Parade_30_April_2024_(2)[1] fixx(1).pptx

morning report

1. MORNING REPORT PROGRAM STUDI ANESTESIOLOGI DAN TERAPI INTENSIF 30 April 2024 PEMBIMBING Dr. dr. Zafrullah Khany Jasa, SpAn -TI, Subsp. NA(K) dr. Rahmi, SpAn-TI, Subsp. AR(K) dr. Yusmalinda , SpAn -TI, Subsp AO (K) dr. Hafizh Arief , Sp An-TI dr. Rossalia Yuliana, SpAn -TI Chief Of Chief dr. Rio Chief Kamar Operasi dr. Muqsith /Arshad Chief Critical Care dr. Fariz Chief Poliklinik /Ambulatory dr. Dede Chief Emergency/METS dr. Cilu

2. OKA III ( Bedah Onkologi ) DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) 4 Rencana Anestesi

3. OK III ( Bedah Onkologi ) O K CITO DPJP : DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Siti/Dedi -Tiana 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 N, Pr , 37th Tumor Intrabuchal Dextra Insisi Biopsi dr. Noer Faisal, Sp.B K- Onk III General Anestesi HCU 2 AH, Pr , 26Th Tumor Phyloides Mammae Sinistra Simple Mastectomy dr. Noer Faisal, Sp.B K- Onk II General Anestesi Ruangan 3 D, Pr , 24Th Tumor Kulit Ar Facialis Eksisi Tumor dr. Noer Faisal, Sp.B K- Onk I General Anestesi -LMA Ruangan 4 SH, Pr , 30th Tumor tyroid bilateral + tumor trakea post Trakeostomy Total Tiroidektomi dr. Noer Faisal, Sp.B K- Onk III General Anestesi ICU

4. ) OK III ( Bedah Onkologi ) O K CITO DPJP : DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Siti/Dedi -Tiana 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 N, Pr , 37th Tumor Intrabuchal Dextra Insisi Biopsi dr. Noer Faisal, Sp.B K- Onk ASA III - Kemungkinan sulit intubasi dan ventilasi , krn massa mudah berdarah , sulit buka mulut <3jari, no teeth - Hipertensi terkontrol , TD : 132/89 mmHg, METs 5, klinis nyeri dada (-), sesak napas (-), berdebar (-), cepat lelah (+) Gallop (-), Murmur (-), EKG: Sinus Takikardia , QRS rate 104 bpm, RAD, LAD, Cardiomegali (+), CTR 55%, th / amlodipin 1x5mg - Leukositosis 20,220/mm3 - Trombositosis 538.000/mm3 - Geriatri usia 73Th, frailty scale 5 General Anestesi HCU

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6. ) OK III ( Bedah Onkologi ) O K CITO DPJP : DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Siti/Dedi -Tiana 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 AH, Pr , 26Th Tumor Phyloides Mammae Sinistra Simple Mastectomy dr. Noer Faisal, Sp.B K- Onk ASA II - Airway clear - Anemia Hb 9,3 gr/dL - Trombositosis 580.000/mm3 - Leukositosis 12,670/mm3 General Anestesi Ruangan

7. ) OK III ( Bedah Onkologi ) O K CITO DPJP : DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Siti/Dedi -Tiana 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 D, Pr , 24Th Tumor Kulit Ar Facialis Eksisi Tumor dr. Noer Faisal, Sp.B K- Onk ASA I - Airway clear - Lab dalam batas normal General Anestesi - LMA Ruangan

8. ) OK III ( Bedah Onkologi ) O K CITO DPJP : DPJP: dr. Rahmi, SpAn-TI, Subsp AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Siti/Dedi -Tiana 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 SH, Pr , 30th Tumor tyroid bilateral + tumor trakea post Trakeostomy Total Tiroidektomi dr. Noer Faisal, Sp.B K- Onk ASA III - Airway clear on trakeostomi - Tracheostomi in situ ai tumor colli klinis batuk (-), sesak (-), demam (-), RR 20x/ i , SpO2 95% RA, Ves +/+, Rh -/-, Wh -/-, CXR : Pneumonia, terpasang tracheostomi tube dengan tip distal setinggi korpus VT2, Th/- - Hipertensi stage I, TD saat ini 159/89 mmHg, METs 4, klinis nyeri dada (-), sesak napas (-) berdebar , cepat lelah (+) Gallop (-), Murmur (-), EKG : Sinus Takikardia , QRS rate 105 bpm, normoaxis , CXR Cardiomegali (+), CTR 55%, Th/ - Valsartan2x160mg, Amlodipin 1x10mg - Obesitas grade II BB 94.5 kg, TB 163 cm,BMI 35.6 kg/m2, STOP BANG SCORE 3 intermediate risk of OSA General Anestesi ICU

9. OKA IV ( Bedah Digestif) DPJP: dr. Rahmi, SpAn-TI, Subsp. AR(K) 4 Rencana Anestesi

10. OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 dr. M. yusuf , Sp.B , Subsp.BD (K) III Spinal Anestesi Ruangan 2 dr. M. yusuf , Sp.B , Subsp.BD (K) II Epidural - General Anestesi Ruangan 3 dr. M. yusuf , Sp.B , Subsp.BD (K) III Epidural - General Anestesi HCU 4 IV OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 MI, Pr , 78 Th Hernia Incisional Repair Defect Hernia dr. M. yusuf , Sp.B , Subsp.BD (K) III Spinal Anestesi Ruangan 2 S, Pr , 46 Th Obs Jaundice Ec Batu Common Bile Duct Laparotomy Explore Common Bile Duct + Intraoperative Cholangiogram + T-tube + Cholesistectomy dr. M. yusuf , Sp.B , Subsp.BD (K) II Epidural - General Anestesi Ruangan 3 M, Lk, 41 Th Obs Jaundince Ec Batu Common Bile Duct Laparotomy Explore Common Bile Duct + Intraoperative Cholangiogram + T-tube + Cholesistectomyl dr. M. yusuf , Sp.B , Subsp.BD (K) III Epidural - General Anestesi HCU 4 K, Pr , 69 Th Partial Malignant Bowel Obstruction Ec Susp Gist Dd Fibromyoma Laparotomi Biopsi dr. M. yusuf , Sp.B , Subsp.BD (K) III Spinal Anestesi Ruangan

11. ) OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 MI, Pr , 78 Th Hernia Incisional Repair Defect Hernia dr. M. yusuf , Sp.B , Subsp.BD (K) ASA III Kemungkinan sulit ventilasi no teeth Hipertensi stage II, TD saat ini 160/90 mmhg , METs 5, klinis nyeri dada (-), sesak napas (-), berdebar (-), cepat lelah (-), gallop (-), murmur (-), Ekg : sinus ritme qrs rate 67 bpm, normoaxis , early repolarization, Cxr : Cardiomegally (-), ECHO: tgl 9/11/2023 : Katup-katup MR Mild, TR Mild, Dimensi ruang-ruang jantung Normal, Tidak tampak trombus / vegetasi intrakardiak Bangsi sistolik LV Normal (EF 78% by Teich ), Fungsi sistolik RV Normal (TAPSE 2.0 cm), Fungsi Diastolik LV tidak dapat dievaluasi (AF), Terdapat LV Konsentrik Remodelling , Th/ Amlodipin 1x5 mg DM tipe 2, GDS saat ini 128 mg/dl, Th/ Metformin 2x1 Geriatri usia 78 tahun , frailty scale 5 Spinal Anestesi Ruangan

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14. ) OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 S, Pr , 46 Th Obs Jaundice Ec Batu Common Bile Duct Laparotomy Explore Common Bile Duct + Intraoperative Cholangiogram + T-tube + Cholesistectomy dr. M. yusuf , Sp.B , Subsp.BD (K) ASA II Tanpa penyulit Airway Obs Jaundice ec batu CBD, klinis ikterik (+), Bil T/D/I: 20,11/9,84/10,27. SGOT/SGPT: 189/80, HBsAg non reaktif . Anemia Hb 10,6 g/dl Leukositosis 11.670/mm3 Trombositosis 558.000/mm3 Hipoalbumin 2,8 g/dl Hipokalemia 3,2 mmol/l Epidural - General Anestesi Ruangan

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20. ) OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 M, Lk, 41 Th Obs Jaundince Ec Batu Common Bile Duct Laparotomy Explore Common Bile Duct + Intraoperative Cholangiogram + T-tube + Cholesistectomyl dr. M. yusuf , Sp.B , Subsp.BD (K) ASA III Tanpa penyulit airway Obs Jaundice ec batu CBD, klinis ikterik (+), Bil T/D/I : 5,44/3,88/1,56. SGOT/SGPT : 75/113, HBsAg non reaktif . Obs seizure ec metabolik encepalopti , riwayat kejang 1x (+) 2 hari yll . GCS saat ini E4M6V5. Bil T/D/I : 5,44/3,88/1,56. SGOT/SGPT : 75/113, HBsAg non reaktif . Na/K/: 138/3,90/104. Th/ - Riwayat TB paru tuntas berobat tahun 2021 Klinis sesak (-), Batuk (-), batuk darah (-), penurunan bb (-), nafsu makan menurun (-), RR 20 x/ i , Sp02 97% RA, Ves +/+, Rh -/- wh -/-, CXR: keradangan paru , cor tak tampak kelainan Th/ - DM tipe 2, GDS saat ini 128 mg/dl, Th/ - Epidural - General Anestesi HCU

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26. ) OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 K, Pr , 69 Th Partial Malignant Bowel Obstruction Ec Susp Gist Dd Fibromyoma Laparotomi Biopsi dr. M. yusuf , Sp.B , Subsp.BD (K) ASA III Massa intra abdomen, Lp 86 cm, Venektasi (-), Asites (-), Nyeri tekan (-), Defans muscular (-), Klinis : Sesak napas (-), Demam (-), RR 20 x/ menit , SpO2 97% RA, Ves (+/+), Rh (-/-), Wh (-/-), Pasien dapat tidur terlentang (+), tidak terpasang NGT, Ct Scan Abdomen dengan kontras : massa solid cystic, batas tegas , tepi lobullated disertai hipervaskularisasi didalamnya , uk 18,7x10,6x20,9 cm, di cavum abdomen intraperoneal , mendesak pangkreas dan gaster ke sisi posterior, hepar ke sisi superior, dan usus ke sisi inferior, multiple limpadenopaty di inguinal kanan kiri (<1cm), messerentherical lymphnode ( uk 3,3cm) di hemi abdominal kanan , liver calcification, tak tampak nodul di hepar , kista di upper pole ginjal kanan , spondyloarhrosis , degeneratif disct disease, tak tampak bone metastase , Th/- >>>>>> Spinal Anestesi Ruangan

27. ) OKA IV ( Bedah Digestif) O K CITO DPJP : dr. Rahmi, SpAn-TI, Subsp. AR(K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/Burhan/ R ochida 4 Tatalaksana Anestesi On Duty: dr. Afdhal/Rahmat No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op Anemia Hb 10, 7 g/dl Geriatri usia 69 tahun , frailty scale 4 Saran: Sedia darah PRC 2 kolf Spinal Anestesi Ruangan

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33. OKA VI (Mata) DPJP: Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) 4 Rencana Anestesi

34. OK VI (MATA) O K CITO DPJP : Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Audy / Gita 4 Tatalaksana Anestesi On Duty: dr. Rinda/ Audy No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 SH, Pr , 73 Th Glaucoma + Katarak hipermatur OS Triple Procedure dr. Yulia, Sp. M (K) III General Anestesi Ruangan 2 B, Lk, 55 Th Glaucoma OD Triple Procedure dr. Yulia, Sp. M (K) II General Anestesi -LMA Ruangan 3 MR, LK 8 Th BB: 20 Kg Katarak Traumatik OS AI+ IOL dr. Eva, Sp. M I General Anestesi -LMA Ruangan 4 AA, Lk, 11 Th BB: 27 Kg Kataract Traumatic OD+ Glaucoma Triple Procedure dr. Eva, Sp. M I General Anestesi -LMA Ruangan

35. ) OK VI (MATA) O K CITO DPJP : Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Audy / Gita 4 Tatalaksana Anestesi On Duty: dr. Rinda/ Audy No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 SH, Pr , 73 Th Glaucoma + Katarak hipermatur OS Triple Procedure dr. Yulia, Sp. M (K) ASA III Kemungkinan Sulit Ventilasi usia 73 tahun Bradikardia asimptomatik , klinis nyeri dada (-), riwayat sinkop (-), TD: 132/65 mmHg, HR: 53 Bpm, EKG: Sinus Bradikardia Qrs Rate 47 Bpm normoaxis , CXR: Cardiomegali CTR: 55%, Th/- - Geriatri Usia 73 thn , Frailty Scale 3 General Anestesi Ruangan

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37. ) OK VI (MATA) O K CITO DPJP : Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Audy / Gita 4 Tatalaksana Anestesi On Duty: dr. Rinda/ Audy No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 B, Lk, 55 Th Glaucoma OD Triple Procedure dr. Yulia, Sp. M (K) ASA II Tanpa Penyulit airway Hipertensi stage 1, TD: 147/95 mmHg, METS 5, klinis nyeri dada (-), sesak nafas (-), murmur (-), gallop (-), EKG: Sinus Rytm qrs rate 96 bpm normoaxis , CXR: Cardiomegali (-), Th/-- Leukositosis 14.400/mm3 General Anestesi -LMA Ruangan

38. ) OK VI (MATA) O K CITO DPJP : Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Audy / Gita 4 Tatalaksana Anestesi On Duty: dr. Rinda/ Audy No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 MR, LK 8 Th BB: 20 Kg Katarak Traumatik OS AI+ IOL dr. Eva, Sp. M ASA I Tanpa penyulit airway Lab dalam batas normal General Anestesi -LMA Ruangan

39. ) OK VI (MATA) O K CITO DPJP : Dr. dr. Zafullah Khany Jasa, SpAn -TI, Subsp. NA (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Rinda/ Audy / Gita 4 Tatalaksana Anestesi On Duty: dr. Rinda/ Audy No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 AA, Lk, 11 Th BB: 27 Kg Kataract Traumatic OD+ Glaucoma Triple Procedure dr. Eva, Sp. M ASA I Tanpa penyulit airway Lab dalam batas normal General Anestesi -LMA Ruangan

40. OKA VII ( Bedah Orthopedi ) DPJP: dr. Yusmalinda , SpAn -TI, Subsp AO (K) 7 Rencana Anestesi

41. OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 MS, Pr , 24 Th Nonunion Of The Right Midshaft Femur Fracture Post Removed External Fixation Open Reduction Internal Fixation Dr. dr. Safrizal Rahman, M.Kes , Sp.OT II Spinal Anestesi Ruangan 2 M, Lk, 20 Th Union Fracture Left Humerus Union Fracture Left Tibia Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT I General Anestesi - LMA Ruangan 3 NA, Lk, 17 Th Union Fracture Left Femur Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT Pasien Batal Tindakan Dari Dpjp Ortho 4 A, Pr , 61 Th Union Fracture Of Left Proximal Humerus Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT III General Anestesi - LMA Ruangan 5 RA, Lk, 30 Th Union Fracture Of Left Midshaft Clavicle Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT I General Anestesi - LMA Ruangan

42. OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 6 U, Lk, 64 Th Fracture Calcaneus Of Right Foot Open Reduction Internal Fixation K-Wire Guiding C-Arm dr. Subhan Thaib , Sp.OT (K) II Spinal Anestesi Ruangan 7 NA, Pr , 28 Th Neglected DDH Skeletal Traksi dr. Subhan Thaib , Sp.OT (K) II Sedasi Ruangan

43. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 MS, Pr , 24 Th Nonunion Of The Right Midshaft Femur Fracture Post Removed External Fixation Open Reduction Internal Fixation Dr. dr. Safrizal Rahman, M.Kes , Sp.OT ASA II Airway Clear Tanpa Penyulit Hipoalbumin 2.22 g/dL Spinal Anestesi Ruangan

44. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 M, Lk, 20 Th Union Fracture Left Humerus Union Fracture Left Tibia Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT ASA I Airway Clear Tanpa Penyulit Lab Dalam Batas Normal General Anestesi - LMA Ruangan

45. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 NA, Lk, 17 Th Union Fracture Left Femur Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT Pasien Batal Tindakan Dari Dpjp Ortho

46. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 A, Pr , 61 Th Union Fracture Of Left Proximal Humerus Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT ASA III Kemungkinan sulit ventilasi no teeth Hipertensi stage II, TD 168/108 mmHg, HR 107 x/ i,METs 4, klinis nyeri dada (-), sesak (-), mudah lelah (-), murmur (-) gallop (-). EKG: sinus ritme QRS rate 101 bpm normoaxis ,. CXR: kardiomegali (-). Th/- Saran : Regulasi Tekanan darah target < 150 mmhg General Anestesi - LMA Ruangan

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48. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 5 RA, Lk, 30 Th Union Fracture Of Left Midshaft Clavicle Remove of Implant Dr. dr. Safrizal Rahman, M.Kes , Sp.OT ASA I Airway Clear Tanpa Penyulit Lab Dalam Batas Normal General Anestesi - LMA Ruangan

49. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 6 U, Lk, 64 Th Fracture Calcaneus Of Right Foot Open Reduction Internal Fixation K-Wire Guiding C-Arm dr. Subhan Thaib , Sp.OT (K) ASA II Airway Clear Kemungkinan sulit ventilasi no. Teeth Hipertensi Stage I, TD 140/78 mmHg, METs 5, klinis nyeri dada (-), sesak (-), mudah lelah (-),murmur (-) gallop (-) EKG: sinus ritme QRS rate 63 bpm, normoaxis , CXR: kardiomegali (-) Th/- Geriatri usia 64 th frailty scale 3 Saran : Regulasi Tekanan darah target < 150 mmhg Spinal Anestesi Ruangan

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51. ) OKA VII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra- Prawira / Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira/ Indra- Prawira / Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 7 NA, Pr , 28 Th Neglected DDH Skeletal Traksi dr. Subhan Thaib , Sp.OT (K) ASA II Airway Clear Tanpa Penyulit Nodul tiroid uk 3x2 cm, klinis cepat lelah (+) penurunan BB (+) tremor (+) index wayne score +6, FT4/TSHS : tidak ada data, th /- Sedasi Ruangan

52. OKA VIII ( Bedah Orthopedi ) DPJP: dr. Yusmalinda , SpAn -TI Subsp AO (K) 7 Rencana Anestesi

53. OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 RB, Lk, 15 Th BB: 65 Kg Primary Bone Tumor Of Left Proximal Fibula Due To Osteosarcoma Reseksi tumor, persiapan AKA dr. Onarisa Ayu Sp . OT (K) II Spinal Anestesi HCU 2 SB, Pr , 89 Th -Close Spiral Fracture Of The Left Midshaft Clavicle Allman Type 2- Close Fr. Costae 2 Hemithorax Sinistra Posterior + Tumor Mediastinum ORIF Clavicle + ORIF Plating Costae dr. Onarisa Ayu Sp . OT (K) III General Anestesi HCU 3 AB, Pr , 55 Th Burst Fracture VT 7 Frankel D+ Multiple Spinal Lession Dd Metastatic Bone Disease Dd TB Spine Posterior Dekompresi + Stabilisasi dr. T. Nanta Aulia, Sp.OT (K) Spine III General Anestesi HCU 4 Z, Pr , 61 Th - Close Transverse Fracture Of The 5th Midshaft Metatarsal Of The Left Foot- Close Oblique Fracture Of The Left 4th Midshaft Metatarsal Of The Left Foot (ORIF Miniplate) Open Reduction Internal Fixation dr. T. Nanta Aulia, Sp.OT (K) Spine II Spinal Anestesi Ruangan 5 NF, LK, 36 Th Malunion Of Right Distal Radius Open Reduction Internal Fixation dr. T. Nanta Aulia, Sp.OT (K) Spine I GA-LMA Ruangan

54. OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 6 AA, Lk,53 Th Primary Bone Tumor Of Left Proximal Fibula Due To Osteosarcoma Remove oF Inplate dr. T. Nanta Aulia, Sp.OT (K) Spine II GA-LMA Ruangan 7 MW, Lk, 19 Th Neglected Fracture Of Left Distal Radius Reconstruction wirst joint dr. T. Nanta Aulia, Sp.OT (K) Spine I GA-LMA Ruangan

55. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 RB, Lk, 15 Th BB: 65 Kg Primary Bone Tumor Of Left Proximal Fibula Due To Osteosarcoma Reseksi tumor, persiapan AKA dr. Onarisa Ayu Sp . OT (K) ASA II Airway Clear Tanpa Penyulit Anemia Hb 10,5 g/dL - Leukositosis 11.940/mm3 Spinal Anestesi HCU

56. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 SB, Pr , 89 Th -Close Spiral Fracture Of The Left Midshaft Clavicle Allman Type 2- Close Fr. Costae 2 Hemithorax Sinistra Posterior + Tumor Mediastinum ORIF Clavicle + ORIF Plating Costae dr. Onarisa Ayu Sp . OT (K) ASA III Airway Clear Tanpa Penyulit Susp.Tumor paru kiri dd tumor mediastinum,klinis batuk (+) sesekali , sesak napas (-), dapat tidur terlentang , RR 20x/ i , Sp02 98% RA Ves (+/+) Rh (-/-) Wh (-/-). Th/ N- acylsistein 2x400mg- Anemia HB 10.9 g/dL AKI stg I Ur/Cr : 39/1.20, UOP >0.5cc/ KgBB /Jam Geriatri Usia 89 Th, Frailty Scale 4 Obese Grade 1, BMI 30.1 Kg/m2, STOP BANG Score 3 Intermediate Risk Of OSASaran - Sedia darah PRC 2 kolf General Anestesi HCU

57. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 AB, Pr , 55 Th Burst Fracture VT 7 Frankel D+ Multiple Spinal Lession Dd Metastatic Bone Disease Dd TB Spine Posterior Dekompresi + Stabilisasi dr. T. Nanta Aulia, Sp.OT (K) Spine ASA III Airway Clear Tanpa Penyulit - Burst Fracture VT 7 Frankel D+ Multiple Spinal Lession dd Metastatic Bone Disease dd TB spine, klinis nyeri punggung , kekuatan motorik sup 5555/5555, inf 4444/4444, otonom ( terpasang caterter urin ), hipoestesi (-), inkontinensia urin (-), inkontinensia alvi (-), MRI : Kompresi berat coropus Th7 disertai massa meluas pedikel dan prosesus transversus kanan , kiri , perivertebral space, epidural spase , canalis spinalis dan menginfiltrasi medula spinalis , Spondylosis cervicothoracolumbalis , Th/- Susp. Pneumonia, klinis sesak (-), batuk (-), demam (-). RR 20x/ i , SpO2 98% RA, ves (+/+), rh (-/-), wh (-/-). CXR: pneumonia. Th/-   General Anestesi HCU

58. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op DM tipe 2 GDS saat ini 129 mg/dl levemir 1 x 16 unit Leukositosis 12.700 /mm3l Saran - Pertahankan Gula darah 140-180 mg/dl General Anestesi HCU

59. 3

60. 3

61. 3

62. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 Z, Pr , 61 Th - Close Transverse Fracture Of The 5th Midshaft Metatarsal Of The Left Foot- Close Oblique Fracture Of The Left 4th Midshaft Metatarsal Of The Left Foot (ORIF Miniplate) Open Reduction Internal Fixation dr. T. Nanta Aulia, Sp.OT (K) Spine ASA II Airway Clear Tanpa Penyulit Hipertensi Stage I, TD 145/80 mmHg, METs 5, klinis nyeri dada (-), sesak (-), mudah lelah (-),murmur (-) gallop (-) EKG: sinus ritme QRS rate 71 bpm, normoaxis , CXR: kardiomegali (+),CTR 55%, Th/ - Amlodipin 1x10 mg DM tipe 2 GDS saat ini 250 mg/dl Th – Saran : Regulasi Tekanan sarah target <150 mmhg Regulasi gula darah target 140-180 Spinal Anestesi Ruangan

63. 4

64. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 5 NF, LK, 36 Th Malunion Of Right Distal Radius Open Reduction Internal Fixation dr. T. Nanta Aulia, Sp.OT (K) Spine ASA I Airway Clear Tanpa Penyulit Lab Dalam Batas Normal GA-LMA Ruangan

65. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 6 AA, Lk,53 Th Primary Bone Tumor Of Left Proximal Fibula Due To Osteosarcoma Remove oF Inplate dr. T. Nanta Aulia, Sp.OT (K) Spine ASA II Airway Clear Tanpa Penyulit DM tipe 2, GDP 131 mg/dl, Th/- GA-LMA Ruangan

66. ) OK VIII ( Bedah Orthopedi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Afdhal/ Indra-Nanu/Caesar 4 Tatalaksana Anestesi On Duty: dr. Wira Indra-Nanu/Caesar No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 7 MW, Lk, 19 Th Neglected Fracture Of Left Distal Radius Reconstruction wirst joint dr. T. Nanta Aulia, Sp.OT (K) Spine ASA I Airway Clear Tanpa Penyulit Lab dalam batas normal GA-LMA Ruangan

67. OKA IX ( Bedah Urologi dan Bedah Plastik ) DPJP: dr. Yusmalinda , SpAn -TI, Subsp AO (K) 4 Rencana Anestesi

68. OKA IX ( Bedah Urologi dan Bedah Plastik ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Putra 4 Tatalaksana Anestesi On Duty: dr. Wira/ Putra No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 S, Lk, 59 Th BB 60 Kg TB 170 Cm Retensio Urine Ec Blood Clot + Suspek Massa Retrovesika + Fournier Gangren Vesikolitotomi Evakuasi Blood Clot + Persiapan Biopsi Massa Buli + Tutup Defek dr. Jufriadi Ismy , SpU (K) Join dr. Syamsul Rizal, SpBP -RE III Spinal Anestesi Ruangan 2 N, Pr , 46 Th Fistula Vesikovagina Sistoskopi + Persiapan Repair Fistula Vesikovagina Dr. dr. Dahril , SpU II Spinal Anestesi Ruangan 3 Y, Lk, 53 Th Akut Superimposed Chronic Kidney Disease Ec Obstruktif Uropaty Ec Batu Ureter Billateral + Hydronefrosis Billateral + Riwayat Nefrostomy Perkutan Dextra Ureteroscopic Lithotripsy + Litotripsi Batu Ureter Bilateral Dr. dr. Dahril , SpU II Spinal Anestesi Ruangan 4 YJ, Pr , 66 Th Hidronesfrosis Sinistra Ec Suspek Stenosis Ureter Sinistra + Kista Ginjal Dekstra + DJ Stent Insitu Billateral Nefrektomi Sinistra Dr. dr. Dahril , SpU III Epidural - General Anestesi HCU

69. ) OKA IX ( Bedah Urologi dan Bedah Plastik ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Putra 4 Tatalaksana Anestesi On Duty: dr. Wira/ Putra No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 S, Lk, 59 Th BB 60 Kg TB 170 Cm Retensio Urine Ec Blood Clot + Suspek Massa Retrovesika + Fournier Gangren Vesikolitotomi Evakuasi Blood Clot + Persiapan Biopsi Massa Buli + Tutup Defek dr. Jufriadi Ismy , SpU (K) Join dr. Syamsul Rizal, SpBP -RE ASA III Airway clear HHD, TD  saat ini 161/93 mmHg, METs 3, Klinis : Nyeri dada (-), sesak (-), cepat lelah kadang-kadang (+), murmur (-), gallop (-), CXR : cardiomegali (+) CTR 55%, EKG : Sinus ritme QRS rate 75x/ menit , normoaxis th /- DM Tipe 2 terkontrol , GDS 94 mg/dL, Th/Levemir 1x10 IU AKI Stage 2, Ur/Cr (32/3,1mg/dL), UOP > 0,5 cc/ KgBB /Jam Anemia Hb 9,3 gr/dL Leukositosis 18,310 /mm3 Hipoalbumin 2,6 gr/dL Saran: Regulasi anemia, target Hb > 10,0 gr/dL Regulasi hipertensi , target TD < 150/90 mmHg, Amlodipin 1x10 mg, Valsartan 1x160 mg, Lorazepam 1x0,5 mg Pertahankan GDS 140-180 mg/dL Sedia PRC 2 kolf Spinal Anestesi Ruangan

70. 1

71. ) OKA IX ( Bedah Urologi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Putra 4 Tatalaksana Anestesi On Duty: dr. Wira/ Putra No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 N, Pr , 46 Th Fistula Vesikovagina Sistoskopi + Persiapan Repair Fistula Vesikovagina Dr. dr. Dahril , SpU ASA II Airway clear Leukositosis 14,530 /mm3 Spinal Anestesi Ruangan

72. ) OKA IX ( Bedah Urologi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Putra 4 Tatalaksana Anestesi On Duty: dr. Wira/ Putra No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 Y, Lk, 53 Th Akut Superimposed Chronic Kidney Disease Ec Obstruktif Uropaty Ec Batu Ureter Billateral + Hydronefrosis Billateral + Riwayat Nefrostomy Perkutan Dextra Ureteroscopic Lithotripsy + Litotripsi Batu Ureter Bilateral Dr. dr. Dahril , SpU ASA II Airway clear AKI Stage 2, riw HD 1 kali (5 hari yg lalu ), Ur/Cr post HD (63/3,0 mg/dL), UOP > 0,5 cc/ KgBB /Jam Leukositosis 25,790 /mm3 Hiperkalemi 5,4 mmol/L Spinal Anestesi Ruangan

73. ) OKA IX ( Bedah Urologi ) O K CITO DPJP : dr. Yusmalinda , SpAn -TI, Subsp AO (K) DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Putra 4 Tatalaksana Anestesi On Duty: dr. Wira/ Putra No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 YJ, Pr , 66 Th Hidronesfrosis Sinistra Ec Suspek Stenosis Ureter Sinistra + Kista Ginjal Dekstra + DJ Stent Insitu Billateral Nefrektomi Sinistra Dr. dr. Dahril , SpU ASA III Airway clear, kemungkinan sulit ventilasi no teeth Hipertensi terkontrol , TD  saat ini 112/74 mmHg, METs 4, Klinis : Nyeri dada (-), sesak (-), cepat lelah (-), murmur (-), gallop (-), CXR : cardiomegali (+) CTR 53%, EKG : SR QRS rate 75x/ menit , normoaxis , th / Amlodipin 1x5 mg Peningkatan faal ginjal , Ur/Cr (51/1,3 mg/dL), UOP > 0,5 cc/ KgBB /Jam Anemia Hb 10,8 gr/dL Geriatri usia 66 thn , frailty scale 3 Saran: Pertahankan TD < 150/90 mmHg Sedia PRC 3 kolf Epidural - General Anestesi HCU

74. 4

75. OKA X (THT-KL) DPJP: dr. Hafizh Arief , SpAn -TI 4 Rencana Anestesi

76. OK X (THT-KL) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/Rahmat/ Herman 4 Tatalaksana Anestesi On Duty: dr Nanda/ Herman No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 MH, Lk, 68 Th Suspek Karsinoma Nasofaring Biopsi dr. Benny, SpTHT -KL (K) III General Anestesi Ruangan 2 N, Pr , 61 Th Suspek Karsinoma Nasofaring Biopsi dr. Benny, SpTHT -KL (K) II General Anestesi Ruangan 3 AA, Lk, 5 Th BB: 19 Kg Adenoid Hipertrofi Adenoidektomy dr. Benny, SpTHT -KL (K) III General Anestesi Ruangan 4 RT, Lk, 27 Th Abses Mandibula + Karies Dentis Insisi Drainase Abses + Insisi Drainase Intraoral + Ekstraksi Ginggiva dr. Febriansyah , SpTHT -KL + dr. Chairunnas , SpBM III General Anestesi HCU

77. ) OK X (THT-KL) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/Rahmat/ Herman 4 Tatalaksana Anestesi On Duty: dr Nanda/ Herman No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 MH, Lk, 68 Th Suspek Karsinoma Nasofaring Biopsi dr. Benny, SpTHT -KL (K) ASA III Kemungkinan sulit ventilasi no teeth- Riwayat TB paru tuntas berobat 2 tahun lalu . Klinis batuk (-), sesak (-), demam (-), RR 22 x/ mnt , SpO2 96%, vesikuler , rh (-/+) minimal paru kiri , wheezing (-/-), Cxr : TB paru . Th/ Nacetilsistein 3x200 mg. Bradikardi asimptomatik , HR 58 x/ i , METs 5, Klinis : Nyeri dada (-), sesak nafas (-), cepat lelah (-), murmur (-), gallop (-), CXR: cardiomegali (-), EKG : Sinus Bradikardi , QRS rate 57 bpm, normoaxis . Th/ - Geriatri Usia 68 th , Frailty scale 5. General Anestesi Ruangan

78. 1

79. 1

80. ) OK X (THT-KL) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/Rahmat/ Herman 4 Tatalaksana Anestesi On Duty: dr Nanda/ Herman No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 N, Pr , 61 Th Suspek Karsinoma Nasofaring Biopsi dr. Benny, SpTHT -KL (K) ASA II Hipertensi stage I, TD 141/98 mmHg, HR 85 x/ i , METs 5, klinis : nyeri dada (-), sesak (-), mudah lelah (-), murmur (-) gallop (-), EKG: sinus ritme qrs rate 85 x/ mnt , normoaxis , CXR: cardiomegali (+), CTR 57%, Th/- Saran : - Pertahankan TD < 150/90 mmHg General Anestesi Ruangan

81. 2

82. ) OK X (THT-KL) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/Rahmat/ Herman 4 Tatalaksana Anestesi On Duty: dr Nanda/ Herman No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 AA, Lk, 5 Th BB: 19 Kg Adenoid Hipertrofi Adenoidektomy dr. Benny, SpTHT -KL (K) ASA III Kemungkinan sulit intubasi dan ventilasi ec hipertrofi adenoid Hiperaktif (+), Ganguan pertumbuhan (-), Gangguan perkembangan (-) General Anestesi Ruangan

83. 3

84. 3

85. ) OK X (THT-KL) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/Rahmat/ Herman 4 Tatalaksana Anestesi On Duty: dr Nanda/ Herman No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 RT, Lk, 27 Th Abses Mandibula + Karies Dentis Insisi Drainase Abses + Insisi Drainase Intraoral + Ekstraksi Ginggiva dr. Febriansyah , SpTHT -KL + dr. Chairunnas , SpBM ASA III Kemungkinan sulit intubasi dan ventilasi bukaan mulut < 3 jari . DM type 2 GDS saat ini 95 g/dl, th /Levemir 2x6 IU Hipoalbumin 2.55 g/dl Saran: - Pertahankan GDS 140-180 mg/dL General Anestesi HCU

86. 4

87. 4

88. 4

89. 4

90. 4

91. OKA XI ( Obstetri dan Gynekologi dan Bedah Anak) DPJP: dr. Hafizh Arief , Sp An-TI 3 Rencana Anestesi

92. OKA XI ( Obstetri dan Gynekologi dan Bedah Anak) O K CITO DPJP : dr. Hafizh Arief , Sp An-TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Sharah / Hamid-siddiq 4 Tatalaksana Anestesi On Duty: dr. Nanda/ Sharah No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 S, Pr , 53 Th Neoplasma Ovarium Kistik Suspect Malignancy Laparotomi Surgical Staging Dr. dr. Hasanuddin , SpOG (K) III General Anestesi - Epidural HCU 2 A, Pr , 2 Bln BB 5 Kg TB 55 Cm Suspect Hirshsprung Disease Full Thickness Biopsi dr. Muntadhar , Sp.B , Subsp. Ped (K) III General Anestesi – Claudal Ruangan 3 AN, Pr , 1 Th 10 Bln BB 8 Kg Suspect Hirshsprung Disease Full Thickness Biopsi dr. Muntadhar , Sp.B , Subsp. Ped (K) III General Anestesi - LMA Ruangan

93. ) OKA XI ( Obstetri dan Gynekologi ) O K CITO DPJP : dr. Hafizh Arief , Sp An-TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Sharah / Hamid-siddiq 4 Tatalaksana Anestesi On Duty: dr. Nanda/Sharah No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 S, Pr , 53 Th Neoplasma Ovarium Kistik Suspect Malignancy Laparotomi Surgical Staging Dr. dr. Hasanuddin , SpOG (K) ASA III Bronchitis Kronis , klinis batuk (-), sesak (-), demam (-), RR 20x/ i , SpO2 97% ves (+/+) rh (-/-), wh (-/-) cxr . Bronchotis Chronis, tampak corakan bronchovaskular Paru ramai dan Kasar , Th/- Distensi LP 88cm klinis sesak (-), venektasi (-), asites (-), distensi (-), nyeri tekan (-), defans muscular (-), dapat tidur terlentang (+), rr 20x/ i SpO2 97%, ves (+/+), rh (-/-), wh (-/-) Distensi abdomen ec NOK, Lp 88 cm, Venektasi (-), Asites (+), Nyeri tekan (-), Defans muscular (-), Klinis : Sesak napas (-), Demam (-), RR 20 x/ menit , SpO2 97 % RA, Ves (+/+), Rh (-/-), Wh (-/-), Pasien dapat tidur terlentang (+), Terpasang NGT: - USG :- . >>>>>> General Anestesi - Epidural HCU

94. ) OKA XI ( Obstetri dan Gynekologi ) O K CITO DPJP : dr. Hafizh Arief , Sp An-TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Sharah / Hamid-siddiq 4 Tatalaksana Anestesi On Duty: dr. Nanda/Sharah No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op Sinus takikardi , mets 4 TD : 120/80, HR 98 Reguler , Missing beat (-), Klinis mudah lelah (+), Nyeri dada (-), sesak (-), murmur(-), gallop (-), Ekg : Sinus takikardi QRS rate 104 bpm normoaxis pvc occational 1x, Cxr : cardiomegali (-), Th/- Saran Sedia PRC 2 kolf Saran pemeriksaan Ur/Cr dan pT / ApTT General Anestesi - Epidural HCU

95. 1

96. 1

97. ) OKA XI ( Bedah Anak) O K CITO DPJP : dr. Hafizh Arief , Sp An-TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Sharah / Hamid-siddiq 4 Tatalaksana Anestesi On Duty: dr. Nanda/ Sharah No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 A, Pr , 2 Bln BB 5 Kg TB 55 Cm Suspect Hirshsprung Disease Full Thickness Biopsi dr. Muntadhar , Sp.B , Subsp. Ped (K) ASA III Trombositosis 639.000/mm3 General Anestesi – Claudal Ruangan

98. ) OKA XI ( Obstetri dan Gynekologi Bedah Anak) O K CITO DPJP : dr. Hafizh Arief , Sp An-TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda/ Sharah / Hamid-siddiq 4 Tatalaksana Anestesi On Duty: dr. Nanda/ Sharah No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 AN, Pr , 1 Th 10 Bln BB 8 Kg Suspect Hirshsprung Disease Full Thickness Biopsi dr. Muntadhar , Sp.B , Subsp. Ped (K) ASA III Anemia HB 9.4 g/dl Leukositosis 21.600/mm3 Saran Sedia PRC 2x50cc General Anestesi - LMA Ruangan

99. OKA XII ( Bedah Saraf) DPJP: dr. Hafizh Arief , SpAn -TI 3 Rencana Anestesi

100. OK XII ( Bedah Saraf) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda-Wira/Febri 4 Tatalaksana Anestesi On Duty: dr. Nanda/Febri No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 RY, Pr , 52 Th SOL (Space Occupying Lesion) intracranial Craniectomy removal tumor dr. Iskandar, SpBS III General Anestesi - CVC - ABP ICU 2 II, Lk, 61 Th Bone deformity Cranioplasty dr. Imam, SpBS II General Anestesi Ruangan 3 S, Lk, 61 Th SOL (Space Occupying Lesion) ar. frontoparietal sinistra Craniectomy Removal Tumor dr. T. Yose, SpBS III General Anestesi - CVC - ABP ICU

101. ) OK XII ( Bedah Saraf) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda-Wira/Febri 4 Tatalaksana Anestesi On Duty: dr. Nanda/Febri No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 RY, Pr , 52 Th SOL (Space Occupying Lesion) intracranial Craniectomy removal tumor dr. Iskandar, SpBS ASA III Airway clear Peningkatan TIK kronik ec. SOL intrakranial , GCS saat ini E4M6V5 : 15, klinis nyeri kepala (+), muntah (-), kejang (+) terakhir 5 bulan yll , Parese nervus II dextra sinistra, visus ODS 1/300, pupil isokor 3mm/3mm, RC +/+, kekuatan motorik sup 5555/5555, inf. 4444/4444, kesan paraparese inferior, sensorik dan otonom dalam batas normal, CT-Scan kepala (24/4/2024) : Massa dengan kalsifikasi multiple disertai tentakel like edema di parietal lobe di lobus parietal yang mendorong ventrikel lateralis kanan ke kiri dan menyebabkan deviasi mid line ke kiri sejauh ± 1,3 cm dd/ oligodendroglioma,  General Anestesi - CVC - ABP ICU

102. ) OK XII ( Bedah Saraf) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda-Wira/Febri 4 Tatalaksana Anestesi On Duty: dr. Nanda/Febri No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op Astrocytoma Hipertensi stage I, TD 143/85 mmHg, METs sdn , klinis nyeri dada (-), sesak (-), mudah lelah (-), murmur (-), gallop (-), EKG: sinus ritme qrs rate 70 bpm, normoaxis , T inverted di V1 - V5, kesan OMI anteroseptal, CXR: Cardiomegali (+) CTR 57%, th / Saran : - Sedia darah PRC 4 kolf , FFP 500, TC 500 General Anestesi - CVC - ABP ICU

103. 1

104. 1

105. ) OK XII ( Bedah Saraf) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda-Wira/Febri 4 Tatalaksana Anestesi On Duty: dr. Nanda/Febri No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 II, Lk, 61 Th Bone deformity Cranioplasty dr. Imam, SpBS ASA II Airway clear Post craniectomy evakuasi SDH 3 bulan yll , GCS saat ini E4M6V5 : 15, pupil isokor (3mm/3mm) RC +/+, kekuatan motorik sup 5555/5555 inf 5555/5555, sensorik dbn , otonom dbn , CT Scan kepala (19/1/2024) : SDH ar. frontotemporoparietal dextra ( sebelum operasi ) Hipertensi stage 1, TD 159/89 mmHg, METs 5, klinis nyeri dada (-), sesak (-), mudah lelah (-), murmur (-), gallop (-), EKG: sinus ritme qrs rate 88 bpm, normoaxis , CXR: Cardiomegali (-), th / Amlodipin 1x10 mg ( tidak rutin) Saran : Regulasi TD, target < 150/90 mmHg Amlodipin 10 mg ( malam ) Lorazepam 2 mg ( malam ) Valsartan 80 mg ( pagi ) General Anestesi Ruangan

106. 2

107. 2

108. ) OK XII ( Bedah Saraf) O K CITO DPJP : dr. Hafizh Arief , SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Nanda-Wira/Febri 4 Tatalaksana Anestesi On Duty: dr. Nanda/Febri No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 S, Lk, 61 Th SOL (Space Occupying Lesion) ar. frontoparietal sinistra Craniectomy Removal Tumor dr. T. Yose, SpBS ASA III Kemungkinan sulit ventilasi , no teeth Peningkatan TIK kronik ec. SOL intrakranial , GCS saat ini E4M6V5 : 15, klinis nyeri kepala (+), muntah (-), kejang (-), Parese nervus (-), pupil isokor 3mm/3mm, RC +/+, kekuatan motorik , sensorik dan otonom dalam batas normal, CT-Scan kepala (24/4/2024) : Area hipodens di lobus frontotemporoparietal kiri disertai tentakel edema dengan midline shifting sejauh ± 0,8 cm ke sisi kanan --> suspek SOL intracranial Saran : - Sedia darah PRC 4 kolf , FFP 500, TC 500 General Anestesi - CVC - ABP ICU

109. 3

110. 3

111. Endos- Bronkos DPJP: dr. Rossalia Yuliana, SpAn -TI 19 Rencana Anestesi

112. Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 1 M, Lk, 58Th Melena fundus Binding, varises esofagus bleeding, ulkus gaster , hepatomegali ec dd hepatoma EGD + kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH III Sedasi Ruangan 2 M, Lk, 26Th Dispepsia + Hematoaskezia EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH II Sedasi Ruangan 3 Y, Pr , 59Th Dispepsia tipe Like Ulcer + Konstipasi + Hipertensi On therapy + vertigo + AKI prerenal on dd acute CKD EGD Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH II Sedasi Ruangan 4 S, Lk, 53Th Dyspepsia type like Ulcer, RUQ pain + Jaundice ec dd 1 kolelitiasis dengan kolesistitis , kolangitis , koledokolitiasis EGD GA Dr. dr. Fauzi Yusuf, SpPD -KGEH II Sedasi Ruangan 5 I, Pr , 30Th Sindrome Dyspepsia dign Alarm Sympton ec od Ulkus Gaster, Ukus Duodenum, Gastritis Erosive EGD GA Dr. dr. Fauzi Yusuf, SpPD -KGEH I Sedasi Ruangan 6 MM, Lk, 54Th Right Upper Quadran Pain Hepatomegali EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH III Sedasi Ruangan

113. Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur ASA Tatalaksana P o st Op 7 K, Pr , 22Th Dyspepsia + Hematokezia EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH I Sedasi Ruangan 8 MY, Lk 74Th Hematemesis Melena es dd Varises Esofagus Bleeding, Varises Fundus Bleeding, Gastropati , Sirosis Hepatis EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH III Sedasi Ruangan 9 BH, Pr , 49Th Epigastric pain ec dd Gastritis, Ulkus Gaster , Vomitus ec Gastropati , Nefrolithiasis EGD GA Dr.dr.Fauzi , Sp. PD II Sedasi Ruangan 10 NE, Pr , 40th Epigatric Pain, Change of Bowel Habit ASAII Kemungkinan tanpa penyulit airway - Peningkatan fungsi ginjal , Ur/Cr 15/1,19 mg/dl, UOP > 0,5 cc/ Kgbb /jam IV Sedasi Ruangan

114. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 1 M, Lk, 58Th Melena fundus Binding, varises esofagus bleeding, ulkus gaster , hepatomegali ec dd hepatoma EGD + kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA III - tanpa penyulit Airway - pneumothorax Dextra , klinis sesak nafas (+) batuk (+) nyeri dada (-), RR 22 x/ i , SpO2 97% RA, Ves (++), Rh (-/-), Wh (-/-), CXR: Pneumothorax Dextra , - anemia hb 9,2g/dl - peningkatan fungsi hati Bil tot/ dir / ind : 5,54/3,74/1, 80, klinis ikterik (-) th /- Sedasi Ruangan

115. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 2 M, Lk, 26Th Dispepsia + Hematoaskezia EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA II - tanpa penyulis airway - trombositosis 514.000/mm3 Sedasi Ruangan

116. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 3 Y, Pr , 59Th Dispepsia tipe Like Ulcer + Konstipasi + Hipertensi On therapy + vertigo + AKI prerenal on dd acute CKD EGD Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA II - tidak ada sumbatan airway - Hipertensi Terkontrol TD 117/89mmhg HR: 89x/ i , METs 5, klinis nyeri dada (-), sesak (-), mudah lelah (-), murmur (-) gallop (-) EKG: sinus ritme QRS rate 92 x/ i , normoaxis . CXR: kardiomegali (+)Th/ - Amlodipin 1x5 mg, candesartan 1x16mg Sedasi Ruangan

117. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 4 S, Lk, 53Th Dyspepsia type like Ulcer, RUQ pain + Jaundice ec dd 1 kolelitiasis dengan kolesistitis , kolangitis , koledokolitiasis EGD GA Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA II - tidak ada penyulit airway - Sinus Bradikardi , klinis Nyeri dada (-), mudah lelah (-), sesak (-), ECG sinus bradikardi QRS rate 52bpm, normoaxis Sedasi Ruangan

118. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 5 I, Pr , 30Th Sindrome Dyspepsia dign Alarm Sympton ec od Ulkus Gaster, Ukus Duodenum, Gastritis Erosive EGD GA Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA I - Tanpa penyulit airway - Lab dalam batas normal Sedasi Ruangan

119. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 6 MM, Lk, 54Th Right Upper Quadran Pain Hepatomegali EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA III - Tanpa penyulit airway - Hepatomegali ec dd abses hepar , kista hepar , LP 83 cm, distensi abdomen (+), klinis dapat tidur terlentang (+), ikterik (+), acytes (-), venektasi (-), penurunan kesadaran (-), sesak (-) ,RR 22 x/ i , SpO2 95 % RA Ves (+/+) Rh (-/-) Wh (-/-), Albumin 2,22 gr/dl, Bil Tot/In/Dir : 4,15/2,87/5,40, SGOT/SGPT : 50/28 U/L, HbsAg non Reaktif , Th/- - Hipoalbumin 2,22 g/dL - Trombositosis 475.000/mm3 - Leukositosis 22.510/mm3 - Hiponatremia 131 mmol/L Sedasi Ruangan

120. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 7 K, Pr , 22Th Dyspepsia + Hematokezia EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA I - Tanpa penyulit airway - Lab dalam batas normal Sedasi Ruangan

121. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 8 MY, Lk 74Th Hematemesis Melena es dd Varises Esofagus Bleeding, Varises Fundus Bleeding, Gastropati , Sirosis Hepatis EGD + Kolonoskopi Dr. dr. Fauzi Yusuf, SpPD -KGEH ASA III - Kemungkinan sulit ventilasi , no teeth - Sirosis hepatis std dekompensata child pugh class B, LP 106 cm, distensi abdomen (-), klinis dapat tidur terlentang (+), ikterik (+), acytes (+), venektasi (-), penurunan kesadaran (-), sesak (-) ,RR 20 x/ i , SpO2 95 % RA Ves (+/+) Rh (-/-) Wh (-/-), Albumin 2,70 gr/dl, Bil Tot/In/Dir : 0,77/0,36/0,41, SGOT/SGPT : 171/68 U/L, HbsAg non Reaktif , Th/- Aminofusin fls /24 jam - Dm tipe 2, GDS 177 g/dL, Th/- glimepirid 1x5mg - Anemia Hb 10,0 g/dL - Trombositopenia 149.000/mm3 - Hipoalbumin 2,70 g/dL - Geriatri usia 74 tahun , Frailty scale 4 Sedasi Ruangan

122. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 9 BH, Pr , 49Th Epigastric pain ec dd Gastritis, Ulkus Gaster , Vomitus ec Gastropati , Nefrolithiasis EGD GA Dr.dr.Fauzi , Sp. PD ASA II - Tanpa penyulit airway - Hipertensi Stage I, TD saat ini 158/105 mmHg, METs 4, Klinis : Nyeri dada (-), berdebar (-), keluhan yang lain (-), sesak (-), murmur (- ), Gallop (-), HR : 65x/ i , EKG: Sinus ritme QRS rate 82 bpm normoaxis , CXR: Cardiomegali (-), CTR (48)%, Th/- - Dm tipe 2, GDS 93 g/dL, Th/- Saran: - Koreksi Hipertensi , target TD <150/90 mmhg Sedasi Ruangan

123. ) Endos- Bronkos O K CITO DPJP : dr. Rossalia Yuliana, SpAn -TI DPJP : dr. Rifky Jamal, SpAn -TI Pre Op: dr. Cilu/Rinda/Radhi/Hamid/Herry/Arif 4 Tatalaksana Anestesi On Duty: dr. No Nama Diagnosa Pro s edur Status Fisik Tatalaksana P o st Op 10 NE, Pr , 40th Epigatric Pain, Change of Bowel Habit EGD + Kolonoskopi Dr. dr. Azzaki Abubakar, SpPD KGEH ASA II - Kemungkinan tanpa penyulit airway - Peningkatan fungsi ginjal , Ur/Cr 15/1,19 mg/dl, UOP > 0,5 cc/ Kgbb /jam Sedasi Ruangan