 Other Examination
 Rontgen Manus Sinistra (13/01/2020)
Skin Avultion, fracture ( -)
Assessment
ASA II GA
 3. Identity

 Name : Ridho Alpani

 Sex : male
 Age : 6 , 8 - 10
 Room : Lakitan 1.2 / Room 6
 Med.rec : 335406
 Diagnosis : MAR without fistula
 Pro : PSARP
 subjective
the patient loses the skin and tissue of the ring finger of the left hand while getting out of the car,
the finger wearing the ring is stuck, and the patient pulls it forcefully so that it erodes the tissue
on his finger .
 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 History of hipertension ( - )
 History of diabetes ( - )
 Alergy ( - )
 objective

o Sense : Compos mentis

o BP : N/A mmHg
o HR : 78x/menit
o RR : 24x/menit
o T : 36.5 ºC
o 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 (17/12/2019)
• Hb : 12.1
• Ht : 37
• Leucocyte : 11.500
• Trombocyte : 398.000
• Na/K/ : 139/6.7
• CT/BT : 10.0/2.0
• BSS : 96
 Radiology Examination
FENTANYL 2 AMP[ 100 Mcg/Kg
Assessment
ASA I GA
 2. Identity

 Name : Revaldo Angga

 Sex : male
 Age : 10 yo
 Room : Lakitan 1.2 / Room 6
 Med.rec : 335406
 Diagnosis : MAR without fistula
 Pro : PSARP
 subjective
the patient loses the skin and tissue of the ring finger of the left hand while getting out of the car,
the finger wearing the ring is stuck, and the patient pulls it forcefully so that it erodes the tissue
on his finger .
 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( + )
First Surgical treatment with General Anesthesia without Issue
 History of hipertension ( - )
 History of diabetes ( - )
 objective

o Sense : Compos mentis

o BP : N/A mmHg
o HR : 80x/menit
o RR : 20x/menit
o T : 36.5 ºC
o 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 (23/12/2019)
• Hb : 12.9
• Ht : 37
• Leucocyte : 11.500
• Trombocyte : 398.000
• Na/K/ : 139/6.7
• CT/BT : 10.0/2.0
• BSS : 96
 Radiology Examination
N/A
Assessment
ASA I GA