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MORNING REPORT
PROGRAM STUDI ANESTESIOLOGI DAN
TERAPI INTENSIF
21 AGUSTUS 2023
PEMBIMBING dr. Teuku Yasir, SpAn-TI Subsp TI(K)
dr. Rifky Jamal, SpAn-TI
dr. Hafizh Arief , Sp.An-TI
dr. Rahmi, SpAn-TI (K), Subsp AR(K)
dr. Rozi Fadhori, SpAn-TI
Chief Of Chief dr. Indah
Chief Kamar Operasi dr. Aoelia/Fahmi/Ardi/Satria/Muqsith
Chief Critical Care dr. Muqsith
Chief Poliklinik/Ambulatory dr. Satria
Chief Emergency/METS dr. Ardi
PARADE
21 AGUSTUS 2023
OKA V (Bedah Plastik)
DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K)
4 Rencana Anestesi
OKA V (Bedah Pastik)
DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K)
Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1
S, Pr, 36
Thn
Adik ipar
dr.Indah
chronic wound ec
diabetic ulcer at right foot
Debridement
dr. Syamsul Rijal SpBPRE
III Ankle blok Ruangan
2
S, Pr, 61
Thn
fascitis necroticans ar left
thigh to left gluteus
Redebridement ke 6
+necrotomy
dr. Mirna,SpBPRE
III General anestesi-LMA Ruangan
3
I, LK, 66
Thn
fascitis necroticans at
regio flank to scrotal
Redebridement ke 5
+necrotomy
dr. Mirna,SpBPRE
II Spinal Anestesi Ruangan
4
S, Pr, 82
Thn
diabetic ulcer at regio
pedis (d) + non vital digiti
3 pedis (d)
Redebridement ke 2 +
necrotomy
dr. Mirna,SpBPRE
Pasien ditunda oleh bagian
bedah plastik
OKA V (Bedah Pastik)
DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K)
Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1
S, Pr, 36
Thn
Adik ipar
dr.Indah
chronic wound
ec diabetic ulcer
at right foot
Debridement
dr. Syamsul Rijal
SpBPRE
ASA III
- CHF NYHA III ec CAD 3VD , TD 122/73
mmhg, METs 4 klinis, nyeri dada -
sesak +, mudah lelah -, murmur -,
gallop -, EKG: SR QRS 92 rate Q
patologis di III dan AVF OMI inferior,
CXR : Cardiomegali +, CTR : 56%, Th/
Ticagrelor 1x20mg terakhir minum tgl
20/8/23 pukul 08.00WIB, valsartan
1x160mg
- Pneumonia klinis nyeri dada -, demam
+, Temp 38,3 C, sesak +, batuk +, RR 24
x/i Ves +/+, Rh-/-, Wh-/- SpO2 98% NK
3Lpm, CXR : Pneumonia, udem
pulmonal Th/-
- DM tipe II GDS saat ini 345 gr/dl, Th/
lantus 1x24iu, novorapid 3x8 iu
- AKI stage I UR/CR 64/1.40 mg/d
- Obese grade I, BMI 30.5 kg/m2, STOP
Bang score 3 intermediate risk of OSA
- Leukositosis 15.45 /mm3
Saran :
- Regulasi GDS <200 gr/dl
Ankle block Ruangan
1
OKA V (Bedah Pastik)
DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K)
Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
2
S, Pr, 61
Thn
fascitis
necroticans ar
left thigh to left
gluteus
Redebridement
ke 6
+necrotomy
dr.
Mirna,SpBPRE
ASA III
- CHF NYHA II-III, TD 103/55 mmhg,
METs 4 klinis nyeri dada-, sesak-,
mudah lelah +, murmur + , gallop -,
EKG : Sinus takikardi QRS rate 106 x/i,
normoaxis, Cxr : kardiomegali (+) CTR:
52%, th/-
- DM Tipe II GDS saat ini 156 mg/dL Th/
Novomix 10-0-10 IU, Lantus 1×14 IU
- Obese grade I BMI 32.3 kg/m2
STOPBANG Score 2 low risk of OSA
- Leukositosis 26.190/mm3
- Hipoalbumin 1.82 gr/dl
- Anemia 8.8 gr/dl
- Riwayat pemakaian heparin, terakhir
tgl 19/8/23
- Kemungkinan sulit intubasi leher
pendek
- Geriatri usia 61 th, frailty score 5
Saran :
- Konsul bagian kardiologi untuk
dilakukan ECHOKoreksi HB >10
gr/dlkoreksi hipoalbumin target >3
gr/dlStop heparin 6 jam sebelum
operasi
General Anestesi-LMA Ruangan
2
OKA V (Bedah Pastik)
DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K)
Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
3
I, LK, 66
Thn
fascitis
necroticans at
regio flank to
scrotal
Redebridement
ke 5
+necrotomy
dr.
Mirna,SpBPRE
ASA II
Geriatri usia 66 thn, frailty scale 4
Kemungkinan sulit ventilasi no teeth
Spinal Anestesi Ruangan
OKA XII (Bedah Saraf)
DPJP: dr Rozi Fadhori, SpAn-TI
2 Rencana Anestesi
OK XII ( Bedah Saraf)
DPJP: dr Rozi Fadhori, SpAn-TI
Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1 F, Pr, 45 Thn
Meningioma ar
temporoparietal
sinistra
Craniotomy removal tumor
dr.Iskandar, SpBS
III GA-CVC-ABP ICU
2 R, Pr, 63 Thn
Meningioma Ar
Frontalis
Craniotomi Removal Tumor
dr. Fitra, SpBS
III GA-CVC-ABP ICU
OK XII ( Bedah Saraf)
DPJP: dr Rozi Fadhori, SpAn-TI
Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1
F, Pr, 45
Thn
Meningioma ar
temporoparietal
sinistra
Craniotomy
removal
tumor
dr.Iskandar,
SpBS
ASA III
- Peningkatan TIK kronik ec Meningioma,
GCS saat ini E4V5M6, klinis nyeri kepala-,
muntah-, kejang+ terakhir 1 bulan yg
lalu, < 5 menit, pandangan kabur-,
gangguan penglihatan-, pupil isokor
3mm/3mm, RCL+/+, Kekuatan motorik
sup et inf 5555/5555, sensorik, dan
otonom dbn, head CT scan: Meningioma
pada lobus parietalis sinistra uk
6.33x5.54x5.47 cm yang mendesak
ventrikel lateralis sinitistra ke arah
dextra, perifocal edema +, midline
deviasi ke arah dextra sejauh 1.28 cm,
edema cerebri difuse, soft tissue tumor
regio temporalis sinistra mengarah
gambaran lipoma, th/-
- HT stg I, TD 147/85 mmhg, METs 5, klinis
nyeri dada-, sesak-, murmur-, gallop-,
EKG SR QRS rate 82 bpm, normoaxis,
CXR: cardiomegali-, Th/-
- Obese class I, BMI 30.2 kg/m², STOP
BANG Score 1, Low risk of OSA
Saran:
- Sedia PRC 4 kolf, FFP 500cc, TC 500cc
GA-CVC-ABP ICU
1
OK XII ( Bedah Saraf)
DPJP: dr Rozi Fadhori, SpAn-TI
Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
2
R, Pr, 63
Thn
Meningioma Ar
Frontalis
Craniotomi
Removal
Tumor
dr. Fitra, SpBS
ASA III
- Peningkatan TIK kronis ec Tumor
intracranial, GCS saat ini E4V5M6 (15),
Klinis nyeri kepala (-) muntah (-) riw
kejang (+) terakhir 2 minggu yg lalu
selama 1-2 menit, pupil isokor
3mm/3mm, Reflek cahaya +/+, kekuatan
motorik sup (5555/5555), kekuatan
motorik inf (5555/5555), sensorik (dbn),
otonom (dbn), CT scan :
Oligodendroglioma, Th/-
- HT terkontrol 111/71 pmmHg, METs 5,
klinis nyeri dada (-), berdebar (-), sesak (-
), murmur (-), gallop (-), EKG : Sinus ritme
QRS rate 81 bpm, Normo axis, CXR :
Cardiomegali (-), th/- Amlodipin 10 mg
- DM tipe 2, GDS 135 gr/dl, th/-
Metformin 2x500mg, vildagliptin 2x50
mg
- CXR : Pneumonia, susp. Plate - like
atelectasis, Fibrosis, klinis Batuk (-),
sesak (-), RR 18x/i, SpO2 97%RA,
ves(+/+) rh(-/-) wh (-/-), th/-
Saran:
- Sedia PRC 4 kolf, FFP 500cc, TC 500cc
GA-CVC-ABP ICU
2
OKA XIV (Bedah Kardiothorax - Vaskular)
DPJP: dr. Rifky Jamal,SpAn-TI
3 Rencana Anestesi
OK XIV ( Bedah Vaskular)
DPJP: dr. Rifky Jamal,SpAn-TI
Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1
C, Pr, 15 Thn,
BB 50 kg
Condroma costae VII
sinistra
Eksisi condroma
dr. Syaltut,SpBTKV
III General Anestesi Ruangan
2 A, Pr, 58 Thn
Gangrene ar digiti II
pedis dextra
Angiography + Angioplasty +
Debridement
dr. Lauhil,SpBVE
III Spinal Anestesi Ruangan
3 H, Pr, 55 Thn
Abses pedis dextra
post debridement
Angiography + Angioplasty +
Debridement
dr. Fachrul Junaidi,SpBVE
III Spinal Anestesi Ruangan
OK XIV ( Bedah Vaskular)
DPJP: dr. Rifky Jamal,SpAn-TI
Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
1
C, Pr, 15 Thn,
BB 50 kg
Condroma
costae VII
sinistra
Eksisi
condroma
dr.
Syaltut,SpBTKV
ASA III
- ISPA hari ke 5. Klinis batuk (+) pilek
(+) demam (-), RR 20 x/i, SpO2 98%
RA Ves (+/+) Rh (-/-) Wh (-/-), CXR :
dbn, th:/-
Saran:
- Konsul divisi anak terkait ISPA. pasien
dengan klinis batuk (+) pilek (+). Mohon
tatalaksana dan evaluasi terkait kondisi
ISPA
General Anestesi Ruangan
1
OK XIV ( Bedah Vaskular)
DPJP: dr. Rifky Jamal,SpAn-TI
Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
2 A, Pr, 58 Thn
Gangrene ar
digiti II pedis
dextra
Angiography +
Angioplasty +
Debridement
dr.
Lauhil,SpBVE
ASA III
- DM tipe II. GDS : 287 mg/dl, th:/
Novorapid 3x8iu, lantus 1x14iu
- Leukositosis 15.950/mm³
Saran:
- Koreksi GDS target 140-180 mg/dl
Spinal Anestesi Ruangan
OK XIV ( Bedah Vaskular)
DPJP: dr. Rifky Jamal,SpAn-TI
Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi
No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op
3 H, Pr, 55 Thn
Abses pedis
dextra post
debridement
Angiography +
Angioplasty +
Debridement
dr. Fachrul
Junaidi,SpBVE
ASA III
- DM tipe II. GDS : 403 mg/dl. Th:/
Levemir 1x10 iu SC
- Hipertensi Stg II. TD : 162/89 mmhg
METs 4-5. Klinis nyeri dada (-) sesak
nafas (-) cepat lelah (+). CXR :
cardiomegaly (-), EKG : sinus ritmis,
QRS rate 117 bpm, normoaxis. Th :/
Amlodipine 1x10mg
- Obese class I. BMI 31,2 kg/m².
STOP BANG skor 3 intermediate risk
of OSA
- kemungkinan sulit ventilasi no
teeth
Saran:
- Koreksi GDS target 140-180 mg/dl
- Koreksi TD target < 150/90 mmhg
- Cek faal koagulasi, PT/APTT
Spinal Anestesi Ruangan
3

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SLide MR 21 Agt 2023 (4).pptx

  • 1. MORNING REPORT PROGRAM STUDI ANESTESIOLOGI DAN TERAPI INTENSIF 21 AGUSTUS 2023 PEMBIMBING dr. Teuku Yasir, SpAn-TI Subsp TI(K) dr. Rifky Jamal, SpAn-TI dr. Hafizh Arief , Sp.An-TI dr. Rahmi, SpAn-TI (K), Subsp AR(K) dr. Rozi Fadhori, SpAn-TI Chief Of Chief dr. Indah Chief Kamar Operasi dr. Aoelia/Fahmi/Ardi/Satria/Muqsith Chief Critical Care dr. Muqsith Chief Poliklinik/Ambulatory dr. Satria Chief Emergency/METS dr. Ardi
  • 2.
  • 4. OKA V (Bedah Plastik) DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K) 4 Rencana Anestesi
  • 5. OKA V (Bedah Pastik) DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K) Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 S, Pr, 36 Thn Adik ipar dr.Indah chronic wound ec diabetic ulcer at right foot Debridement dr. Syamsul Rijal SpBPRE III Ankle blok Ruangan 2 S, Pr, 61 Thn fascitis necroticans ar left thigh to left gluteus Redebridement ke 6 +necrotomy dr. Mirna,SpBPRE III General anestesi-LMA Ruangan 3 I, LK, 66 Thn fascitis necroticans at regio flank to scrotal Redebridement ke 5 +necrotomy dr. Mirna,SpBPRE II Spinal Anestesi Ruangan 4 S, Pr, 82 Thn diabetic ulcer at regio pedis (d) + non vital digiti 3 pedis (d) Redebridement ke 2 + necrotomy dr. Mirna,SpBPRE Pasien ditunda oleh bagian bedah plastik
  • 6. OKA V (Bedah Pastik) DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K) Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 S, Pr, 36 Thn Adik ipar dr.Indah chronic wound ec diabetic ulcer at right foot Debridement dr. Syamsul Rijal SpBPRE ASA III - CHF NYHA III ec CAD 3VD , TD 122/73 mmhg, METs 4 klinis, nyeri dada - sesak +, mudah lelah -, murmur -, gallop -, EKG: SR QRS 92 rate Q patologis di III dan AVF OMI inferior, CXR : Cardiomegali +, CTR : 56%, Th/ Ticagrelor 1x20mg terakhir minum tgl 20/8/23 pukul 08.00WIB, valsartan 1x160mg - Pneumonia klinis nyeri dada -, demam +, Temp 38,3 C, sesak +, batuk +, RR 24 x/i Ves +/+, Rh-/-, Wh-/- SpO2 98% NK 3Lpm, CXR : Pneumonia, udem pulmonal Th/- - DM tipe II GDS saat ini 345 gr/dl, Th/ lantus 1x24iu, novorapid 3x8 iu - AKI stage I UR/CR 64/1.40 mg/d - Obese grade I, BMI 30.5 kg/m2, STOP Bang score 3 intermediate risk of OSA - Leukositosis 15.45 /mm3 Saran : - Regulasi GDS <200 gr/dl Ankle block Ruangan
  • 7. 1
  • 8. OKA V (Bedah Pastik) DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K) Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 2 S, Pr, 61 Thn fascitis necroticans ar left thigh to left gluteus Redebridement ke 6 +necrotomy dr. Mirna,SpBPRE ASA III - CHF NYHA II-III, TD 103/55 mmhg, METs 4 klinis nyeri dada-, sesak-, mudah lelah +, murmur + , gallop -, EKG : Sinus takikardi QRS rate 106 x/i, normoaxis, Cxr : kardiomegali (+) CTR: 52%, th/- - DM Tipe II GDS saat ini 156 mg/dL Th/ Novomix 10-0-10 IU, Lantus 1×14 IU - Obese grade I BMI 32.3 kg/m2 STOPBANG Score 2 low risk of OSA - Leukositosis 26.190/mm3 - Hipoalbumin 1.82 gr/dl - Anemia 8.8 gr/dl - Riwayat pemakaian heparin, terakhir tgl 19/8/23 - Kemungkinan sulit intubasi leher pendek - Geriatri usia 61 th, frailty score 5 Saran : - Konsul bagian kardiologi untuk dilakukan ECHOKoreksi HB >10 gr/dlkoreksi hipoalbumin target >3 gr/dlStop heparin 6 jam sebelum operasi General Anestesi-LMA Ruangan
  • 9. 2
  • 10. OKA V (Bedah Pastik) DPJP: dr. Kulsum,SpAn-TI Subsp.NA (K) Pre Op: dr. Cilu/Sharah-Ira-Siti On Duty: dr. Fariz/Sharah No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 3 I, LK, 66 Thn fascitis necroticans at regio flank to scrotal Redebridement ke 5 +necrotomy dr. Mirna,SpBPRE ASA II Geriatri usia 66 thn, frailty scale 4 Kemungkinan sulit ventilasi no teeth Spinal Anestesi Ruangan
  • 11. OKA XII (Bedah Saraf) DPJP: dr Rozi Fadhori, SpAn-TI 2 Rencana Anestesi
  • 12. OK XII ( Bedah Saraf) DPJP: dr Rozi Fadhori, SpAn-TI Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 F, Pr, 45 Thn Meningioma ar temporoparietal sinistra Craniotomy removal tumor dr.Iskandar, SpBS III GA-CVC-ABP ICU 2 R, Pr, 63 Thn Meningioma Ar Frontalis Craniotomi Removal Tumor dr. Fitra, SpBS III GA-CVC-ABP ICU
  • 13. OK XII ( Bedah Saraf) DPJP: dr Rozi Fadhori, SpAn-TI Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 F, Pr, 45 Thn Meningioma ar temporoparietal sinistra Craniotomy removal tumor dr.Iskandar, SpBS ASA III - Peningkatan TIK kronik ec Meningioma, GCS saat ini E4V5M6, klinis nyeri kepala-, muntah-, kejang+ terakhir 1 bulan yg lalu, < 5 menit, pandangan kabur-, gangguan penglihatan-, pupil isokor 3mm/3mm, RCL+/+, Kekuatan motorik sup et inf 5555/5555, sensorik, dan otonom dbn, head CT scan: Meningioma pada lobus parietalis sinistra uk 6.33x5.54x5.47 cm yang mendesak ventrikel lateralis sinitistra ke arah dextra, perifocal edema +, midline deviasi ke arah dextra sejauh 1.28 cm, edema cerebri difuse, soft tissue tumor regio temporalis sinistra mengarah gambaran lipoma, th/- - HT stg I, TD 147/85 mmhg, METs 5, klinis nyeri dada-, sesak-, murmur-, gallop-, EKG SR QRS rate 82 bpm, normoaxis, CXR: cardiomegali-, Th/- - Obese class I, BMI 30.2 kg/m², STOP BANG Score 1, Low risk of OSA Saran: - Sedia PRC 4 kolf, FFP 500cc, TC 500cc GA-CVC-ABP ICU
  • 14. 1
  • 15. OK XII ( Bedah Saraf) DPJP: dr Rozi Fadhori, SpAn-TI Pre Op: dr. Chalis/Emil On Duty: dr. Chalis/Emil No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 2 R, Pr, 63 Thn Meningioma Ar Frontalis Craniotomi Removal Tumor dr. Fitra, SpBS ASA III - Peningkatan TIK kronis ec Tumor intracranial, GCS saat ini E4V5M6 (15), Klinis nyeri kepala (-) muntah (-) riw kejang (+) terakhir 2 minggu yg lalu selama 1-2 menit, pupil isokor 3mm/3mm, Reflek cahaya +/+, kekuatan motorik sup (5555/5555), kekuatan motorik inf (5555/5555), sensorik (dbn), otonom (dbn), CT scan : Oligodendroglioma, Th/- - HT terkontrol 111/71 pmmHg, METs 5, klinis nyeri dada (-), berdebar (-), sesak (- ), murmur (-), gallop (-), EKG : Sinus ritme QRS rate 81 bpm, Normo axis, CXR : Cardiomegali (-), th/- Amlodipin 10 mg - DM tipe 2, GDS 135 gr/dl, th/- Metformin 2x500mg, vildagliptin 2x50 mg - CXR : Pneumonia, susp. Plate - like atelectasis, Fibrosis, klinis Batuk (-), sesak (-), RR 18x/i, SpO2 97%RA, ves(+/+) rh(-/-) wh (-/-), th/- Saran: - Sedia PRC 4 kolf, FFP 500cc, TC 500cc GA-CVC-ABP ICU
  • 16. 2
  • 17. OKA XIV (Bedah Kardiothorax - Vaskular) DPJP: dr. Rifky Jamal,SpAn-TI 3 Rencana Anestesi
  • 18. OK XIV ( Bedah Vaskular) DPJP: dr. Rifky Jamal,SpAn-TI Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 C, Pr, 15 Thn, BB 50 kg Condroma costae VII sinistra Eksisi condroma dr. Syaltut,SpBTKV III General Anestesi Ruangan 2 A, Pr, 58 Thn Gangrene ar digiti II pedis dextra Angiography + Angioplasty + Debridement dr. Lauhil,SpBVE III Spinal Anestesi Ruangan 3 H, Pr, 55 Thn Abses pedis dextra post debridement Angiography + Angioplasty + Debridement dr. Fachrul Junaidi,SpBVE III Spinal Anestesi Ruangan
  • 19. OK XIV ( Bedah Vaskular) DPJP: dr. Rifky Jamal,SpAn-TI Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 1 C, Pr, 15 Thn, BB 50 kg Condroma costae VII sinistra Eksisi condroma dr. Syaltut,SpBTKV ASA III - ISPA hari ke 5. Klinis batuk (+) pilek (+) demam (-), RR 20 x/i, SpO2 98% RA Ves (+/+) Rh (-/-) Wh (-/-), CXR : dbn, th:/- Saran: - Konsul divisi anak terkait ISPA. pasien dengan klinis batuk (+) pilek (+). Mohon tatalaksana dan evaluasi terkait kondisi ISPA General Anestesi Ruangan
  • 20. 1
  • 21. OK XIV ( Bedah Vaskular) DPJP: dr. Rifky Jamal,SpAn-TI Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 2 A, Pr, 58 Thn Gangrene ar digiti II pedis dextra Angiography + Angioplasty + Debridement dr. Lauhil,SpBVE ASA III - DM tipe II. GDS : 287 mg/dl, th:/ Novorapid 3x8iu, lantus 1x14iu - Leukositosis 15.950/mm³ Saran: - Koreksi GDS target 140-180 mg/dl Spinal Anestesi Ruangan
  • 22. OK XIV ( Bedah Vaskular) DPJP: dr. Rifky Jamal,SpAn-TI Pre Op: dr. Cilu/Radhi On Duty: dr. Cilu/Dipi No Nama Diagnosa Prosedur Status Fisik Tatalaksana Post Op 3 H, Pr, 55 Thn Abses pedis dextra post debridement Angiography + Angioplasty + Debridement dr. Fachrul Junaidi,SpBVE ASA III - DM tipe II. GDS : 403 mg/dl. Th:/ Levemir 1x10 iu SC - Hipertensi Stg II. TD : 162/89 mmhg METs 4-5. Klinis nyeri dada (-) sesak nafas (-) cepat lelah (+). CXR : cardiomegaly (-), EKG : sinus ritmis, QRS rate 117 bpm, normoaxis. Th :/ Amlodipine 1x10mg - Obese class I. BMI 31,2 kg/m². STOP BANG skor 3 intermediate risk of OSA - kemungkinan sulit ventilasi no teeth Saran: - Koreksi GDS target 140-180 mg/dl - Koreksi TD target < 150/90 mmhg - Cek faal koagulasi, PT/APTT Spinal Anestesi Ruangan
  • 23. 3