Morning Report Thursday, February 1st 2024.pptx

Morning Report
Thursday, February 1st 2024

OR Kanigara 5-1 ENT
Dr. dr. Jefferson K. Hidayat, Sp. An-TI, Subsp. AKV (K) / Edwin - Asis - Rafli
1. Boy 4 Y / BW 16 kg / 4618677
Diagnosis : Delayed speech
Procedure : Brain evoked response auditory
Status : ASA 2
• Global developmental delay with Speech delay, in speech and occupational therapy
• History of Morbus Hirschprung with closed colostomy, currently clinically calm, without abdominal
distension, without therapy
• Without airway difficulty
Plan : Sedation
Post-op : Ward

OR Kanigara 5-1 ENT
2. Boy 12 Y / BW 22.5 kg / 3780462
Diagnosis : Stenosis subglottis cotton myer 3
Procedure : Tracheostomy, diagnostic laryngoscopy, stenosis release up to T-tube placement
Status : ASA 3
• Transposition of great arteries PA-VSD post BT shunt 2011 and post BCPS 2013, clinical with cyanosis, RR 28-
30x/minute, SpO2 56-62% room air, SpO2 at home 51-80%, without upper respiratory infection in the last 2
weeks, Hb 19. 8, Echo: atrial situs solitus, BCPS patent, sluggish flow, PG 6 mmHg, dextrocardia, moderate to
large ASD 13 mm, bidirectional shunt, large malalignment VSD, no forward flow from RV to PA, malposed
aorta, aorta from RV, well contracting ventricles, paradoxical movements, LV E/A 0.8, LV EF 79% FS 46%, RV
TAPSE 15 mm, Corangio(19/3/23): Dextrocardia, situs solitus, PA-VSD, ventricular imbalance, on therapy:
Sidenafil 1x17.5 mg, Acetylsalisylic Acid 1x80 mg (stopped since 1/30/24).
• Impending airway obstruction. subglottic stenosis, with cyanosis since birth, without additional breath
sounds, without respiratory distress/retractions, able to lie supine, SpO2 56-62% room air, CT scan
nasopharynx 2/10/23: Subglottic stenosis of the trachea at C7 vertebra level with a slight defect in the
anterior aspect of the cervical subcutis at C7 vertebra level.
• Possibility of difficult airway due to subglottic stenosis
Plan : GA
Post-op : PICU/CICU

OR Kanigara 5-1 ENT
3. 58 Y / M / 4300057
Diagnosis : Stenosis subglottis after stenosis release (2021) on T-tube
Procedure : Diagnostic laryngoscopy, T-tube placement, bronchoscopy cryo-APC
Status : ASA 2
• Controlled hypertension, BP 129/82 mmHg, HR 100 x/minute, without chest pain/dyspnea, FC1, METS >4,
ECG (1/29/24): Sinus tachycardia, rate 106 bpm, P wave normal, PR interval 0.16s, QRS duration 0.08s, ST T
changes absent, BBB/VH absent. CXR (1/29/24): Compared with the previous thoracic radiograph, currently
cardiomegaly with elongation, no radiologic abnormalities in both lungs, t-tube stoma as high as C7-T1
vertebra, on therapy, Amlodipine tachycardia, rate 106 bpm, P both lungs, t-tube stoma as high as C7-T1
vertebra, on therapy, Amlodipine is present. CXR (1/29/24): Compared with previous thoracic radiograph,
currently cardiomegaly with elongation, without radiologic abnormalities in both lungs, t-tube stoma as high
as C7-T1 vertebra, on Amlodipine 1x5mg PO.
• Type 2 diabetes mellitus, clinically stable, RBG 241, without HbA1c result, on Metformin 3x500mg PO
• On tracheostomy tube
Plan : GA
Post-op : ICU

OR Kanigara 5-2 ENT
1. Boy 5 Y / BW 17 kg / 4756967
Diagnosis : Tonsiloadenoid hypertrophy
Procedure : Tonsiloadenoidectomy
Status : ASA 2
• Moderate upper respiratory tract infection day 1, with dry cough, with by runny nose with white
secretions, without rhonchi and wheezing, RR 22x/min, SpO2 100% room air, without therapy,
without therapy
• Anemia Hb 10.9
• Possibility of difficult intubation due to palatine tonsil T3 T3
Plan : GA
Post-op : Ward

OR Kanigara 5-2 ENT
2. Boy 3 Y / BW 15 kg / 4510246
Diagnosis : Beckwith Wiedeman Syndrome, Post-pancreatectomy congenital hyperinsulinemia, congenital
hypothyroidism
Procedure : Decannulation and bronchoscopy
Status : ASA 2
• Beckwith Wiedeman Syndrome, with global delvelopmental delay, post pancreatectomy, post
tongue reconstruction surgery ec palatine tonsil hypertrophy, adenoid and macroglossia. currently
active, Abdominal Ultrasound 16/1/24: within normal limits, Echo 24/1/2024: Normal Heart, RFL
available without expertise, on medical rehabilitation
• Congenital hypothyroid, TSH/T4 0.996/1.27, on Levothyroxine 1x25 mcg
• On tracheostomy
Plan : GA
Post-op : Ward

OR Kanigara 5-2 ENT
3. 51 Y / M / 4542079
Diagnosis : Stenosis subglottis cotton myer III after stenosis release on T-tube
Procedure : Diagnostic laryngoscopy, stenosis release to tracheostomy cannula replacement
Status : ASA 2
• Subglottic stenosis on T-tube, without dyspnea, RR 18 SpO2 100% room air, Nasolaryngoscopy
3/1/24: cavum ansi airy, inferior concha eutrophic, posterior pharyngeal wall quiet, without
secretions, no aspiration penetration. there is narrowing under the glottis with about 60% closure,
Tracheoscopy 3/1/24: t tube patent, lower arm: carina well visualized, without granulation tissue,
superior arm: with tissue movement during breathing, 60% upper arm coverage, without therapy.
• on T-tube
Plan : GA
Post-op : Ward

OR Kanigara 5-3 Vascular
dr. Arif H. M. Marsaban, Sp. An-TI, Subsp. AP (K),Subsp. AA (K) / Edwin - Prima - Tika - Norman
1. 43 Y / M / 4670918
Diagnosis : Chronic kidney disease G5A3, with history of uremic encephalopathy, hyperphosphatemia (10.7), history of metabolic acidosis
Procedure : Long term cathether double lumen insertion 14.5 Fr cuff to tip 19cm intra jugular vein dextra and short term cathether double
lumen aff intra jugular vein dextra
Status : ASA 3
• Stage V chronic kidney disease on last supportive haemodialysis 25/1/2024, routine haemodialysis Monday-Thursday,
clinically without signs of fluid overload, UO 800 ml/24 hours, Ureum/Creatine 81.3/5.6 eGFR 11.4 K 5.7 on natrium
bicarbonat 3x1000 mg, calcium carbonat 3x500 mg, Folic acid 1x1 mg.
• Hypertension BP 133/88 N81, FC 1 METS > 4, clinically able to lie supine, CXR without radiologic abnormalities of the heart,
ECG (18/1/2024): Sinus rhythm, HR 78 bpm, normoaxis, p wave 0.04 sec, PR interval 0.16 sec, QRS duration 0.06 sec. LV
strain impression. without LVH/RVH/RBBB/LBBB. QTc 502 ms, without echo, ramipril 1x10mg.
• Suspected rectovesical mass, clinical defecation scales, without abdominal distension, without therapy.
• Anemia Hb 10.1
• Malnutrition high risk refeeding syndrome BW 40 kg BH 165 cm
Plan : Sedation
Post-op : Ward

2. 57 Y / F / 4670773
Diagnosis : Focal to bilateral symptomatic epilepsy, dextra hemiparesis, cognitive impairment et causa tuberculoma suspected paradoxical
reaction to pulmonary tuberculosis, chronic kidney disease on haemodialysis
Procedure : cathether double lumen insertion 14.5 Fr by intrajugular vein dextra, cuff to tip 19 cm
Status : ASA 3
• acute on chronic kidney disease dd/ chronic kidney disease G5A, without history of haemodialysis, Ur 119.8, Cr 3.4, without
signs of fluid overload, UO > 1 ml/kg/hour
• Symptomatic epilepsy focal to bilateral et causa suspected tuberculoma suspected paradoxical reaction pulmonary
tuberculosis clinical neck involuntary movement, last seizure 3 months ago, GCS E4M6V5 motor 4444/5555 CT scan
contrast RSCM (14/1/24): Multiple intraaxial lesions with rim enhancement juxta cortical left frontoparietal and left
temporal lobes, DD/infectious process, neoplasm. Aggressive characteristic osteolytic lesion in the right frontoparietal os on
Phenytoin 3x100 mg.
• History of pulmonary TB 2022, completed 9 months of treatment, clinically without coughing / wheezing / choking /
wheezing, RR 19x / min SpO2 99% room air CXR Features of pulmonary TB with cavitary components and bronchiectasis
with tracheal, hilum and mediastinal retraction to the right side, being PCR genxpert check no therapy yet.
Plan : Sedation
Post-op : PACU

3. 59 Y / F / 4615252
Diagnosis : Left Axillary Vein stenosis post left humerus open reduction internal fixation
Procedure : venography and venoplasty
Status : ASA 2
• Type 2 diabetes melitus, clinically stable, RBG 126, on Metformin 3x500mg
• Hypertension BP 130/78 HR 74 METS > 4 FC I, able to lie supine, ECG normal sinus rhythm, CXR
(5/6/23): without radiologic abnormalities of the heart, without echo, on Ramipril 1x10 mg,
Amlodipine 1x10 mg
Plan : GA
Post-op : Ward

4. 83 Y / F / 4671221
Diagnosis : Acute limb ischemic Rutherford grade III A
Procedure : Angiography, Angoplasty, Open thrombectomy and above knee amputation of right leg
Status : ASA 3
• Atrial fibrilation CHADS2 VASc 6 (age >75, history of stroke, vascular disease, female) HASBLED 4 (Hypertension, AKI, stroke,
anticoagulant use) Clinical BP: 108/93 mmHg, HR 113x/min irregular, FC and METS could not be assessed. ECG: AF HR 65x/m
normo axis pr int 0.20 qrs 0.04, without ST T Changes. without echo result. On Heparin 20,000 IU/24 hours therapy.
• History of cereberovascular disease stroke ischaemic in 2022, clinical GCS E4M5Vaphasia, restlessness, right side weakness,
motor strength 3333/5555. without CT scan of head. On therapy Vitamin B6 2x10 mg, Vitamin B12 2x50 mcg, Folic acid 2x5
mg, Simvastatin 1x20 mg.
• Acute kidney disease dd/ acute on chronic kidneyy disaeas, clinical without signs of fluid overload, UO impression > 0.5
m/kg/h, Ureum 79.2 Creatine 2.4, K 3.8, without history of hemodialysis. On NS 0.9% 1000 cc/24 hours and NAC 2x1200 mg
PO.
• Anemia Hb 8.3 without manifestation of active bleeding. PRC transfusion plan 250 ml
• Geritari 83 years old, frailty scale 7, severe frailty
Plan : Optimalization

OR Kanigara 5-4 Oncology
dr. Arif H. M. Marsaban, Sp. An-TI, Subsp. AP (K),Subsp. AA (K) / Habel - Tika - Norman
1. 36 Y / F / 4689310
Diagnosis : Tall cell variant papillary thyroid carcinoma pT3aN1M0 post total thyroidectomy (January 2023) Post
radioactive iodine therapy 1 time
Procedure : Radical Neck Dissection
Status : ASA 2
• Tall cell variant papillary thyroid carcinoma pT3aN1M0 post total thyroidectomy (January 2023)
Post radioactive iodine therapy 1 time, clinically with voice change and easy cold since after
surgery (January 2023), without swallowing disorder/dyspnea, calcium 1.11, TSH 0.48, T4 1.61, on
Eutyrox 1x100 mcg therapy.
Plan : GA
Post-op : PACU

OR Kanigara 5-4 Oncology
dr. Arif H. M. Marsaban, Sp. An-TI, Subsp. AP (K),Subsp. AA (K) / Habel - Tika - Norman
2. 30 Y / F / 4413536
Diagnosis : Follicular Papillary Carcinoma of the Thyroid T2N0M0 history Thyroidectomy (January 2023) and
Completion thyroidectomy (July 2023)
Procedure : Thyroidectomy
Status : ASA 2
• Papillary thyroid follicular carcinoma Variant T2NoMo Post isthmolobectomy dextra (January 11,
2023) and completion thyroidectomy (July 28, 2023) at Koja Hospital + incomplete structure,
clinically stable, without voice change, without dyspnea, without swallowing disorder, TSH 0.004,
Ca ion 1.18, Complete Neck Ultrasound 11/12/23: Multiple heterogeneous solid lesions in right
thyroid bed, DD/residual lesions, residual, without residual in left thyroid bed, without bilateral
neck lymphadenopathy, on Levotyroxin 1x200 mcg PO.
Plan : GA
Post-op : PACU

OR Kanigara 5-5 Obgyn
dr. Andy Omega, Sp.An-TI / Habel - Ines - Raga
1. 36 Y / F / 4756709
Diagnosis : Cystic ovarian neoplasm suspected malignancy
Procedure : Laparotomy frozen section
Status : ASA 3
• Abdominal enlargement due to cystic ovarian neoplasm suspected borderline dd malignancy,
abdominal circumference 111 cm, without distension, able to lie supine, FC 1 and METs>4,
palpable abdominal mass, RR 20x/min, SpO2 98% room air, USG 12/12/2023: Cystic mass with
multilocular (>10 locules) size 17. 4 x 18 x 20 cm, vol 4300 ml, with solid part measuring 6 x 8 cm,
no history of chemotherapy/radiation, CT Abdomen: multilocular cystic mass with septation,
suspected to originate from the right adnexa that extends to the abdominal cavity, pressing the
intestinal organs to the superior, without history of chemotherapy/chemoradiation, without
therapy.
Plan : GA - Epidural - CVC- ABP
Post-op : ICU

OR Kanigara 5-5 Obgyn
dr. Andy Omega, Sp.An-TI / Habel - Ines - Raga
2. 83 Y / F / 4736930
Diagnosis : Stage I vaginal cancer (melanoma maligna)
Procedure : Wide excision
Status : ASA 3
• Heart failure preserved ejection fraction (EF: 65. 6%), without dyspnea/chest pain, BP 133/61 mmHg, HR 78x/minute, RR
18, able to lie supine, FC METS difficult to assess due to knee pain, ECG 17/10/23: Sinus rhythm, HR 67 bpm, normoaxis,
normal P gel, pr int 206 ms, qrs 84 ms, no S-T segment changes, VH/BBB negative, T inv in AVR, V1, Ro throrax 17/10/23:
Cardiomegaly with aortic elongation and calcification, Echocardiography 19/10/23: LA dilated, LVH concentric, Global
normokinetic, MR mild; TR mild, normal LV systolic function (EF 65.6% Simpson), grade I diastolic dysfunction, normal RV
function (TAPSE 22.3), without thrombus or pericardial effusion, on Ramipril 1x10 mg, Amlodipine 1x10 mg
• Stage 3 chronic kidney disease, without signs of fluid overload, UO >0.5ml/kg/hour, Ureum 38.5, Creatinine 1.5, EGFR 32,
Potassium 4.1, without history of hemodialysis, on Natrium Bicarbonate 3x500 mg, Folic Acid 1x1 mg PO
• Stage 1 vaginal cancer (malignant melanoma), clinically without abdominal distension/active bleeding, without history of
chemotherapy, without therapy
• Type 2 diabetes mellitus, clinically stable, RBG 104, on therapy Gliquidon 2x30 mg PO
• Anemia Hb 10.8
• Geriatric 82 years old, frailty scale 4, living with very mild frailty
Plan : Spinal
Post-op : Ward

OR Kanigara 5-6 Plastic
dr. Andy Omega, Sp.An-TI / Yulius - Oliv – Eci - Benni
1. 61 Y / M / 4669843
Diagnosis : Chronic limb-threatening ischemia of dextra leg W2I0Fi3 history of angiography and antegrade angioplasty (9/1/24), gangrene
of digiti 2 and 3 of dextra pedis history of amputation and debridement (18/12/23) post debridement, amputation of digiti I,
IV, V of dextra pedis (15/1/2023)
Procedure : Re-debridement
Status : ASA 3
• Chronic limb-threatening ischemia dextra leg post amputation digiti 2, 3 pedis dextra, platelet 201000, last heparin
administration on 25/1/2024
• Chronic kidney disease st IV ec Diabetic Kidney Disease et due to obstructive uropathy di hydronephrosis grade III left,
clinically without signs of fluid overload, without dyspnea,able to lie supine, UO <0.5 ml / kgBB / hour, Ureum 100.6
Creatinine 2 eGFR 35, Potassium 4.6, without history of demodialysis
• Type 2 diabetes mellitus, clinically stable, last RBG 122, on Glargine insulin 1x8 IU SC, Aspart insulin 16-16-16 IU SC
• Hypertension, clinically without dyspnea/chest pain, able to lie supine, FC 1, METS >4, BP 165/96 mmHg, HR 98x/minute, RR
16x/minute, without wheezing/rhonki, Chest X-ray (13/1/24): without radiologic abnormalities in the heart and lungs,
without echo, on Candesartan 1 x 16 mg PO, Amlodipine 1 x 10 mg PO.
• Anemia Hb 10.5
• Geriatric 61 years old, Frailty scale 4, living with very mild frailty
Plan : Femoropopliteal block
Post-op : Ward

dr. Andy Omega, Sp.An-TI / Yulius - Oliv – Eci - Benni
2. Boy 11 Y / BW 74 kg / 4757896
Diagnosis : Nevus epidermal dd lymphatic malformation dd filiform warts
Procedure : Electrosurgery
Status : ASA 2
• First day acute respiratory infection, clinically with runny nose and cough, without fever and
dyspnea, RR 20x/minute SpO2 99% room air, without rhonki/wheezing, CXR 26/1/24: heart and
lungs within normal limits, currently without therapy
• Intermittent asthma, last attack Nov 23rd, triggered by acute respiratory infection, relieved by
nebulization, currently without complaints, without rhonki/wheezing, CXR 26/1/24: Heart and
lungs within normal limits, without therapy
• Obesity grade I, BW 74 kg Height 158 cm IMT 29, STOP BANG Score 2, low risk OSA
Plan : GA
Post-op : Back up PICU

OR Kanigara 5-7 Orthopaedy
dr. Aino Nindya Auerkari, Sp.An-TI / Affra - Prima - Pasha – Imam – Kadir - Adit
1. 61 Y / F / 4734927
Diagnosis : Back pain due to compression fracture of L4 Right leg pain due to lumbal canal stenosis L23, L34, L4-
5
Procedure : Open decompression by laminectomy, flavectomy L3-L5 and posterior instrumentation of L3-L5 (C-
Arm)
Status : ASA 2
• Compression fracture L4 due to MBD, with low back pain radiating to right leg, without
immobilization, X-ray of lumbar vertebrae 2 positions: Straight lumbar, Compression insufficiency
of L1 and L3 vertebrae corpus grade 2, Compression insufficiency of L4 vertebrae corpus grade 3,
Intervertebral disc degeneration, Bilateral sacroilitis grade III, Osteopenia, on therapy Actonel
1x35mg PO, Kolkatriol 1x0.5 mcg PO, Natrium Diclofenac 2x50mg PO.
• Controlled type 2 diabetes mellitus, clinically stable, RBG 135, on Metformin 2x500 mg
• Anemia Hb 10.3, PRC transfusion plan 1 bag
• Geriatric 61 years old, frailty scale 3 managing well
Plan : GA
Post-op : Ward

dr. Aino Nindya Auerkari, Sp.An-TI / Affra - Prima - Pasha – Imam – Kadir - Adit
2. 26 Y / F / 4732815
Diagnosis : Back pain due to spondylitis tuberculosis of Th12L1 with paravertebral abscess and psoas abscess Frankle E
Procedure : Debridement, biopsy, abscess evacuation, posterior stabilization Th10-Th11 and L2-L3, augmentation using
MESH (C-Arm)
Status : ASA 2
• Spondylitis tuberculosis of Th12-L1 with paravertebral abscess and psoas abscess, with back pain, able to lie
supine, cannot stand for long due to pain, without dyspena/cough, RR 18 xmin, SpO2 100% room air, CT
Whole Abdomen Contrast 06/9/23: Suggestive picture of spondylitis at T12-L2 vertebrae with paravertebral
abscess formation extending to m. psoas major and m. iliopsoas bilaterally, m. quadratus lumborum, and
abscess on the posterolateral wall of the right hemiabdomen, suggestive of e.c. TB, Tree-in-bud opacity,
fibrosis, and multiple nodules at the basal of both lungs visualized, as well as nodular thickening of the left
posterobasal pleura, suspected tuberculosis, Cystic lesion in the right adnexa, DD/functional cyst, on
antituberculosis drug month 4
Plan : GA - CVC
Post-op : ICU

dr. Arief Cahyadi, Sp.An-TI / Affra - Prima - Pasha – Imam – Kadir - Adit
3. 74 Y / M / 3068609
Diagnosis : Compression fracture of L3L4 due to MBD from prostate cancer
Procedure : Transpedicular biopsy (C-Arm)
Status : ASA 3
• HFrEF 51.4% due to CAD 3VD post CABG and valve repair 2015, clinical without chest pain/dyspnea, FC 1 METS >4, can lie supine, BP 150/90
mmHg, HR 69 x/min, ECG: Sinus rhythm, HR 61 bpm, LAD, P wave 0.10s, PR interval 0.18s, QRS duration 0.11s, qS leads II, III, aVF, no ST-T
changes, no LBBB/RBBB, no LVH/RVH, Echo: LA and LV dilatation, LV wall eccentric hypertrophy, Segmental hypokinetic, MR mild, AR mild
with aortic sclerosis (calcification in RCC and NCC), TR mild, PR mild, normal LV systolic function, Grade II diastolic dysfunction with increased
LAP, RV systolic function decreased, without thrombus or pericardial effusion found, IVC not dilated (expiratory 1. 3 cm, inspiratory 1.1 cm),
EF 51.4%, TAPSE 12.6 mm, on Candesartan 1x4 mg, Bisoprolol 1x1.25 mg, Acetylsalicylic acid 1x80 mg (Stop Monday, January 22, 2024)
• Prostate adenocarcinoma cTxNxMx, GS 4+5=9 GG 5 post transperineal prostate biopsy (22/9/2023), on Zoladex therapy
• Lower back pain due to hernia nucleus pulposus compression L4, due to suspected metastases, clinical with back pain, aggravated when
patient walks or lifts heavy weight, can sit or lie supine, Ro Lumbar 12/1/24: Mild compression of L4 vertebra, Spondyloarthrosis of L3-4 to
L5-S1 vertebra, Spondylosis of L4-5 and L5-S1 vertebra, in physiotherapy
• Geriatric 73 years old, frailty scale 3, managing well
Plan : GA - ABP
Post-op : HCU

dr. Aino Nindya Auerkari, Sp.An-TI / Affra - Pasha – Imam – Kadir - Adit
1. 47 Y / F / 1922817
Diagnosis : Periprosthetic Joint Infection of the left hip with history of recurrent dislocation of left THR post
closed reduction (March 2023)
Procedure : Debridement, deep specimen culture and biopsy, acetabular component revision up to of bone
spacer application
Status : ASA 2
• STSI of left hip, clinically with pain and redness of left thigh, without temperature instability,
Leukocytes 9360, CRP 26.4, without therapy
• Recurrent left leg DVT in antiphospolid syndrome, currently clinical with left leg pain without
edema, PT 0.8x, 9.7 (11.1), D-dimer 2530, Platelets 489000, on Xarelto 1x10 mg PO (last taken
(1/30/24), Ascardia 1x80mg (last taken 1 week ago)
• Anemia Hb 10.7
Plan : GA – Fasciailiaca block
Post-op : PACU / Backup HCU

dr. Aino Nindya Auerkari, Sp.An-TI / Affra - Pasha – Imam – Kadir - Adit
2. 47 Y / F / 4735408
Diagnosis : Posterior dislocation of THR of left hip, Chondrosarcoma of left pubic and ischium bone extending to
sacrum, left hip joint, and bilateral gluteal joint.
Procedure : Open reduction of dislocated total hip replacement
Status : ASA 3
• Skin and soft tissue infection on wound dehisence post wide excision partial sacretomy on left
gluteus tumor suspected soft tissue sarcoma cT2N0M0 with rectum-sigmoid impingement,
clinically with left pelvic pain, immobilized almost 2 months post surgery, on stoma, BP: 106/70
mmHg, HR: 110x/min, RR 20x/min, Spo2: 98% room air, without temperature instability,
temperature 36.3 leukocytes 7360, CRP 345 PCT 0.76 without history of chemo/radiation, on
Ampicilin Sulbactam 4x1.5gr IV, Paracetamol 3x1 gr PO
• Hypoalbuminemia 2.6
• Anemia Hb 10.5
• Grade II obesity, BMI 33.4 BW 71 kg TB 145 cm
Plan : GA – CVC
Post-op : HCU

Dr. dr. Ratna Farida Soenarto, Sp.An-TI, Subsp. AKV (K) / Affra - Pasha – Imam – Kadir - Adit
1. Boy 16 Y / BW 69 kg / 4563550
Diagnosis : Left anterior cruciate ligament rupture
Procedure : Arthroscopic-assisted anterior cruciate ligament, anterolateral ligament reconstruction
Status : ASA 1
Plan : Spinal
Post-op : Ward

2. 75 Y / F / 4576500
Diagnosis : Periprosthetic joint infection of left knee Tsukayama Segawa type IV, history of bilateral total knee
replacement (right Feb 2022), left (Jul 2023)
Procedure : Debridement and insert replacement with implant retention
Status : ASA 2
• Hypertension, BP: 140/98 mmHg HR: 79x/min, current clinical without chest tightness/pain, able to
lie on his back, FC 1 METS >4, ECG: , CXR: Cardiomegaly with aortic elongation and calcification,
Echo: Heart chamber dimensions not dilated, LV concentric hypertrophic, Global normokinetic,
Aortic sclerosis, AR mild, TR mild, LV and RV systolic function good, LV diastolic dysfunction grade I,
IVC not dilated.
• EF 66.7%, TAPSE 22 mm, on Amlodipine 1 x 5 mg
• Geriatric 75 years old, frailty scale 5 mildly frail
• Possibility of difficult ventilation due to edentulous
Plan : CSE
Post-op : HCU

3. 60 Y / M / 4774739
Diagnosis : Primary bone tumor of metatarsal suspected benign dd/ GCT
Procedure : Core biopsy
Status : ASA 2
• Type II diabetes mellitus, clinically stable without complaints, RBG 112 mmHg, on Metformin
2x500mg, Sitagliptin 1x50mg, Glimepirid 1x2mg
• Anemia Hb 10.9
• Hypercoagulable state, Ddimer 1940 fibrinogen 473, without therapy
• Geriatric 60th, frailty scale 4, living with very mild frailty
Plan : Spinal
Post-op : Ward

dr. Arief Cahyadi, Sp.An-TI / Yulius - Oliv – Eci - Benni
2. 24 Y / F / 3819993
Diagnosis : Lymphedema of inferior extremity dextra ISL stage 3 post lymphaticovenous bypass, Homans
procedure, and debulking liposuction
Procedure : Lymphatic gland autologous transplantation, excision and lymphedema reconstruction
Status : ASA 1
Plan : GA
Post-op : Ward

3. Boy 1 Y / BW 10.3 kg / 4681399
Diagnosis : Bilateral right incomplete and cleft lip and alveolus with Veau 4 cleft palate post labioplasty
Procedure : Palatoplasty
Status : ASA 2
• Chest X-ray: Right perihillary and paracardial infiltrate, Lung hyperaeration, clinically without
shortness of breath or cough, without history of pulmonary TB, RR 20 x/min, SpO2 99% on room
air, without therapy.
Plan : GA
Post-op : Ward

4. Girl 4 M / BW 5 kg / 4760178
Diagnosis : Bilateral complete cleft lip and alveolus with Veau 4 cleft palate
Procedure : Labioplasty
Status : ASA 2
• Bilateral complete cleft lip and alveolus with Veau 4 cleft palate, clinically active child, no other congenital
abnormalities found, Echo 12/1/24: Dimension/M-Mode/Doppler, Atrial situs solitus, AV VA concordance,
Normal pulmonary and systemic venous drainage, Balanced four chamber, No TR, no MR, no PR, no AR, PFO
2.9 mm, L to R shunt, Intact IVS, without PDA, Left aortic arch, no coarctation of aorta, Well contracting
ventricles, without paradoxical movements, LV systolic function EF 62% FS 31%, LV diastolic function E/A 1.7
RV systolic function TAPSE 17 mm, No vegetation, Minimal pericardial effusion at anterior 5 mm, apex 4 mm,
without history of cyanosis, dyspnea, without therapy.
• Anemia Hb 10.1
• Thorax X-ray 20/12/23: Bilateral right perihillary paracardial infiltrates, Hypereration of both lungs, without
symptoms of cough or dyspnea, SpO2 99% on room air, without therapy.
• Possibility of difficult airway cannot be ruled out
Plan : GA
Post-op : Ward

OR Kanigara 5-11 Dental
dr. Fildza Sasri Peddyandhari, Sp.An-TI / Habel – Ines - Raga
1. Girl 5 M / BW 6.3 kg / 4774206
Diagnosis : Labioschizis bilateral
Procedure : Labioplasty
Status : ASA 2
• Anemia Hb 9.4
Plan : GA- Infraorbital block
Post-op : Ward

2. 53 Y / M / 4589078
Diagnosis : Multiple impaction
Procedure : Multiple odontectomy
Status : ASA 2
• Systemic lupus erythematous with mucocutaneous, musculoskeletal involvement, and history of
neuropsychiatric systemic lupus erythematous, currently without complaints, without fluid
overload, UO > 0.5 ml/kg/hour, Ur/Cr/eGFR: 30.0/0.80/102.0, with Mycophenolic acid and
Metylprednisolone
Plan : GA
Post-op : Ward

3. 83 Y / F / 4671221
Diagnosis : Chronic limb threatening ischemia
Procedure : Re-debridement
Status : ASA 3
• Systemic inflammatory response syndrome due to chronic limb threatening ischemia of right leg,
post debridement day 3, without temperature instability, currently 36.4 C BP 134/76 mmHg HR
103 x/minute, without support, Leukocytes 7940, without antibiotic
• Diabetic foot ulcer, with history of below knee amputation of left leg, and right leg debridement
day 3, GDS 169 on Insulin Aspart 3x8 U
• Anemia Hb 9
Plan : Femoropopliteal block
Post-op : Ward

dr. Fildza Sasri Peddyandhari, Sp.An-TI / Yulius - Oliv – Eci - Benni
1. Girl 2 Y / F / BW 12 kg / 4670225
Diagnosis : Chronic burn wound residual raw surface 25% TBSA regio anterior trunkus, posterior trunkus, bilateral superior
extremities, bilateral inferior extremities, and genitalia post excisional debridement, amputation of digiti 3, 4, 5
of right hand, digiti 1, 3, 4, 5 of left hand, and split thickness skin graft
Procedure : GV with sedation up to non-excisional debridement
Status : ASA 3
• Improved sepsis due to skin and soft tissue infection due to deep dermal to full thickness burn of anterior and
posterior trunk region, bilateral superior and inferior extremities, and genitalia with infected eschar 37.5%
TBSA due to scald onset day 47, treatment day 38, final post excisional debridement H+6, clinically active,
with history of febrile seizure 1x on 5/1/24 at 16.45, BP 115/76 mmHg, HR 161x/min, RR 22 x/min, SpO2 99%
room air, with history of temperature instability, highest temperature 38 C this morning, current temperature
36, UO 2 ml/kg/hour, Leukocytes 18,460, Platelets 448,000, Procalcitonin 0.6, CRP 55.5, Lactate 3.3, on D10
Tigesicline 2x20 mg, D4 Ceftazidim 3x1200 mg IV.
• Anemia Hb 11.4
• Hyponatremia 133
• Without airway difficultu
Plan : GA - CVC
Post-op : Burn unit HCU

2. 21 Y / M / 4671100
Diagnosis : Superficial dermal to full thickness burn TBSA 51.5% ec head region fire, anterior trunk, anterior and
posterior trunk, bilateral superior and inferior extremities
Procedure : Excisional debridement
Status : ASA 3
• Superficial dermal to full thickness burn TBSA 51.5% ec fire day 11, treatment day 7, clinical CM
blood pressure: 121/67 mmHg, pulse: 108 beats per minute with norepinephrine 0.01
mcg/kg/hour, RR 18 x/min, SpO2 100% on NK 3 lpm UO > 0.5 ml/kg/hour leukocytes, PCT 45.91
CRP 181.2 on Meropenem 1 gram/8 hours IV E6
• Prolonged APTT 1.4x without bleeding manifestation, without therapy
Plan : GA (CVC and ABP already installed)
Post-op : Burn unit ICU

3. Girl 4 Y / BW 12 kg / 4752042
Diagnosis : Pittsburgh 5 palate fistula in history of bilateral cleft lip and palate post labiopalatoplasty and fistula
repair
Procedure : Fistula repair with buccal flap
Status : ASA
• CXR: Right paracardial infiltrate, clinical without cough, without tightness, RR: 24 x/m, SpO2: 99%
room air, without therapy
• Possibility of difficutl airway cannot be ruled out
Plan : GA
Post-op : Ward

OR Kanigara 6-1 Neurosurgery
Dr. dr. Riyadh Firdaus, Sp. An-TI, Subsp. NA (K) / Nadra - Novi
1. 42 Y / F / 4763015
Diagnosis : Upper motor neuron paraplegia due to intramedullary lesion of Th4-Th12
Procedure : Laminectomy removal tumor Th10
Status : ASA 2
• Upper motor neuron paraplegia due to intramedullary lesion Th4-Th12 suspected ependymoma,
weakness in both limbs, hypesthesia as high as Th-11 and below, urinary and fecal incontinence ,
able to lie supine, thoracolumbar MRI (24/1/24): Irregularly shaped rim enhancing lesion with
indistinct border in the intramedullary spinal cord as high as Th10 level sizing 2.1 x 0.9 x 0.8 cm,
eccentrically located in the posterior side of the spinal cord tending to protrude to the left
dorsolateral side, accompanied by extensive perilesional edema from Th4 to L1 level, suspected
malignant, without therapy.
• CXR (1/29/24): Minimal linear opacity in the lower field of the left lung, dd/fibrosis, clinically
without coughing/dyspnea, RR 16 x/min, SpO2 99% room air, without therapy.
Plan : GA - ABP
Post-op : HCU BS

OR Kanigara 6-2 Urology
Dr. dr. Dita Aditianingsih, Sp. An-TI, Subsp. TI (K) / Nadra - Kiki - Ance - Riza
1. 54 Y / M / 4682928
Diagnosis : Stage V chronic kidney dissease
Procedure : Kidney transplantation (right implantation)
Status : ASA 3
• Stage V CKD, with routine HD every Tuesday - Thursday - Saturday (Last 31/1/24), clinically currently able to lie supine, without signs of fluid
overload with anuria. Left hand AVF HD access, 600 ml/day fluid restriction, last HD Monday 1/31/24: 4 hours hd, qb 250 ml/min, qd 500
ml/min, ufg 3000 ml, regular heparin, EPO injection, pre HD weight 60 kg post HD weight 57 Kg, pre HD Lab Ur/Cr 89. 9/9.5, eGFR 5.6,
Potassium 3.2, post HD lab no result yet, on Folic Acid 1x400 mg Po, Sevelamer Carbonate 1x800 mg PO, Bicnat 2x1 gram PO
• Hypertension, BP 122/89 mmHg, HR 80x/min, clinical without signs of overload, FC 2 METS >4, echo: Concentric LVH, Global normokinetics,
LV systolic function good (EF: 60%), MR mild, RV systolic function good (TAPSE: 29 mm), Pseudonormal diastolic dysfunction, Effusion (-),
thrombus (-) on Carvedilol 1x6.25 mg PO.
• Cirrhotic Hepatis CTP A with esophageal varices post ligation 29/1/24 ec Chronic hepatitis C not yet DAA. History of hematemesis melena 6
years ago, without abdominal distension, without ascites, without icteric, GCS E4V5M6. EGD results: grade 2 esophageal varices, portal
hypertensive gastroduodenopathy, hiatal hernia, abdominal ultrasound 29/11/23 chronic liver dyseae, Fibroscan 29/11/23 CAP 118 kPA 5.5,
Hep C F0F1, OT/PT: 23/16, Bil T/D/I: 0.89/0.26/0.63, pt/aptt 1x/1x, albumin 5. Without therapy
• Contrast thoracic CT scan: Opacity tree in bud segment 2, 6, 8, 9, 10 right lung and segment 1/2, 6, 8, 10 left lung, DD/TBC lung. Small
subpeural bullae apical to the right lung (0.9 cm in diameter). Igra test result was negative. Clinical without signs of respiratory distress,
without complaints of coughing/shortness, RR 20x/min, Spo2 99% RA, without rhonki/wheezing, without therapy.
• Anemia Hb 10.5
Plan : GA - QL Block - CVC - ABP
Post-op : ICU

Dr. dr. Dita Aditianingsih, Sp. An-TI, Subsp. TI (K) / Nadra - Kiki - Ance - Riza
2. Boy 5 Y / BW 16.7 kg / 4689949
Diagnosis : Right inguinal palpable undescended testis
Procedure : Right open orchidopexy
Status : ASA 1
Plan : GA - Caudal
Post-op : Ward

dr. Alfan Mahdi Nugroho, Sp. An-TI, Subsp. AO (K), Subsp. AR (K) / Karina - Kiki - Ance - Riza
1. 50 Y / F / 4682936
Diagnosis : Kidney donor
Procedure : Left LLDN
Status : ASA 2
• TORCH infection, clinically asymptomatic, Anti rubella IgG 11.8 reactive, Anti Toxoplasma IgG 88.2
reactive, Anti CMV IgG 593.9 reactive, without therapy
Plan : GA - QL Block
Post-op : PACU

2. 50 Y / M / 4542880
Diagnosis : Right pyonephrosis in right urolithiasis post vesicolithotripsy and right URS Lithotripsy and right RPG and right PCNL and right Nephrostomy and
right APG (8/1/24) post aff Nephrostomy (23/1/24)
Procedure : Right nephrostomy
Status : ASA 4
• Septic shock due to right pyonephrosis and HAP high risk, clinical with decreased consciousness GCS E2M3V2 ec dd/intracranial uremic
encephalopathy, temperature instability with highest temperature 38, current temperature 37.5, bilateral basal rhonchi, BP 130/64 HR 115-
125x/min on NE 0.1 mcg/kg/min, RR 24-26x/min SpO2 100% on simple mask 10 lpm. Leukocytes 20220, PCT 29.4, AGD:
7.37/50.2/117.3/29.6/98.2%, CXR 30/1: Bilateral paracardial infiltrates, suspected pneumonia. On Meropenem 2x500mg D2 (30/1),
Vancomycin 1x1000mg D2 (30/1).
• Post renal acute kidney disease on chronic HD (HD today 31/1), currently anuria, on left renal agenesis (single functional kidney). Current
clinical with decreased consciousness GCS E2M3V2 uremic encephalopathy, anuria, Lab post HD 29/1: Ur/cr/eGFR: 109.1/5.5/11.1, E:
137/5.2/97, Folic acid 1x1 mg, CaCO3 3x500 mg, kalitake 3x5 grams, insulin 10 units + D40 50 mL.
• Dysarthria et causa suspected CVD SI unknown onset
• Type 2 DM, clinical with recurrent hypoglycemia GDS 178, on D40% 5 mL/hour
• 2x aptt prolongation, aPTT: 62,9 (31,9)
• Anemia Hb 9.4
• Hypoalbuminemia 2.2
Plan : MAC
Post-op : Medical HCU

3. 64 Y / F / 4542783
Diagnosis : Right grade IV hydronephrosis due to mass compression
Procedure : Cystoscopy right RPG, right DJ stent insertion up to right nephrostomy
Status : ASA 2
• Acute on CKD dd stage IIIa CKD due to obstructive uropathy in grade IV right hydronephrosis due to
mass compression in recurrent cervical carcinoma IIIB, post complete chemoradiation Nov 2022,
U>0.5 ml/kg/hr, without signs of overload, Cr 1.2 ur 25.7, K 4.3, no history of HD, without therapy
• CXR: Nodular opacity in the lower field of the left lung dd pulmonary nodule, without
cough/dyspnea RR 18 x/min SpO2 99%, without therapy
• Anemia Hb 11.7
• Geriatric 63 years old FS 3 managing well
Plan : Spinal
Post-op : Ward

4. 52 Y / F / 4733411
Diagnosis : Left hydronephorsis on DJ stent
Procedure : Cystoscopy, right RPJ and right DJ stent insertion up to right nephrostomy
Status : ASA 2
• AKI dd acute on CKD due to Left hydronephrosis on DJ Stent due to Endometrial mass suppression, clinical
without signs of fluid overload, able to lie supine, Ur/ Cr/ eGFR : 186.2/ 5.4/ 8.5, Na/K/C: 135/ 4.3/ 99.1, UO
<0.5ml/kg/hour, no history of HD, without therapy.
• Endometrial Ca stage IV B, current clinical with pelvic mass, multiple paraaortic and pelvic KGB, and lung
metastasis, post laparotomy incomplete surgical staging (HTSOB, RSI Bogor July 2023), post chemoradiation
10 times (last October 2023), post chemotherapy 3, without echo results.
• Hypertension BP 155/92, HR 90x/min, FC 2 METS <4, ECG 26/1/24: Sinus rhytm, normoaxis p wave normal, HR
99x, p wave normal, QRS 0.09s, ST T changes no VH BBB no, without echo results, on candesartan 1x8 mg,
amlodipine 1x5 mg PO- Type 2 DM, clinically calm, GDS 199, controlled with diet
• Anemia Hb 10
Plan : Sedation – Spinal
Post-op : Ward

OR Kanigara 6-4 Digestive
Dr. dr. Aida R. Tantri, Sp. An-TI, Subsp. AR (K) / Karina – Vircha - Ira
1. 30 Y / F / 4737790
Diagnosis : Multiple symptomatic cholecystolithiasis
Procedure : Laparascopy cholecystectomy
Status : ASA 2
• Hypertension, without dyspnea/ chest pain, FC 1 METs>4, blood pressure 127/90 mmHg, pulse
rate 91x/min, thoracic X-ray (11/12/23): without radiologic abnormalities in the heart and lungs,
able to lie supine, currently without therapy.
• Multiple cholesistolithiasis with history of obstructive jaundice, without abdominal pain, without
jaundice, AST/ALT15/19, total/direct/indirect bilirubin 0.43/0.20/0.23, ERCP (1/12/23): Intra and
extrahepatic biliary dilatation due to choledocholithiasis (post stone crushing and extraction),
multiple cholecystolithiasis, currently without therapy.
• Anemia Hemoglobin 10.8
Plan : GA
Post-op : Ward

Dr. dr. Aida R. Tantri, Sp. An-TI, Subsp. AR (K) / Karina – Vircha - Ira
2. 19 Y / M / 4760045
Diagnosis : Giant condyloma
Procedure : Giant condyloma fulguration
Status : ASA 2
• Sindrom imunodefisiensi akuisita, klinis saat ini dengan giant condyloma regio perianal, dengan
perdarahan merembes, nyeri hilang timbul, tanpa demam/batuk/diare lama, tanpa riwayat
pengobatan tuberkulosis, Leukosit 10.210, CD4 375, viral load undetected, dalam terapi
antiretroviral Dolutegravir/Lamivudine/Tenofovir 50 mg/300mg/300mg (mulai 5 Januari 2023)
• Sifilis laten, klinis saat ini tenang, RPR : reaktif titer 1:2, TPHA reaktif, titer 1: 1280, tuntas terapi
Benzatin Pensilin 3 kali IM
• Tanpa penyulit jalan napas
Plan : Spinal
Post-op : Ward

dr. Rahendra, Sp. An-TI, Subsp. AR (K) / Karina – Vircha - Ira
1. 32 Y / F / 4758896
Diagnosis : Intraabdominal mass due to suspected recidive mesenteric fibromatosis
Procedure : Laparotomy biopsy
Status : ASA 3
• Intra-abdominal mass due to suspected mesenteric fibromatosis residual dd right kidney mass suspected
malignant, clinical with abdominal distension and venectation, unable to lie supine, more comfortable lying
on his side, RR 22 x/min, SpO2 96% with nasal cannula 3 lpm, abdominal circumference 108 cm, CT scan
abdomen contrast (29/1/24): Malignant mass of right kidney origin, extending superiorly, urging the liver
posteriorly, involving bilateral m. rectus abdominis, compressing and constricting the inferior vena cava, with
massive ascites with a picture of peritoneal carcinomatosis, without history of chemotherapy/radiation,
without therapy.
• Hypercoagulable state, with bilateral limb DVT, D dimer 2490, PT/aPTT 0.9/0.93x, under Heparin 20,000U/24
hours
• Hypoalbuminemia 1.7, planned corrected with 20% Albumin
• Anemia Hb 9.5
Plan : GA
Post-op : PACU

dr. Rahendra, Sp. An-TI, Subsp. AR (K) / Karina – Vircha - Ira
2. 55 Y / M / 4744585
Diagnosis : Multiple symptomatic cholecystolithiasis
Procedure : Laparoscopy cholecystectomy
Status : ASA 2
• Hypertension, wihtout chest pain/dyspnea, FC1 METS>4, BP 131/82 mmHg, HR 68x/min, Chest X-
ray (11/29/23): Mild cardiomegaly, no pulmonary radiologic abnormalities, ECG 11/12/23: SR, QRS
rate 75 bpm, normoaxis, normal P wave, PR interval 0.12 s, QRS 0.08 s, ST-T changes, VH BBB
negative, on Amlodipine 1 x 5 mg.
• Symptomatic multiple cholecystolithiasis with history of acute cholecystitis, without abdominal
pain/nausea/vomiting, without jaundice, AST/ALT17/15, without therapy.
• Grade 1 obesity , BMI 32, BW 82 kg, BW 160 cm, STOP Bang score 4, intermediate risk OSA
Plan : GA
Post-op : Ward

OR Kanigara 6-6 Neurosurgery
dr. Pryambodho, Sp. An-TI, Subsp. AR (K) / Nadra - Irfan - Rania
1. 30 Y / F / 4650008
Diagnosis : Schwannoma of sacrum region
Procedure : Partial sacrectomy, reconstruction using pedicle screw system until possibility of colon and urinary
bladder repair (by digestive and urology division)
Status : ASA 2
• Tumor of sacrum region, GCS 15, without motor impairment, intermittent pelvic pain,
Lumbosacral MRI 15/12/23: solid soft tissue tumor involving the pre-sacral region and right
foramina sacralis up to the spinal canal at S1-S3 sizing DD/ Schwannoma, without history of
chemo/radiation, without therapy.
• Mental retardation, clinically cooperative, on Aripiprazole 1x5 mg PO
Plan : GA - CVC - ABP
Post-op : ICU

OR Kiara Obgyn
Dr. dr. Andi Ade Wijaya Ramlan, Sp. An-TI, Subsp. AP (K) / Gaya - Ganda - Gilang - Kathena
1. Boy 10 M / BW 10 kg / 4655800
Diagnosis : Atresia ani fistel perineal on sigmoid colostomy
Procedure : PSARP
Status : ASA 2
• Anal atresia perineal fistula on sigmoid colostomy, without abdominal distension, without other
congenital abnormalities, vital stoma without abdominal distension, Echo July 2023: PDA
spontaneous closure, PFO 2 mm L to R shunt, normal heart, without therapy.
• Anemia Hb 9.5
Plan : GA - Caudal
Post-op : Ward

OR Kiara Obgyn
dr. Komang Ayu Ferdiana, Sp.An - TI / Gaya - Ganda - Gilang – Kathena - Wawan
1. 39 Y / F / 4736180
Diagnosis : G3P0A2 39 weeks pregnancy alive singleton with head presentation, small for gestational age fetus
(5.8 percentile), mother with SLE hematologic and muskuloskeletal involvement, secondary APS,
grade I obesity (BMI 28.8 kg/m2)
Procedure : Cesarean section
Status : ASA 2
• Systemic lupus erythematosus with musculoskeletal and hematologic involvement, clinically with
recurrent joint pain and anemia, without active bleeding, Hb 8.2, thrombocytopenia 60,000, post
PRC transfusion LD 4 bags, planned TC transfusion 6 bags 1 hour before SC
• Secondary antiphospholipid syndrome, with recurrent abortion, on Heparin 2x5000 IU SC (last on
31/1/24 at 14.00), Aspilet 1x80 mg PO (delayed since 1 month)
• Pregnancy
Plan : GA - Caudal
Post-op : Ward

OR Kiara Obgyn
dr. Komang Ayu Ferdiana, Sp.An - TI / Gaya - Ganda - Gilang – Kathena - Wawan
1. 23 Y / F / 4773977
Diagnosis : G1 38+3 weeks pregnant, alive singleton with head presentation, fetus with cardiac rhabdomyoma,
short limbs, mother with reactive HbsAg, underweight (BMI 17 kg/m2)
Procedure : Cesarean section, intrauterine device
Status : ASA 2
• Ectopic atrial rhythm, clinically without complaints of chest pain/palpitation/dyspnea, able to lie
supine, BP 107/63 mmHg, HR: 61 x/min, ECG (23/1/24): Ectopic atrial rhythm, HR: 76 x/min,
normoaxis, gel. P inversion in II, III, aVF, and I, V2-V6, T-inverted in II, II, aVF, without BBB, and VH
absent, without echo result, without therapy.
• Pregnancy.
Plan : Spinal
Post-op : Backup HCU

OR Kiara Pediatric
Dr. dr. Andi Ade Wijaya Ramlan, Sp. An-TI, Subsp. AP (K) / Gaya - Ganda - Gilang – Kathena - Wawan
2. Baby Boy 1 M / BW 1.4 kg / 4671109
Diagnosis : Neonatal hemochromatosis due to suspected gestational allo-utoimmune liver disease (GALD)
Procedure : Incisional biopsy
Status : ASA 3
• Neonatal sepsis with premature neonates inadequate for gestational age gestational age 35 weeks, 1,440 grams, PCA 39
weeks, clinical with shortness of breath, with chest wall retraction, RR 40-46x/min, CPAP FiO2 21%, PEEP 8, SpO2 95-97%,
without temperature instability, leukocytes 12,830, CXR 27/1/24: Heart within normal limits, bilateral perihilar and right
paracardial infiltrates, IVC projection PICC tip, on Ampicillin 2x70 mg iv E2, Gentamicin 1x7 mg E2.
• Neonatal hemochromatosis e.c. suspected gestational alloutoimmune liver disease (GALD), clinical without abdominal
distension, history of 2x exchange transfusion in previous hospital, with elevated SGOT/SGPT 366/98, on Urdafalk 3x8mg
per NGT
Plan : GA
Post-op : PICU

OR Kiara Pediatric
3. Girl 17 Y / BW 32 kg / 3071791
Diagnosis : Ascites complex post-splenectomy a/i. infected lien cyst rupture (21/12/23)
Procedure : Laparotomy abscess drainage
Status : ASA 3
• Ascites complex post-splenectomy due to infected lien cyst rupture (21/12/23), clinical with abdominal distension, abdominal cirxumference
71.5 cm, able to lie supine, more comfortable sleeping on the left side, abdominal pain on epigastrium and left upper abdominal region
fluctuating FLACC 3-4, with temperature instability, highest temperature 39.2 Celsius 1 day ago, currently 36 Celsius, BP 106/68 mmhg HR
120x/min, leukocytes 11.510, PCT 0.47, CRP 98.3 PT/aPTT 1x/1.3x, Lipase 4, with brown NGT production of 78 ml dark brown color,
abdominal ultrasound 11/1/24: Ascites complex due to suspectes bleeding, infection Hydronephrosis grade 2 bilateral kidney, Cystitis, on
Meropenem 3x600 mg D6, Mycafungin 1x60 mg E10, Metronidazole 3x500 mg E4 (Stop 29/1/2024)
• Thallasemia beta major, without signs of active bleeding, able to lie supine, with maxilla abnormality, SpO2 97℅ room air, Hb 12.2 after
transfusion 1 Bag, Echo 22/1/24: Severe PH, moderate pericardial effusion (estimated volume 90 mm), mild bilateral pleural effusion, history
of routine transfusion every 2 weeks since 16 years ago,
• Hypoalbumin 2.7 with pericardial effusion, clinically with dyspnea, RR 24x/min, SpO2 97% room air, with piting edema of lower extremities,
with Albumin 20% transfusion plan
• ARI day 2, clinically with cough with phlegm, RR 24 x/min, SpO2 97% room water, CXR 22/1/24: Cardiomegaly with suspected pulmonary
edema, on Paracetamol 4x400 mg PO and Acetylsistein 3x200 mg PO.
• Thrombocytopenia 68,000, trombocyte transfusion with target >100,000
Plan : GA - Epidural - CVC - ABP
Post-op : PICU

OR Kiara Pediatric
4. Girl 9 Y / BW 24 kg / 4663081
Diagnosis : High-output stoma on double barrel ileostomy status (6/1/23) due to ileal perforation, post-relaparotomy due to generalized peritonitis
(13/1/23)
Procedure : Takedown ileostomy (ileo-ileal resection-anastomosis)
Status : ASA 3
• High-output stoma in double barrel ileostomy status (6/1/23) due to ileal perforation, post-relaparotomy due to generalized peritonitis, with
history of repeated surgeries, current clinical stoma vital, brownish yellow liquid stool, lopography (7/24/2023): Colonic lumen from clean
stoma to intact anus, stoma to intact proximal ileus, without filling defect or additional shadow, without fistula or extralumen contrast
extravasation, NGT installed, without therapy.
• Cerebral.palsy with cerebral infarction in caudate region, clinical apathy, history of seizure 2 months ago, Head CT 30/4/23: Multiple chronic
infarctions in bilateral caudate nucleus, bilateral anterior crus internal capsules, and pons, without bleeding, pathological obstruction or
intracranial solid occupying lession, Cerebral atrophy, on therapy Phenobarbital 2x60mg PO, Levetiracetam 2x250mg PO.
• Stage III acute kidney injury, clinically without fluid overload, 24-hour diuresis 1 ml/kgb/hr, Cr/Ur 0.6/0.8, potassium 5, without therapy
• Possible infective endocarditis, clinical without blue/dyspnea, BP 95/70 mmHg, Pulse 116x/min, echo: normal heart, EF 69%, Ceftriaxone
2x1000mg IV E17, Gentamicin 3x46mg IV E10/14, Fluconazole 1x70 mg PO E6
• Elevated transaminase enzymes AST/ALT 41/145
• On tracheostomy
Plan : GA - Epidural - CVC
Post-op : PICU

1. 77 Y / M / 4462778
Diagnosis : Failed graft of right eye
Procedure : Re-keratoplasty of posterior lamelar of right eye
Status : ASA 2
• Suspected non toxic goiter
• CXR: hilum thickening, suspected pneumonia dd pleural effusion, without dyspnea
• Geriatric 77 tahun, frailty scale 3, managing well
Plan : GA
Post-op : Ward
OR Kirana Opthalmology
dr. Bintang Pramodana, Sp.An-TI / Chacha - Tomo – Dara - Prita – Panji

2. Girl 1 Y / BW 10 kg / 4710239
Diagnosis : Intraocular mass suggestive of suspected retinoblastoma of both eyes, stage 3 or 4 group B/C
retinoblastoma of right eye, group B/C retinoblastoma (vitreous seeding) of left eye
Procedure : Retinal camera of both eyes
Status : ASA 2
• Upper respiratory tract infection day 14, with fever, cough with sputum, with temperature
instability, current temperature 38.9, without rhonchi or wheezing, on Paracetamol and
Acetylcysteine
• Anemia Hb 10.8
Plan : Optimization
Post-op : PICU

3. 44 Y / F / 4629003
Diagnosis : Right eye sebaceous cell carcinoma post wide excision, vries coupe, 12 months skin flap, right eye
cicatrix entropion with trichiasis, right eye suspected bacterial corneal ulcer
Procedure : Lid splitting, muccosa buccal graft of right eye
Status : ASA 3
• Uncontrolled hypertension, clinically without complaints of chest pain/dyspnea, able to lie supine,
FC 1 METS >4, BP 213/19 mmHg pulse 83 x/min, ECG (24/1/24): Sinus rhythm, normal axis, HR 83,
normal P gel, PR int 0.14s, QRS int 0.08s, no ST/T abnormality, no BBB/VH, CXR (1/22/24): No
radiologic abnormalities in the heart and lungs, on Amlodipine 1x5 mg
• Adenomatous struma, with neck lump, clinically euthoroid, Wayne index +3 (palpable thyroid),
without FT4 and TSH results, without therapy
Plan : GA
Post-op : Ward

4. Boy 3 Y / BW 12.5 kg / 4762204
Diagnosis : Juvenile cataract of both eyes
Procedure : Lens extraction, primary posterior capsulectomy, intraocular lens of both eyes, intraoperative
biometry
Status : ASA 2
• Anemia Hb 8.2
• Hiponatremia 132
Plan : GA
Post-op : Ward

5. Boy 3 Y / BW 13 kg / 4593620
Diagnosis : Retinoblastoma grade C-D of left eye, free tumor of right eye
Procedure : Retinal camera up to intravitreal melphalan
Status : ASA 2
• Retinoblastoma on arterial chemotherapy, clinically without jaundice/dyspnea/cyanosis, active,
able to lie on supine, with a history of 6 cycles of chemotherapy, IAC 2x last November 2023, SpO2
99% room air, HR 97x/min, CXR 17/10/2023: enlarged heart size, echo: normal heart, without
therapy.
• Anemia Hb 9.7
Plan : GA
Post-op : Ward

6. Boy 8 Y/ BW 21.5 kg / 4407989
Diagnosis : Juvenile cataract of left eye, pseudophakia post cataract extraction of right eye, intraocular lens of
right eye
Procedure : Lensectomy, primary posterior capsulectomy intraocculer lens of left eye
Status : ASA 1
Plan : GA
Post-op : Ward

7. Boy 16 Y / BW 50 kg / 4760942
Diagnosis : Congenital ptosis of both eyes (heavier right eye), suspected amblyopia of right eye
Procedure : Frontalis flap and levator resection of right eye
Status : ASA 2
• Intermittent asthma, last relapse 1 year ago, triggered with cough and cold, currently without
dyspnea/cough, RR 18 beats per minute, SpO2 100% room air, thoracic x-ray 27/1/24: without
radiologic abnormalities in the heart and lungs, without therapy.
Plan : MAC up to GA
Post-op : Ward

8. 30 Y / F / 4708580
Diagnosis : Esotropia suspected Brown syndrome, preferred eye of right eye
Procedure : Recess and resect of left eye
Status : ASA 1
Plan : GA
Post-op : Ward

9. 31 Y / F / 4762566
Diagnosis : Superior palpebrae tumor of right eye
Procedure : Excisional biopsy of right eye and trial curretage incision of right eyelid
Status : ASA 1
Plan : GA
Post-op : Ward

10. 35 Y / M / 4756521
Diagnosis : Secondary glaucoma of left eye in vitrectomized eye (post silicone oil evacuation October 2023),
retinal detachment of right eye, hearing and speech impairment
Procedure : Virna glaucoma implant of left eye
Status : ASA 2
• Fibrosis of the left lower lung, clinically without coughing / wheezing, without temperature
instability. Rr 18x/min, vesicular breath sounds, no rhonki and wheezing, Leukocytes 9,260,
Thoracic Photo (18/1/24): Fibrosis in the left lower lung field, no radiologic abnormalities in the
heart. ECG (24/1/24): Sinus rhythm, normal axos, HR 71, normal P gel, PR int 0.18s, QRS int 0.09s,
no ST/T abnormality, no BBB/VH, without therapy.
Plan : GA
Post-op : Ward

11. 48 Y / M / 4738653
Diagnosis : Secondary nasolacrimal duct obstruction of right eye, fistula due to suspected lacrimal sac tumor,
chronic dacryocytitis of right eye, palpebral tumor suspected lacrimal sac of right eye dd lacrimal sac
abscess
Procedure : External dacryocystorhinostomy of right eye
Status : ASA 1
Plan : GA
Post-op : Ward

12. 53 Y / M / 3864965
Diagnosis : Graft rejection of right eye, history of corneal ulcer right eye due to bacterial infection, pseudophakia
of both eyes, granular dystrophy of both eyes
Procedure : Penetrating keratoplasty of right eye
Status : ASA 2
• Type 2 diabetes mellitus, clinically stable, without complaints of dyspnea / weakness, GDS
(31/1/24): 87 mg/dl, on Metformin/Sitagliptin 1x1 tab and Metformin/Glimepirid 1x1 tab.
Plan : GA
Post-op : Ward

13. 64 Y / M / 4671022
Diagnosis : Endophtalmitis post phaco intraocular lens of left eye
Procedure : Eviceration, dermatofat graft of left eye
Status : ASA 2
• Hypertension, BP 138/90 mmHg, clinically without complaints of chest pain / dyspnea, able to lie
supine, FC 4, METS 4, Chest X-ray 22/1/2024: No radiological abnormalities in the heart, ECG
22/1/2024: Sinus rhythm, HR 60x/min, normal p wave, PR interval 0.12, QRS 0.08s, ST changes are
absent, T inverted is absent. RBBB incomplete, on Ramipril 1x5mg PO
• Type 2 diabetes mellitus, clinically calm, GDS: 140, on Glimepiride 1x1mg PO
• Leukocytosis 17660
• Geriatric 64 years old, frailty scale 3, managing well
Plan : GA
Post-op : Ward

14. 72 Y / M / 4762694
Diagnosis : Late endophthalmitis right eye, secondary open angle glaucoma due to lens particle of right eye
Procedure : Vancomycin Ceftazidime injection
Status : ASA 2
• Geriatric 72 years olf, frailty scale 3, managing well
Plan : GA
Post-op : Ward

• GA : 43
• Spinal : 6
• Epidural : 3
• Block : 6
• CSE : 1
• Sedation : 4
• Caudal : 2
• Combination : 7
• CVC : 8
• ABP : 5
• Ward : 32
• HCU : 6
• ICU : 4
• Neurosurgery HCU : 1
• Burn unit HCU : 1
• ICU Burn unit : 1
• PACU : 6
• PICU : 2
Resume

Morning Report Thursday, February 1st 2024.pptx

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Morning Report Thursday, February 1st 2024.pptx