PARADE

31 JANUARI 2020
OKA II ( Obgyn)

DPJP : dr. Kulsum, SpAn

3 Rencana Anestesi
 OK II (OBGYN)
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Huzaival
●
3 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
S, Pr, 48th ● ●
Laparotomi ●
ASA II ●
General ●
Ruang
AUB dd
●
Histerectomy ●
- Anemia 10,3 Anestesi- an
Sarcoma Uteri + ●

Ca Endometrium dr. Sarah Ika SpOg Epidural

● ●

● 2 ●
W, Pr, 65th ● ●
Debulking ASA III
● ●
General ●
HCU
●
NOK Susp. Tumor ●
- DM tipe 2, GDS 212, Anestesi-
Ganas + DM tipe ●

II dr. Sarah Ika SpOg th/Apidra 8-8-8. Lantus 0-0-0- Epidural

● ● 10 -EKG: Tinverted V1-V6 nyeri
● dada -, Mets 4-5 th/-
●
-Geriatri 65th
●
Saran: regulasi GDS, target
<200 Jika target tercapai
● 3 ●
D, Pr, 53th ●
Ca Endometrium ● ●
ASA II ●
General ●
Ruang
Post Kemo 3x ● Surgical Staging ● - Riwayat kemoterapi 3siklus, Anestesi- an
●

dr. Sarah Ika SpOg terakhir kemo 6/1/2020 Epidural

●
●
-Leukopenia 2500
 OKA III ( THT)

DPJP : dr. Azwar Risyad, SpAn

3 Rencana Anestesi
 OK III (THT)
●

● DPJP: dr. Azwar Risyad, SpAn

●
PPDS : dr. Fadhil
●
3 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
H, Lk, 50th ●
OMSK tipe ●
Thympanoplasty ●
ASA I General Ruangan
Aman Fase Tipe II Dex ●
Anestesi ●

Tenang Dex ●
- Lab dalam batas normal ●
●
dr. Azwar - Tanpa penyulit airway
SpTHT-KL
● 2 ●
E, Lk, 36th ●
Coloid goiter ●
Thyroidectomy ●
ASA I General Ruangan
Anestesi
● ●

●
dr. T. Husni - Lab dalam batas normal
SpTHT-KL - Tanpa penyulit airway

● 3 ●
MR, Lk, 12th ●
Tonsilitis Kronik ●
Tonsilectomy ●
ASA I General Ruangan
Hipertropi ● ●
Anestesi
●
dr. Novina - Lab dalam batas normal
SpTHT - Tanpa penyulit airway
 OKA IV
( Bedah Anak dan Bedah Digestiv)

DPJP : dr. Azwar Risyad, SpAn

2 Rencana Anestesi
 OK IV●

●
(Bedah Anak dan Bedah Digestive)
● DPJP: dr. Azwar Risyad SpAn

●
PPDS : dr. Aulia/ Hidayati
●
2 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
By.Ny.IK, 1 ●
Hisprung ●
TETP ●
ASA III ●
General ●
PICU
Bln Disease ●
Dr. T. Yusriadi ●
- PCA 37 minggu, VACTERL +, Anestesi
●
BB2,5kg SpBA
PFO L to R shunt, Sianosis (-)
●
- Hiperbillirubinemia Bil (T/D/I) :
8,2/0,6/7,57, Ikterik (+)
●
- Anemia 10,8g/dl
●
- Trombositosis 575.000
● 2 ●
CE, Pr, 34th ●
Ca Esofagus ● ●
ASA II ●
GA-CVC- ●
ICU
●
Gastric Pull Up ●
- EKG: T inv. II,III, AVF, V3-V5, ABP
Pers.
Thoracotomy Echo: Sistolik LV dan RV normal
● EF: 67%, Globalnormokinetik,
●
dr. Yusuf SpB- Katup-katup normal, Mets 5,
KBD Nyeri dada -,
●
+ - Hipoalbumin 2,9
●
dr. Yopie
SpBTKV - Anemia 10,3
 OKA V
( Bedah Orthopedi dan Bedah Saraf)

DPJP : dr. Azwar Risyad , SpAn

2 Rencana Anestesi
 ●
OKA V
( Bedah Orthopedi dan Bedah Saraf )
● DPJP: dr. Azwar Risyad, SpAn

●
PPDS : dr. Ryan/Dedy
●
2 Rencana Anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
TM, Lk, 2th ●
Union Fr. ●
ROI ● ●
General ●
Ruang
●
BB Supracondiler ●
●
ASA II Anestesi an
Humerus Sin ●
dr. Onarisa Putri ●
SpOT
●
-Anemia 10.8 g/dl
● 2 ●
UK, Pr, 44th ●
Hemangioma ●
Removal Tumor ● ●
GA-CVC ●
ICU
ASA III -ABP
●
●
●
dr. Iskandar
SpBS
●
-Hemiparese dextra , dextra
kekuatan motorik superior
44444/55555 , inferior
44444/55555, parese N VII &
XIII , klinis : nyeri kepala (+),
mulut merot (+),CT scan :
massa regio
frontotemporoparietal kiri
dengan midline shift ke kanan
dd meniongoma,
●
Th: - citicolin 1000mg/12 jam ,
piracetam 1200 mg /12 jam

- leukositosis 16.000 mm3

2
 OKA VI ( Mata)

DPJP : dr. Yusmalinda, SpAn

2 Rencana Anestesi
 ●
OKA VI ( Mata )
● DPJP: dr. Yusmalinda SpAn

●
2 Rencana Anestesi
●
1
PPDS : dr. Aulia/ Aldilla
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
RU, Pr, 84th ●
Ulkus Kornea ●
Reformince ● ●
General ●
Ruang
Perforasi COA + Amnion ●
ASA II Anestesi- an
membran graft - HT stage I, TD 142/82,METs LMA
●
>6,EKG SR HR 84 x/i, CXR
●
dr. Cut Putri, cardiomegali (-), murmur
SpM
(-),
gallop (-)
- Leukositosis 12900

● 2 ●
SA, Pr, 12th Ulkus Kornea ●
Periosteal Graft ●
ASA I ●
General ●
Ruang
●
BB 29kg Sinistra ●
- Lab dalam batas normal Anestesi- an
● ●
dr. Enni, SpM
- Tanpa penyulit airway LMA
1
OKA VII ( Bedah Onkologi )

DPJP : dr. Yusmalinda, SpAn

1 Rencana Anestesi
 ●
OKA VII ( Bedah Onkologi)
● DPJP: dr. Yusmalinda SpAn
●
PPDS : dr. Ryan/ Aldilla
●
1 Rencana Anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksan ● Post Op
o a
● 1 ●
MH, Lk, 57th ●
STT ar Thorak ●
Eksisi ●
ASA I ●
General ● Ruangan
Poterior ●
- Lab dalam batas normal, Anestesi
●
dr. Nur Faisal
SpB(k)Onk - Tanpa penyulit airway.
1
OKA VIII ( Bedah Orthopaedi )

DPJP : dr. Yusmalinda, SpAn

10 Rencana Anestesi
 OK VIII (Bedah Orthopaedi)
●

● DPJP: drYusmalinda SpAn

●
PPDS : dr. Ryan/Wahyuni/ Rosalia/ Ardiansyah
●
10 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
N, Pr, 42th ●
Burst Fr. VT ●
ROI ASA I
● ●
General ●
Ruang
Lumbal 1 post ● ●
- Lab dalam batas normal Anestesi an
Stabilisasi ●
Dr. Azharuddin ●
- Tanpa Penyulit Airway
Posterior SpOT
● 2 ●
J, Pr, 75th ●
Close Neck ● ●

Femur Dekstra ●
Bipolar ASA III
●

artroplasty - Hipertensi Terkontrol, TD

●
113/49mmHg, METs 3-4,
Dr. Azharuddin EKG : atrial fibrilasi HR
SpOT 120bpm, CXR :
●
cardiomegali (-) Th/
candesartan 1x8mg,
concor 1x1,25mg, digoxin
1x0,5mg, furosemid
1x40mg
- geriatri 75 thn
- Kemungkinan sulit ventilasi :
no teeth
-
Saran : Konsul Kardiologi untuk
evaluasi AF RVR
 OK VIII (Bedah Orthopaedi)
●

● DPJP: drYusmalinda SpAn

●
PPDS : dr. Ryan/Wahyuni/ Rosalia/ Ardiansyah
●
10 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 3 ●
I, Lk, 37th ●
Bone ekspose ● ●
ASA II ●
Spinal ●
Ruang
post ORIF Tibia ●
ROI ●
- hipernatremia, Na 147 Anestesi an
Fibula ●

Dr. Azharuddin
SpOT
●

● 4 ●
MR, Lk, 14th ●
OMC Cruris ●
Debridement ●
ASA II ●
General ●
Ruang
Dekstra ● ●
- Anemia Hb 12,9 Anestesi an
●
Dr. Ona SpOT
 OK VIII (Bedah Orthopaedi)
●

● DPJP: drYusmalinda SpAn

●
PPDS : dr. Ryan/Wahyuni/ Rosalia/ Ardiansyah
●
10 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 5 ●
Y, Pr, 60th ●
Close Humerus ●
ORIF ● ●
General ●
Ruang
Dekstra ●
ASA III
●
Anestesi an
●
Dr. T. Nanta - Hipertensi stage II TD
SpOT 180/92mmHg, METs 5-6,
EKG : Sinus Ritme 90bpm,
CXR cardiomegali CTr 55%,
Th/ candesartan 1x16mg,
amlodipin 1x10mg, HCT
1x25mg
- DM Type 2, GDS 186mg/dl Th/
lantus 0-0-0-11, metformin
3x500mg
Saran : Regulasi Tekanan Darah,
Target TD < 140mmHg
● 6 ●
RE, Lk, 58th ●
Fr ●
ORIF persiapan ●
ASA III ●
Spinal Ruangan
Subtrocanther THR - Hipertensi terkontrol, TD Anestesi ●

Dekstra ●
120/60mmHg, METs 4-5,
Dr. T. Nanta SpOT EKG : Q patologis lead III,
●
aVF, Sinus Ritme 62bpm,
LVH
Th/ candesartan 1x16mg, concor
1x1,25mg
 OK VIII (Bedah Orthopaedi)
●

● DPJP: drYusmalinda SpAn

●
PPDS : dr. Ryan/Wahyuni/ Rosalia/ Ardiansyah
●
10 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 7 ●
H, Pr, 43th ●
Fr Radius ●
ORIF ●
ASA II ●
General ●
Ruang
Dekstra ●
- Obese grade II, BMI 35kg/m2, Anestesi an
●
Dr. T. Nanta STOPBANG score 2, Low
SpOT risk For OSA
- Leukositosis 11.100
● 8 ●
CH, Pr, 51th ●
Fr Clavicula 1/3 ●
ORIF ●
ASA II ●
General ●
Ruang
Lateral Dekstra ●
- Ht stage I, TD 140/90mmHg, Anestesi an
●
Dr. T. Nanta METs 4-5, EKG : Sinus
SpOT Ritme 80bpm, T inverted II,
●
III, aVF, nyeri dada (-),
sesak nafas (-) CXR :
cardiomegali 58% Th/
Amlodipin 1x10mg
- leukositosis 13.200
● 9 ●
AJ, Lk, 20th ●
Neglected Fr ●
Rekonstruksi + ASA I ●
General ●
Ruang
Clavicula ORIF - Lab dlm batas normal Anestesi an
● -
●
Dr. T. Nanta
SpOT
● 1 ●
HS, Lk, 19th ●
Implant Failure ●
Revisi + Re ASA I ●
General ●
Ruang
0
ar Femur ORIF - Lab dlm batas normal Anestesi an
●

●
2
5
6
8
OKA Endos/Bronkos

DPJP : dr. Kulsum, SpAn

8 Rencana Anestesi
 OK Endos/Bronkos
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Liza/ Hafizh/ Mahyal/ Indah
●
8 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 1 ●
DS, Pr, 54th ●
Gastroparese ●
EGD ● ●
Sedasi ●
Ruang
ec DM ●
ASA III
●
an
●
Dr. dr. Fauzi ●
- Dyspnea ec distensi
Yusuf, SpPD- abdomen, LP 111 cm, perkusi
KGEH Hiperthympani, RR 26 x/menit,
vesikuler (+), Rh dan Wh (-),
SpO2 95 % Room Air.
- DM tipe II, GDS 226 mg/dl, th
Lantus 1x14 Iu, Apidra 3x 6
Iu
- Hipokalemia 3.3 mmol/L
- Anemia Hb 10.6 gr/dl
- Instabilitas suhu, Temp : 39.8 C
●

●
Saran :
●
1. Regulasi suhu 36.5-37.5 C
●
2. Koreksi kalium target 3.5-5
mmol/L
●
3. Regulasi GDS target GDS
120-180 mg/dl
●
Jika target tercapai
●
 OK Endos/Bronkos
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Liza/ Hafizh/ Mahyal/ Indah
●
8 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 2 ●
HH, Lk, 39th ●
Dyspepsia ●
EGD ●
ASA II ●
Sedasi ●
Ruang
●
- DM terkontrol, GDS 119 an
●
Dr. dr. Fauzi mg/dl, th novorapid 3x20
Yusuf, SpPD- IU
KGEH - anemia Hb 11.1 gr/dl
● 3 ●
M, Lk, 35th ●
Dyspepsia ●
EGD ●
ASA I ●
Sedasi ●
Ruang
●
- Lab dalam batas normal an
●
Dr. dr. Fauzi - Tidak ada penyulit airway
Yusuf, SpPD-
KGEH
● 4 ●
RM, Pr, 50th ●
PSMBA + ●
EGD + ● ●
Sedasi ●
Ruang
PSMBB kolonoskopi ●
ASA III an
GA ●

●
- HT stage I, TD 150/90 mmHg,
Dr. dr. Fauzi METs 6, EKG SR dengan
Yusuf, SpPD- QRS rate 86x/menit
KGEH dengan RBBB inkomplit,
●
klinis nyeri dada (-), CXR
CTR 56% Cardiomegali
dengan kongestive paru
- Anemia Hb 9.7 gr/dl
 OK Endos/Bronkos
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Liza/ Hafizh/ Mahyal/ Indah
●
8 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 5 ● WM, Pr, 29thn ●
PSMBA ● ●
ASA II ●
Sedasi ●
Ruang
●
EGD
●
-HBsAg Reaktif, peningkatan an
●
fungsi Hati, SGOT/PT : 32/56,
demam (-).
●
Dr. dr. Fauzi
Yusuf, SpPD-
KGEH
●

● 6 ●
HA, Lk, 47th ●
Tumor paru ●
Bronkoskopi ●

kanan ●
●
ASA Ill
dr. Herry SpP
●
●
●
- Hipertiroid. FT4 21,48; TSHs 0,214.
Klinis palpitasi (+2) nafsu makan
meningkat (+2), lebih senang
suasana dingin (+5) kelelahan (+2),
tidak teraba massa tiroid (-3), tidak
terdengar bruit tiroid (-3), BB turun
(+3) tangan hangat (+2). Wayne
index score 13. Th propanolol
2x10mg, tyrozol 2x10mg
●
- CXR tumor paru kanan, ves (+/+) rh
(-/-), Wh (-/-). Spo2 96%. RR 20 x/i.
Batuk (+), dahak (+)
●
- DM tipe 2, GDS 150, th/ apidra 8-
8-8, lantus 0-0-0-10 unit.
●
 OK Endos/Bronkos
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Liza/ Hafizh/ Mahyal/ Indah
●
8 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksana ● Post
o Op
● 7 ●
TA, Lk, 59th ●
Tumor paru ●
Bronkoskopi ● ●
General ●
Back
kanan ● ●
ASA III Anestesi Up
●
dr. Herry SpP
●
- Tumor paru kanan, dengan ICU
sindroma vena cava superior. edema
pada wajah, JVP meningkat R+3cm.
venektasi (-) klinis sesak (-) RR 28x/i,
ves (menurun/+), rh (-/-), Wh (-/-),
Spo2 93-95% RA. Pasien tidak bisa
tidur terlentang lama. CXR:
fibroinfiltrat di paru kiri dan kanan,
kesan TB. Tidak ada pemeriksaan
gene expert. Th/ levofloxacin
750mg/hari (H8), combivent nebul,
ventolin nebul.
●
- Angina pectoris stabil. Nyeri dada
(-). Murmur (-), gallop (-), EKG: Sinus
Takikardia, HR 100x/mnt, T inverted
lead I, II, V4-V6. Echo: EF 69%, global
normokinetik, katup2 normal.
●
Th/ concor, nitrocaf retard,
spironolakton.
●
- Leukositosis 22000/mm3
●
- Trombositosis 762000/mm3
 OK Endos/Bronkos
●

● DPJP: dr. Kulsum, SpAn

●
PPDS : dr. Liza/ Hafizh/ Mahyal/ Indah
●
8 Rencana anestesi
● N ● Nama ● Diagnosa ● Prosedur ● Status Fisik ● Tatalaksan ● Post
o a Op
● 8 ●
YK, Lk, 30th ●
Tumor paru ●
Bronkoskopi ● ●
General ●
Back
●
ASA III Anestesi Up
●
ICU
- CXR: fibroinfiltrat di paru
kanan dan kiri, konsolidasi
di paru kanan atas (kesan
TB paru) Gen Expert: tidak
ditemukan MTB. Ves (+/+)
wh -/-, rh +/-. RR 22-26x/i
SpO2 : 92-96% via nasal
kanul 5 Lpm.
- Pasien tidak bisa tidur
terlentang.
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