MORNING REPORT

Operating Theatre 8
Wednesday, october 19th 2016
dr. Awar Risyad, Sp. An

Patient 1
Mr. MR, Men, 15 yo
Diagnose : rupture of right ACL
Procedure : reconstruction perarthroscopy
Anamnesis
- Complaints : knee pain
- : HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 17 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 120/70 mmHg, HR:82 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

 Adjuvant examination
- Thorax AP (13/10/2016)
: cor & pulmo in normal limit
- Laboratorium (13/10/2016): Hb (14,1), Ht (43), Eri (5,1), Trombo (243),
Na (141), K (4,2), Cl (103), Ur (18), Cr (0,80)
KGDS ( 89)
Conclusion
Planning
Post Op

: ASA I
: Spinal anasthesia
: Ward

Patient 2
Mr. YM, Men, 30 yo
Weight 75 kg, Height : 160 cm
Diagnose : Avascular Necrotic of Hip joint dextra
Procedure : THR
Anamnesis
- Complaints : hip pain, difficult in walking
- : HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 16 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 100/70 mmHg, HR:72 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

 Adjuvant examination
- Thorax AP (13/10/2016)
: cor & pulmo in normal limit
- Laboratorium (6/10/2016): Hb (10,7), Ht (43), Eri (4,0), Trombo (471),
Na (143), K (4,8), Cl (104), Ur (15), Cr (0,54)
KGDS ( 102)
Conclusion

Planning
Post Op

: ASA II with
Anemia (10,2)
Trombositosis (471.500)
Hipoalbumin (3,09)
: Spinal anasthesia
: Ward

Patient 3
Mr. MR, Men, 29 yo
Weight 74 kg, Height : 169 cm
Diagnose : Malunion fracture of distal radius dextra
Procedure : Recontruction and ORIF
Anamnesis
- Complaints : pain in right hand
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 18x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 120/70 mmHg, HR: 82 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

 Adjuvant examination
- Thorax AP (11/10/2016)
- Laboratorium (13/9/2016)
(9,6)

: cor & pulmo in normal limit

: Hb (16,4), Ht (48), Eri (5,8), Trombo (247), L
Na (144), Cl (102), Ur (20),
Cr (0,90)

Conclusion
Planning
Post Op

: ASA I
: General Anesthesia
: Ward

Patient 4
Mr. TMA , 19 yo
Weight 58 kg, Height : 165 cm
Diagnose
: Ruptore of left ACL
Procedure
: Reconstruction perarthroscopy
complaints
: Pain in left knee
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 17x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 120/80 mmHg, HR: 73 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 13-10-2016) : cor & pulmo in normal limit
Laboratorium 29/192016) : Hb (15,5),ht (46), Eri (5,2), trombosit (279), leukosit
(8,0), Na (147), ur (33) Cr (0,96)
- Conclusion : ASA I
Planning
: Spinal Anesthesia
Post Op
: Ward

Patient 5
Mr. MS , Men, 61 yo
Weight kg, Height : cm
Diagnose
: Negleted dislocation of right hip joint post THR
Procedure
: Revision THR
complaints
: Pain in right hip
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 140/90 mmHg, HR: 64 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 13-10-2016) : Cardiomegaly
Laboratorium 14/10/2016) : Hb (12,3),ht (41), Eri (6,6), trombosit (253), leukosit
(7,7), Na (146), ur (24) Cr (0,76)
- Conclusion : ASA II with hyperglicemia (261) and cardiomegaly
Planning
: Spinal Anesthesia
Post Op
: Ward

Patient 6
Mrs. Z , Women, 67 yo
Weight 67 kg, Height : 150 cm
Diagnose
: OA of left knee joint
Procedure
:Debdidement perarthtroscopy
complaints
: Pain in left knee
- Medical history
: HT (+), DM(+), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 150/100 mmHg, HR: 86 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 13-10-2016) :
Laboratorium 14/10/2016) : Hb (12,3),ht (41), Eri (6,6), trombosit (253), leukosit
(7,7), Na (146), ur (24) Cr (0,76)
Conclusion : ASA II with
controlled DM type 2 (GDS 168) in metformin theraphy
Obese (BMI 37,7)
Planning
: General Anesthesia
Post Op
: Ward

Patient 7
Mr. A , Men, 60 yo
Weight kg, Height : cm
Diagnose
: Negleted fracture of left neck femur + colli tumour
Procedure
: THR
complaints
: Pain in left hip
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (3) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 130/90 mmHg, HR: 88 x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 13-10-2016) : cor & pulmo in normal limit
Laboratorium 14/10/2016) : Hb (12,1),ht (37), Eri (4,5), trombosit (429), leukosit
(10,9), Na (146), Alb (2,66), Total T3 (1,80) FT4 (4,89)
- Conclusion : ASA II with susp malignancy of thyroid tumour, subclinical of
hyperthyroid (Total T3 (1,80) FT4 (4,89) TsHS (0,025))
Planning
: Spinal Anesthesia
Post Op
: Ward

Patient 8
Mr. F , Men, 22 yo
Diagnose
: Negleted postrior dislocation of left hip joint
Procedure
: Bipolsr arthtroplasty
complaints
: shortening of left foot
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 110/70 mmHg, HR: 60x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 11-10-2016) : cor & pulmo in normal limit
Laboratorium 14/10/2016) : Hb (12,1), ht (37), Eri (4,5), trombosit (429), leukosit
(10,9), Na (146), Alb (2,66), Total T3 (1,80) FT4 (4,89)
- Conclusion : ASA I
Planning
: Spinal Anesthesia
Post Op
: Ward

Patient 9
Mr. RH , Men, 68 yo
Diagnose
: infected right knee joint post TKR
Procedure
: Reconstruction of TKR + debridement
complaints
: shortening of left foot
- Medical history
: HT (+), DM(-), Asma (-), Alergic (-) SCI (+)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 140/70 mmHg, HR: 60x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap ( 11-10-2016) : cor & pulmo in normal limit
Laboratorium 11/10/2016) : Hb (12,3), ht (40), Eri (5,0), trombosit (342), leukosit
(10,5), Na (146), Na (143), K (4,8), Cl (104)
- Conclusion : ASA III with HHD with captopril 12,5 mg theraphy, ECG with
Patologic Q in lead V1-V3, hypokinetic echo, mild MR, elevated creatinin (1,19),
balloning chateter in 2009
Planning
: Spinal Anesthesia
Post Op
: ICU

Patient 10
Mr. IA , Men, 47 yo
Diagnose
: OMC of right cruris post external fixation
Procedure
: Debridemet
complaints
: shortening of left foot
- Medical history
: HT (-), DM(-), Asma (-), Alergic (-)

Physical examination
Airway
: Malampati (1) , denture (-) , obstruction (-), neck : normal
Breathing
: RR 18x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 120/70 mmHg, HR: 73x/minute, cor: BJ 1 > BJ 2
Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm

Adjuvant examination
Thorax ap : cor & pulmo in normal limit
Laboratorium 13/10/2016) : Hb (12,2), Ht 37), Eri (4,1), trombosit (440), leukosit
(7,4), Na (141), K (4,0), Cl (102)
- Conclusion : ASA II with anemia (12,2)
Planning
: Spinal Anesthesia
Post Op
: Ward

Thankyou