Morning Report

Friday, April 5th 2024

 OR Kanigara 5-9 Thorax
dr. Aries Perdana, Sp. An-TI, Subsp. AKV (K) / Habel - Daniel - Rafli - Igna
1. 57 Y / F / 4670468
Diagnosis : Chronic kidney disease on hemodialysis with temporary catheter double lumen in right femoral

Procedure : Right intra jugular vein tunneling catheter double lumen insertion, left arteriovenous shunt below conus medullaris, removal of
right femoral catheter double lumen.
Status : ASA 3
Coronary artery disease 3 vessel disease post percutaneous coronary intervention with plain old balloon angioplasties to right
coronary artery 02/01/24, post percutaneous coronary intervention to RCA and LAD (15/02/24), without dyspnea/chest
pain, BP 111/63 mmHg HR 82 x/minute, FC 2 METS > 4 SpO2 97%, ECG 22/2/24: Sinus rhythm, HR 82x/minute regular,
normoaxis, p wave normal, QRS 0.09sec, T inverted II, III, aVF, echo January 2024: Segmental hypokinetic, concentric LVH,
decreased LV systolic function, increased LV filling pressure, normal RV systolic function, MR mild-moderate (Carpentier type
IIIb, restricted PML motion), TR PR mild, EF 44%, TAPSE 20 mm, On Aspilet 1 x 80 mg PO, Clopidogrel 1 x75 mg PO --> stop
27/3/24, Atorvastatin 1 x 40 mg PO, Carvedilol 2x3,125 mg PO, Candesartan 1x8 mg PO.
Chronic kidney disease on hemodialysis (Tuesday-Thursday), without signs of fluid overload, last hemodilaysis on Tuesday
2/4/2024 with right femoral catheter double lumen, Ureum 21.4 Creatinine 1.3 Potassium 2.9, on Calcium Carbonate 3x500
mg PO, Folic acid 1x1 mg PO
type 2 diabetes mellitus, clinically stable, RBG 104, Hba1c 6.8, on Insulin Aspart 3 x 5 U, Insulin Glargline 1 x 12 U
• Without airway difficulty

Plan : Sedation

Post-op : PACU
 OR Kanigara 6-1 Neurosurgery
Dr. dr. Riyadh Firdaus, Sp. An-TI, Subsp. NA (K) / Hansen - Tomo - Albert - Jevon
2. 61 Y / M / 4721802
Diagnosis : Tetraparesis due to Spinal Cord Injury ASIA C as high as C6-C7

Procedure : C2-C3-C4-T1-T2 Stabilization

Status : ASA 3
Tetraparesis upper motor neuron due to spinal cord injury as high as C6-C7, fully awake with tetraparesis, with decreased
cough function with abdominal breathing impression, CT of cerviothoracic vertebrae (3/4/24): spondyloptosis of C6 to C7
with bilateral C6-7 pars interarticularis fractures compressing the spinal cord with suspected spinal intracanal hemorrhage
spot at that level, comminuted fracture of C6 vertebral spinous process and fracture of right transverse processus with
surrounding fracture fragments and complete fracture of left transverse processus with fracture fragments relatively in line,
on Methylprednisolone 3x125mg IV (RBG 126 mg/dl), fosfomycin 1x2g IV
Left pleural effusion with possible post-traumatic atelectasis, clinical with dyspnea. RR 28, Spo2 98 on NRM 10 lpm. Lung
sounds decreased on the left side and right basal, without ronchi/wheezing. Pre trauma CXR: normal, post trauma left
pleural effusion with possible left lung atelectasis.
Hyponatremia 131
Elevated transaminase enzymes, without jaundice, AST/ALT 66/60
Geriatric 61 years old, FS 1 (before trauma)
• Possibility of difficult intubation due to cervical trauma

Plan : GA - Scalp block - CVC - ABP

Post-op : ICU
 OR Kanigara 6-4 Digestive
dr. Christopher Kapuangan, Sp. An-TI, Subsp. AP (K) / Ines - Eci - Wawan
1. 82 Y / M / 4754972
Diagnosis : Anorectal mucinous adenocarcinoma cT4N1M0

Procedure : Laparoscopic Abdominoperineal resection-total mesorectal excision

Status : ASA 2
Anorectal mucinous adenocarcinoma cT4N1M1, clinically with bloody and purulent defecation and anal lump,
without abdominal distension, anal pain VAS 4-5, CT whole abdomen with contrast (06/11/23): Asymmetric
irregular circumferential focal thickening suggestive of malignant characteristic mass in rectal wall of 8 cm in
length with a maximum thickness of about 2 cm, up to anorectal junction with extension into anal canal of 2.1
cm up to the anal verge thus narrowing anorectal and rectal lumen, without chemo/radiation, Echo 15/12/23:
Poor echo window; emphysematous, heart chamber dimensions not dilated, LV wall concentric remodeling,
global normokinetics, heart valves within normal limits, LV systolic and diastolic function are normal; EF 60%;
biplane, good RV systolic function, without thrombus and pericardial effusion visualized, without therapy.
Geriatric, 81 years old, frailty score 5, mildly frail
• Possibility of difficult airway due to edentulous

Plan : GA - CVC

Post-op : PACU
 OR Kiara Pediatric
dr. Raihanita Zahra, Sp.An-TI / Prima - Sasti - Tiwi - Dara
1. Baby Girl 3 D / BW 2.5 kg / 4782867
Diagnosis : Duodenal atresia, suspected Down syndrome, suspected congenital heart disease

Procedure : Laparotomy exploration up to duodeno-duodenostomy

Status : ASA 3
Full Term neonate, adequate gestational age 37 weeks, post conceptual age 37 weeks, birth weight 2535 grams,
current BW 2535 grams, suspected Down syndrome, without genetical confirmation, suspected duodenal
atresia, clinically active, without abdominal distension, without history of aspiration, without retraction, RR
40-50 x/minute, SpO2 92-98% on room air, HR 143-158 x/min without oxygen supplementation, diuresis 1.6
ml/kg/hour, Echo (21/2/24): Small patent ductuis arteriosus, small secundum atrial septum defect, Mild
persistent pulmonary hypertension of newborn, AP Abdomen (22/02/2024): duodenal stenosis, currently non
compliance per nil os and attached orogastric tube with blackish production when aspirated, Aptt lengthening
1.8x (on FFP transfusion), on Ampicillin 3x125mg E2, Gentamycin 1x7.5 mg E2.
• Possibility of difficult airway cannot be ruled out

Plan : GA - Caudal - PICC (already inserted)

Post-op : NICU