The morning report discusses the anesthesia plans for scheduled surgical procedures on April 26, 2023. Several gynecological surgeries are scheduled including laparoscopic procedures, hysterectomies, and myomectomies. The patients' medical histories, anesthesia risks, and planned anesthesia techniques are summarized for each case. Spinal or general anesthesia is planned according to the specific procedures and patients' risk factors. Post-operative care locations are also noted.
1. MORNING REPORT
PROGRAM STUDI ANESTESIOLOGI DAN
TERAPI INTENSIF
26 April 2023
PEMBIMBING dr. Fachrul Jamal, SpAn-TI, Subsp. TI(K)
dr. Teuku Yasir, SpAn-TI, Subsp. TI(K)
Dr. dr. Zafrullah Khany Jasa, SpAn-TI, Subsp. NA(K)
dr. Muhammad Iqbal, SpAn-TI
Chief Of Chief Aoelia
Chief Kamar Operasi …….
Chief Critical Care ……..
Chief Poliklinik/Ambulatory …….
Chief Emergency/METS ………
2.
3. OKA X (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-TI
1 Rencana Anestesi
4. )
OK X (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr Muqsith/Faqih On Duty : dr. Muqsith/ Wira
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
1 N, Pr, 51 Th
Adenocarsinoma
Endometrium
Laparotomi surgical staging
dr. Munizar, SpOG
II
General Anestesi
-Epidural
HCU
5. )
OK X (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr Muqsith/Faqih On Duty : dr. Muqsith/ Wira
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
1 N, Pr, 51 Th
Adenocarsinoma
Endometrium
Laparotomi surgical
staging
dr. Munizar, SpOG
ASA II
- Hipertensi stage I, TD 147/90 mmHg,
METs 5, klinis: Nyeri dada (-), berdebar
(-), mudah lelah (-), murmur(-), gallop(-
), EKG: SR, HR 77 bpm, Normoaxis, CXR
: cardiomegali (-), Th/-
- Obese grade I, BMI 32,5 kg/m2, STOP
BANG score 2, low risk of OSA
General
Anestesi
-Epidural
HCU
7. OKA XI (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-TI
3 Rencana Anestesi
8. )
OK XI (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr. Muqsith/Audi On Duty : dr. Audi
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
1 J, Pr, 22 Th
Kista Endometriosis + Infertil
Primer 2 tahun
Laparoscopy diagnostic +
Kistektomi
dr. Hilwah Nora SpOG (K)
II General Anestesi Ruangan
2 H, Pr, 63 Th
Prolaps Uteri Grade II,
Sistokel Grade II, Rectokel
Grade III
TVH SSF, Kolporafi anterior,
kolpoperineorafi
dr. Roziana, SpOG
II Spinal Anestesi Ruangan
3 HY, Pr, 52 Th
Mioma Uteri Intramural uk
4x5 cm
Laparotomy Miomektomi
dr. Hasanudin, SpOG (K)
II Spinal Anestesi Ruangan
9. )
OK XI (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr.Muqsith/Audi On Duty : dr. Audi
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
1 J, Pr, 22 Th
Kista
Endometriosis +
Infertil Primer 2
tahun
Laparoscopy
diagnostic +
Kistektomi
dr. Hilwah Nora
SpOG (K)
ASA II
- Obese Class 1, BMI 30,8 kg/m2,
STOPBANG score 1 Low risk of OSA
- Leukositosis 12.300/mm3
General
Anestesi
Ruangan
10. )
OK XI (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr. Muqsith/Audi On Duty : dr. Audi
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
2 H, Pr, 63 Th
Prolaps Uteri
Grade II, Sistokel
Grade II, Rectokel
Grade III
TVH SSF, Kolporafi
anterior,
kolpoperineorafi
dr. Roziana, SpOG
ASA II
- Hipertensi stage 1, TD 142/79
mmHg, METs 5, klinis nyeri dada (-),
sesak nafas (-), mudah lelah (-),
murmur (-), gallop (-), EKG: Sinus
rythm qrs rate 83 bpm normoaxis,
CXR: Cardiomegali (-), th/-
- Geriatri usia 63 tahun, frailty scale 3
Saran:
- Pertahankan TD < 150/90 mmHg
Spinal
Anestesi
Ruangan
12. )
OK XI (Bedah Obgyn)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr. Muqsith/Audi On Duty : dr. Audi
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
3 HY, Pr, 52 Th
Mioma Uteri
Intramural uk 4x5
cm
Laparotomy
Miomektomi
dr. Hasanudin,
SpOG (K)
ASA II
- DM Tipe 2, GDS 193 mg/dL, Th/
Metformin 1x500 mg, Gliclazide 1x60 mg
- Obese Class 1, BMI 34,2 kg/m2,
STOPBANG score 1, Low risk of OSA
Saran:
- Pertahankan GDS < 200 mg/dL
Spinal
Anestesi
Ruangan
13. OKA XII (Bedah Saraf)
DPJP: dr. Yusmalinda, SpAn-TI
2 Rencana Anestesi
14. )
OK XI (Bedah Saraf)
DPJP: dr. Yusmalinda, SpAn-Ti
Pre op: dr. Dede On Duty :
No Nama Diagnosa Prosedur ASA Tatalaksana
Post
Op
1
SI, Pr, 10 Bl n
BB 7,5 KG
Malfungsi Shunt
Repair Shunt
dr. Iskandar, SpBS
Pasien sudah
dilakukan operasi 12
April 2023
2 N, Pr, 42 Th
Meningioma ar temporal
base
Craniotomy removal tumor
dr. Iskandar, SpBS
Pasien sudah
dilakukan operasi tgl
17 April 2023