MORNING REPORT

Operating Theatre Hybrid

Wednesday, March 8, 2017
dr. Azwar Risyad, Sp.An
 Patient
Patient 2
1
AH, male, 46 years old, Weight: 48kg , Height:165 cm
Diagnose : Effusive pericard
Procedure : Prepericardial window

Anamnesis
Complaints : chest pain
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 24 x/minute, Ves (+/+) Rh (-/-) Wh (-/-), pericardial friction rub
(+)
Circulation : HR: 120 x/minute, BP: 100/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-), small (+)
 Adjuvant examination
CT Scan Thorax (21/2/2017): solid mass at mediastinum anterior, medius,
posterior, lobulated mengencasment vena cava superior, effusive left pleura,
fibrosis at left and right arm, effusive pericard, sclerotic VTH 2 and 10 susp
metastase to pulmo
EKG (27/2/2017) :sinus rhytme, 98 bpm, low viltage
Echocardiografi (27/2/2017): effusive pericard massive, without tamponades
signs
Lab (26/2/2017) : Hb (11,6), Ht (36), Eri (4,0), Leu (13,1), Trom (158),
ur/cr/as.urat (54/0,6/5,8), Na/K/Cl/Ca (136/4,2/103/102), SGOT/SGPT (50/38),
Protein total/direct/indirect (0,55/0,24/0,31), Albumin (3,74), kolesterol
total/HDL/LDL/TG (165/24/97/112), BT/CT (3/8)

Conclusion : ASA III with tumor mediastinum, anemia (11,6), leukositosis (13,1)
Planning : General Anestethic
Post Op : ICU with ventilator
 Patient
2
IS, male, 42 years old, Weight: 55 kg , Height:160 cm
Diagnose : Aneurisma Vena Cephalica Post AV Shunt
Procedure : Repair aneurisma

Anamnesis
Complaints : swelling in the left arm
Medical history : DM (-), HT (+), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 22 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:88 x/minute, BP: 170/100 mmHg, cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (20/2/2017) : cardiomegaly with lung congestive, TB lungs, minimal
effusive right and left pleura
EKG (1/3/2017) : normal sinus rhytme< LVH
Lab (31/1/2017) : Hb (12,2), Ht (36), Eri (4,6), Leu (2,7), Trom (111), ur/cr
(116/12,38), KGDS (103), Na/K/Cl (140/49/108) BT/CT (2/7)

Conclusion : ASA III with CKD stage V on HD regular, hypertension controlled,

TB lungs (15 years ago), cardiomegaly
Planning : Generat Anesthetic
Post Op : ICU
Thank You
 MORNING REPORT
Operating Theatre 2
Wednesday, Maret, 8 , 2017
dr. Azwar Risyad, Sp. An
 Patient
1
IB, female, 22 years old, Weight : 40 kg , Height: 150 cm
Diagnose : Susp Teratoma
Procedure : Laparotomy

Anamnesis
Complaints : abdominal pain and bloating
Medical history : DM(-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing : RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR 88x/minute, BP 120/90 mmHg
Brain : E4M6V5=15, parese (-), pupil isokor
 Adjuvant examination
Rontgen (2/3/17) : cor and pulmo in normal condition
USG (2/3/17) : susp immature teratoma
Lab (2/3/17) : Hb (12,0), Ht (38), Eri (4,8), Leu (7,1), Trom
(448), CT/BT (8/3), Ur/Cr (20/0,83), KGDS (124), Na (142), K (3,9), Cl (106),
SGOT/SGPT (25/16), Alb(4,15), Ca125 (10,03), AFP (0,50), HbsAg (-)

Conclusion : ASA II with

- Underweight

Planning : Epidural Anestethic

Post Op : Ward
Rontgen
 Patient
2
E, female, 25 years old, Weight : 55 kg , Height: 155 cm
Diagnose : Ovarian tumor
Procedure : Debulking tumor

Anamnesis
Complaints : left abdominal pain
Medical history : DM(-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (1) , obstruction (-)
Breathing : RR 18 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR 86x/minute, BP 90/60 mmHg
Brain : E4M6V5=15, parese (-), pupil isokor
 Adjuvant examination
Rontgen (17/02/17) : cor and pulmo in normal condition
Lab : Hb (12,3), Ht (39), Eri (4,8), Leu (6,3), Trom
(339), CT/BT (7/2), Ur/Cr (16/0,62), Na (143), K (3,5), Cl (111), Alb(4,43),
KGDS(114)

Conclusion : ASA II with

- Hypercloremia (111)
- Hypokalemia (3,5)

Planning : General Anestethic

Post Op : Ward
Rontgen
 Patient
3
S, female, 38 years old, Weight: 80 kg , Height: 139 cm
Diagnose : ILO post SC
Procedure : Secondary hecting

Anamnesis
Complaints : pain in the scar
Medical history : DM(+), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing : RR 16 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR 58x/minute, BP 140/90 mmHg
Brain : E4M6V5=15, parese (-), pupil isokor
 Adjuvant examination
Rontgen (6/03/17) : cor and pulmo in normal condition
Lab : Hb (12,9), Ht (42), Eri (5,6), Leu (9,7), CT/BT (7/2),
Trom(585), KGDS(231), Na(141), K(4,0), Cl(104)

Conclusion : ASA II with

- Obesity
- DM type 2 uncontroll (HbA1c 7,5)

Planning : Spinal Anestethic

Post Op : Ward
Rontgen
 Patient
4
N, female, 41 years old, Weight: 65 kg , Height: 160 cm
Diagnose : Neoplasma Ovarian Cyst Malignant
Procedure : Debulking tumor

Anamnesis
Complaints : lower abdominal pain
Medical history : DM(-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing : RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR 84x/minute, BP 120/80 mmHg
Brain : E4M6V5=15, parese (-), pupil isokor
 Adjuvant examination
Rontgen : cor and pulmo in normal condition
Lab : Hb (8,8), Ht (2), Eri (4,3), Leu (6,4), Trom (283), CT/BT(7/2),
Ur/Cr (39/0,94), Na (141), K (3,7), Cl (110), KGDS (98)

ECG :
Echo : LVH (-), EV 81%, globalnormokinetic, diastolic function well,
medium risk

Conclusion : ASA II with

- anemia (8,8)
- hypercloremia

Planning : General Anestethic

Post Op : Ward
ECG
Echo
 Patient
5
SZ , female, 65 years old, Weight: 70 kg , Height: 160 cm
Diagnose : Neoplasma Ovarian Cyst Malignant
Procedure : Debulking tumor

Anamnesis
Complaints : lower abdominal pain
Medical history : DM(-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing : RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR 72x/minute, BP 130/70 mmHg
Brain : E4M6V5=15, parese (-), pupil isokor
 Adjuvant examination
Rontgen : cor and pulmo in normal condition
Lab : Hb (12,5), Ht (40), Eri (5,1), Leu (18,9), Trom (372),
CT/BT(7/2), Ur/Cr (39/0,94), Na (142), K (4,0), Cl (108), KGDS (138), Alb
(4,48), Ca125(63,00)

ECG : Sinus rhythm, HR 86 bpm, RBBB incomplete, ischemic

anterior wall

Conclusion : ASA II with

- geriatry
- leukocytosis (18,9)
- RBBB incomplete
- ischemic anterior wall

Planning : General Anestethic

Post Op : Ward
Rontgen
ECG
Echo
 MORNING REPORT
Operating Theatre 3
Wednesday, March , 8, 2017
Dr.dr. Zafrullah Khany Jasa, Sp. An.
 Patient
1
H ,female, 53 years old, Weight : 60 kg , Height: 157 cm
Diagnose : Carcinoma mammae (D) susp. malignancy
Procedure : Biopsy insicion + VC + MRM + TRAM
Anamnesis
Complaints : Lump at the right breast
Medical history : DM(-), HT (-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 19 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 100/70 mmHg, cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Lab (01/03/2017) : Hb (12,9), Ht (39), Eri (4,5), Leu (9,8), Trom
(321), ur/cr (22/0,64), GDS (128)
Rontgen (26/02/2017) : Cor and Pulmo normal limit
ECG (06/03/2017) : CAD OMI Inferior

Conclusion : ASA III with

- OMI inferior

Planning : General Anestethic

Post Op : ward
THORAX
ECG
 Patient
Patient 2
2
Z, female, 30 years old, Weight: 91 kg , Height : 151 cm
Diagnose : Adenomatous Goter
Procedure : Ismulobectomy

Anamnesis
Complaints : Lump at the neck
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (22/02/2017) : Cor and pulmo normal limit

Lab (23/2/2017) : Hb (13,5), Ht (40), Eri (5,0), Leu (8,9), Trom

(314), ur/cr (14/0,44), Na/K/Cl (142/3,5/106),
T3/T4/TSH (1,57/13,21/1,032), GDS (162)

Conclusion : ASA II with

Obesity grade II (40,71) morbid

Planning : General Anestethic

Post Op : ward
THORAX
ECG
 Patient
Patient 2
3
R, female, 18 years old, Weight: 43 kg , Height : 156 cm
Diagnose : Carcinoma mammae (D) susp. benign
Procedure : Excision

Anamnesis
Complaints : Lump at the right breast
Medical history : HT (-), DM (-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:88x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (27/02/2017) : Cor and pulmo normal limit

Lab (27/2/2017) : Hb (13,3), Ht (39), Eri (4,6), Leu (6,4), Trom

(182), ur/cr (17/0,5), GDS (90)

Conclusion : ASA I
Planning : General Anestethic
Post Op : ward
THORAX
 Patient
Patient 2
4
S, female, 38 years old, Weight: 96 kg , Height : 157 cm
Diagnose : Carcinoma mammae susp. malignancy
Procedure : Excision bilateral

Anamnesis
Complaints : Lump at the left and right breast
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR19x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:75x/minute, BP: 100/60mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (22/02/2017) : Cor and pulmo normal limit

Lab (10/2/2017) : Hb (14,2), Ht (44), Eri (5,2), Leu (9,2), Trom

(220), ur/cr (20/0,62), GDS (108)

Conclusion : ASA II with

Obesity grade II (36,7)

Planning : General Anestethic

Post Op : ward
THORAX
Terima kasih
 MORNING REPORT
Operating Theatre 4
Wednesday, March , 8, 2017
Dr.dr. Zafrullah Khany Jasa, Sp. An.KNA
 Patient
1
S,female, 54 years old, Weight : 85 kg , Height: 160cm
Diagnose : Cholelitiasis
Procedure : Cholecistectomy perlaparoscopy

Anamnesis
Complaints : gastric pain thourgh chest
Medical history : DM(+) (10 years), HT (+), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 18 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:76x/minute, BP: 130/70 mmHg, cor: BJ 1 > BJ 2, regular,
systolic murmur (-)
 Adjuvant examination
Rontgen (14/2/2017) : cardiomegaly, pneumonia, pleura effusion.
Lab (14/2/2017) : Hb (11,6), Ht (35), Eri (4,3), Leu (5,9), Trom
(168), ur/cr (39/1,55), KGDP : 153
Conclusion : ASA II with
- obessity BMI (33,2)
- OMI inferior
- Controlled DM type 2
- Anemia (11,6)
Planning : general anhestasia
Post Op : ward
Rontgen 24/2/2017
ECG 28/2/2017
 Patient
Patient 2
2
S, male, 41 years old, Weight : 75 kg , Height : 165 cm
Diagnose : cholelithiasis
Procedure : cholesistectomy perlaporoscopy with prepation of open operation

Anamnesis
Complaints : abdominal pain on upper right
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 19 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:76x/minute, BP: 110/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (27/2/2017) : Cor and pulmonal in normal condition
Lab (20/2/2017) : Hb (17,2), Ht (51), Eri (6,2), Leu (14,3), Trom (221), ur/cr
(33/1,03), Na/K/Cl (143/3,5/106).
ECG : normal ecg

Conclusion : ASA II
- active smoker
- polisitemia (17,2)
-leukocytosis(14,3)
- hypokalemia (3,5)

Planning : General Anestethic

Post Op : ward
Rontgen 27/2/2017
ECG 2/3/2017
 Patient
Patient 2
3
S, female, 43 years old, Weight : 63 kg , Height : 160 cm
Diagnose : cholelithiasis
Procedure : cholesistectomy perlaporoscopy

Anamnesis
Complaints : abdominal pain on upper right
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (3) , denture (-) , obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (2/3/2017) : Cor and pulmo in normal condition
EKG (2/3/2017) : Sinus rithme
Lab (19/2/2017) : Hb (12,9), Ht (39), Eri (4,75), Leu (5,8), Trom
(245.000), ur/cr (22/0,66), KGDS (93)

Conclusion : - ASA II with

- Anemia (12,4)
- possibility of difficult intubation

Planning : General Anestethic

Post Op : ward
Rontgen 2/3/2017
ECG 2/3/2017
Terima kasih
 MORNING REPORT
Operating Theatre 5
Wednesday, march , 08, 2017
dr. Zafrullah, Sp. An
 Patient
1
BM, male, 5 days, Weight : 3400 g , Height: 55 cm
Diagnose : hydrocephalus + Myolocel
Procedure : VP Shunt

Anamnesis
Complaints : large head circumference
Medical history : DM(-) , HT (-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 38 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR: 115x/minute, cor: BJ 1 > BJ 2, regular, murmur(-)
 Adjuvant examination
Rontgen (6/3/2017) : cor and pulmo in normal condition
Lab (8/11/2016) : Hb (17,3), Ht (49), Eri (5,7), Leu (10,5), Trom
(347), ur/cr (28/0,50), KGDS 86.
Conclusion : ASA III with
- Congenital heart disease with Echocardiography: PFO (+) with
clinical manifestation: Cyanotik (-), murmur (-)
- Hydrocephalus non communicans

Planning : General Anestethic

Post Op : NICU with Ventilator
Foto Thorax
CT-Scan
 Patient
Patient 2
2
S, female, 52 years old, Weight : 55 kg , Height : 150 cm
Diagnose : Osteosarcoma a.r Fronto parietal
Procedure : Removal tumor

Anamnesis
Complaints :chronic headache since 1 year ago
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:82x/minute, BP: 110/70mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (28/2/2017) : Cor and pulmonal in normal condition
EKG (16/2/2017) : Sinus Rhytm, 79 bpm, RAD (+), RBBB (+)
Lab (7/11/2016) : Hb (13,3), Ht (41), Eri (4,8), Leu (9,3), Trom (343.000),
ur/cr (25/0,67), Na/K/Cl (144/4,1/107).

Conclusion : ASA III with

- Hemiparese sinsitra

Planning : General Anestethic

Post Op : ICU
Foto Thorax
EKG
CT-Scan
USG
 Patient
Patient 2
3
P, male, 48 years old, Weight : 75 kg , Height : 165 cm
Diagnose : Asrocytoma grade IV
Procedure : Craniotomy removal tumor bifrontal

Anamnesis
Complaints : decrease consciousness
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (+) , obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:75x/minute, BP: 130/70mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen : Cor and pulmo in normal condition
EKG : Sinus rhytme
Lab (7/11/2016) : Hb (13,6), Ht (41), Eri (4,9), Leu (16,4), Trom
(441.000), ur/cr (43/0,88), KGDS (148)

Conclusion : - ASA III with

- decrease consciousness
- Leukositosis (16,4)

Planning : General Anestethic

Post Op : ICU
 Patient
Patient 2
3
R, Female, 57 years old, Weight : 50 kg , Height : 160 cm
Diagnose : Skull defect a.r temporoparietal
Procedure : Cranioplasty

Anamnesis
Complaints : patient with Subdural hematoma history after accident, and patient
scheduled to cranioplasty
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (+) , obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:75x/minute, BP: 110/70mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen : Cor and pulmo in normal condition
EKG : Sinus rhytme
Lab (7/11/2016) : Hb (11,6), Ht (36), Eri (4,6), Leu (6,2), Trom
(276.000), ur/cr (28/0,44), KGDS (93)

Conclusion : - ASA III with

Anemia (11,6)

Planning : General Anestethic

Post Op : ward
Foto Thorax
EKG
Terima kasih
 MORNING REPORT
Operating Theatre 7
Wednesday, march 08 th, 2017

Dr. dr. Mujahidin, Sp. An - KNA

 Patient
1
Z, male, 58 years old, Weight : 60 kg , Height: 162 cm
Diagnose : CKD stage V e.c Obstructive uropathy e.c renal stone bilateral
Procedure :RPG Bilateral + DJ stant dextra + nephrolithiasis sinistra

Anamnesis
Complaints :dizzy
Medical history : DM(-), HT (+), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 100/90 mmHg, cor: BJ 1 > BJ 2, irregular,
murmur(+)
 Adjuvant examination
Rontgen (27/02/2017) : cardiomegali
Lab (06/03/2017) : Hb (9,4), Ht (27), Eri (3,3), Leu (11,9), Trom
(168), ur/cr (100/4,2), KGDS 270,
BT/CT : 2/7

Conclusion : ASA IV with CKD stage 5 and MR severe

Planning : general Anestethic
Post Op : ICU
Thorax Ro (27/02)
EKG
echo
 Patient
Patient 2
2
AM, female, 45 years old, Weight :40 kg , Height : 140 cm
Diagnose :infected CAPD + CKD stage 5
Procedure :repair CAPD

Anamnesis
Complaints : crowded
Medical history : HT (+), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 24 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:88x/minute, BP: 140/90mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (07/01/2017) : cardiomegali and pneumonia
Lab (17/02/2017) : Hb (9,1), Ht (28), Eri (3,3), Leu (5,6), Trom
(297.000), ur/cr (73/3,40), KGDS (119)
Na/K/Cl (142/3,1/107),

Conclusion : - ASA III with

- CKD stage 5
- HHD

Planning : General Anestethic

Post Op : Ward
Thorax Ro(/02)
ECG (17/02)
 Patient
Patient 2
3
H, male, 24 years old, Weight : 70 kg , Height : 160 cm
Diagnose :avulsi gingiva +fr. dentoalveolar
Procedure :debridement dan hecting

Anamnesis
Complaints : vulnus laceratum a.r upper gum maxilaris anterior
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (II) , denture (-) , obstruction (-)
Breathing: RR 21 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:76x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Lab (16/03/2017) : Hb (15,6), Ht (48), Eri (6,2), Leu (11,9), Trom
(291.000), ur/cr (24/0,80), KGDS (107)
Na/K/Cl (145/4,2/113.

Conclusion : - ASA I

Planning : General Anestethic

Post Op : Ward
 Patient
Patient 2
4
N, female, 58 years old, Weight : 63 kg , Height : 160 cm
Diagnose :ulcus diabeticum a.r pedis sinistra + necrotic digiti
Procedure :debridement dan amputasi

Anamnesis
Complaints :necrotic foot
Medical history : DM (+), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (I) , denture (-) , obstruction (-)
Breathing: RR 24 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:79x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Lab (02/03/2017) : Hb (10,7), Ht (31), Eri (4,2), Leu (15,6), Trom
(587.000), ur/cr (18/0,60), KGDS (130)
Na/K/Cl (129/3,2/96).

Conclusion : - ASA III with DM type II, Hypoalbumin, trombositosis

Planning : spinal Anestethic

Post Op : Ward
EKG
 Patient
Patient 2
3
MU, male, 52 years old, Weight : 48 kg , Height : 163 cm
Diagnose :death limb cruris dextra
Procedure :debridement and amputated

Anamnesis
Complaints :necrotic foot
Medical history : DM (-), HT(+), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (I) , denture (-) , obstruction (-)
Breathing: RR 21 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 110/70mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Lab (06/03/2017) : Hb (11,1), Ht (32), Eri (4,1), Leu (7,2), Trom
(96.000), KGDS (203)

Conclusion : - ASA III with DM type II, anemia, thrombositopenia, and

hypoalbumin

Planning : Spinal Anestethic

Post Op : Ward
rontgen
rontgen
EKG
 Patient
Patient 2
6
An, male, 56 years old, Weight : kg , Height : 160 cm
Diagnose :PAD e.c occlution. Tibialis posterior arthery and ischemic digiti 4,5
dextra
Procedure :amputated

Anamnesis
Complaints :necrotic digiti 4,5
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (I) , denture (-) , obstruction (-)
Breathing: RR 21 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:80x/minute, BP: 120/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
EKG : 11/02/17 : tachycardia, LVH
Lab (16/03/2017) : Hb (10,7), Ht (32), Eri (3,9), Leu (12,2), Trom
(234.000), Na/K/Cl (131/5,0/101.

Conclusion : - ASA III

with uncontrolled hypertention, DM type II, leukositosis (12,2),
cardiomegaly, pneumonia
Planning : spinal Anestethic
Post Op : Ward
EKG
Rontgen
 MORNING REPORT
Operating Theatre 8
Wednesday, March , 08, 2017
dr. Mujahiddin, Sp. An
 Patient
1
H, male, 2 years old, Weight : 10 kg , Height:
Diagnose : CTEV dextra
Procedure : Postero medial release

Anamnesis
Complaints : deformity of ankle dextra
Medical history : Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , obstruction (-)
Breathing: RR 32 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:110 x/minute, cor: BJ 1 > BJ 2, regular, murmur(-)
 Adjuvant examination
Rontgen (20/2/2017) : cor and pulmonal in normal condition
Lab (8/11/2016) : Hb (10,3), Ht (31), Eri (4,5), Leu (7,5), Trom
(384), ur/cr (12/0,4)
Conclusion : ASA II with
- Anemia (10,3)

Planning : General Anestethic

Post Op : ward
 Patient
Patient 2
2
M, male, 30 years old, Weight : 45 kg
Diagnose : Burst Fr. L1
Procedure : Stabilition posterior + decompresi posterior

Anamnesis
Complaints : pain a.r lumbal
Medical history : HT (-), DM(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1) , obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:82x/minute, BP: 110/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (30/1/2017) : Cor and pulmonal in normal condition
Lab (3/3/2017) : Hb (17,0), Ht (49), Eri (5,5), Trom (219.000), ur/cr
(27/0,86), Na/K/Cl (143/4,4/105), KGDS (97)
MRI : MRI : disc bulging to posterolateral

Conclusion : ASA I

Planning : General Anestethic

Post Op : ward
MRI
Foto thoraks
 Patient
Patient 2
3
S, female, 60 years old, Weight : 63 kg
Diagnose : spondilolitiasis L4-L5
Procedure : Stabilition posterior + decompresi posterior

Anamnesis
Complaints : pain a.r lumbal
Medical history : DM (-), HT(+), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1), obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:90 x/minute, BP: 140/80mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (27/2/2017) : Cor and pulmo in normal condition
EKG 6/3/17 : Normal EKG :
Lab (21/2/2017) : Hb (13,0), Ht (39), Eri (5,2), Leu (6,8), Trom
(228), ur/cr (33/0.6), KGDS (58)

Conclusion : - ASA II with

- Hypertension grade 2

Planning : General Anestethic

Post Op : ward
EKG
 Patient
Patient 2
4
S, female, 53 years old, Weight : 45 kg
Diagnose : close fr clavicula dextra + close fr femur sinistra
Procedure : ORIF

Anamnesis
Complaints : pain ar femur sinistra
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1), obstruction (-)
Breathing: RR 19 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:76 x/minute, BP: 130/70mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (30/1/2017) : fr ar os clavicula 1/3 tengah sinistra
fr os femur 1/3 tengah dextra
Lab (1/3/2017) : Hb (12,7), Ht (38), Eri (4,3), Leu (7,8), Trom
(212), ur/cr (38/0,50), KGDS (116)
EKG (2/3/2017) : Normal EKG

Conclusion : - ASA I

Planning : General Anestethic

Post Op : ward
 Patient
Patient 2
5
S, male, 50 years old, Weight : 70 kg, Height : 170 cm
Diagnose : close fr clavicula 1/3 medial sinistra + close fr costae II-III posterior
dextra + CKR
Procedure : ORIF

Anamnesis
Complaints : pain ar shoulder
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1), obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:61 x/minute, BP: 100/60 mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (3/3/2017) : fr costae II-III posterior hemithorax dextra
fr clavicula 1/3 medial sinistra
Lab (2/3/2017) : Hb (13,0), Ht (37,7), Eri (4,5), Leu (9,6), Trom
(196), KGDS (114)
EKG (4/3/2017) : sinus bradikardi

Conclusion : - ASA II with history decrease of conciousness

Planning : General Anestethic

Post Op : ward
 Patient
Patient 2
6
H, female, 60 years old, Weight : 60 kg, Height : 160 cm
Diagnose : Neglected close fr radius ulna
Procedure : ORIF

Anamnesis
Complaints : limited movement a.r wrist sinistra
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1), obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:86 x/minute, BP: 160/100 mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Rontgen (27/2/2017) : cor and pulmonal in normal condition
Lab (27/2/2017) : Hb (13,0), Ht (42), Eri (5,4), Leu (7,1), Trom
(316), KGDS (147)
EKG : sius rhythm, ST elevasi, LVH (+)

Conclusion : - ASA II with

uncontrol HHD
LVH (+)

Planning : General Anestethic

Post Op : ward
 Patient
Patient 2
7
T, male, 55 years old, Weight : 70 kg, Height : 168 cm
Diagnose : infected wound a.r femur dextra + fr zygoma dextra
Procedure : debridement

Anamnesis
Complaints : open wound ar femur
Medical history : DM (-), HT(-), Asthma (-), Alergic (-)
Physical examination
Airway : Clear , Mallampati (1), obstruction (-)
Breathing: RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR:100 x/minute, BP: 100/60 mmHg cor: BJ 1 > BJ 2, regular,
murmur(-)
 Adjuvant examination
Lab (2/3/2017) : Hb (9,8), Ht (29), Eri (3,6), Leu (463), Trom
(25,2), Leu (46,3), Na/K/Cl (115/4,9/89) KGDS
(133)

Conclusion : - ASA II with

Anemia (9,8)
Leukositosis (25,2)

Planning : General Anestethic

Post Op : ward
Terima kasih