MORNING REPORT

Operating Theatre 8
Wednesday, November 09th 2016
dr. T. Yasir, Sp.An
Patient 1
Mr. Y, Men, 37 yo
• Weight 57 kg, Height : 178 cm
• Diagnose : HNP L4-5 + Spine Stenosis L4-5
• Procedure : Posterior dekompresion + posterior stabilitation
Anamnesis
- Complaints : low back pain
- HT (-), DM(-), Asma (-), Alergic (-)

• Physical examination
- Airway : Malampati (1) , denture (-) , obstruction (-), neck : normal
- Breathing : RR 20 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
- Circulation : BP 110/70 mmHg, HR:74 x/minute, cor: BJ 1 > BJ 2
- Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm
• Adjuvant examination
- Thorax AP : cor & pulmo in normal limit

- Laboratorium : Hb (13,9), Ht (44), Eri (5,2), Trombo (218), Leu (5,8)

Na (145), K (4,5), Cl (101), Ur (23), Cr (0,83)
KGD (90)

• Conclusion : ASA I
• Planning : General anasthesia
• Post Op : word
Patient 2
Ms. R, Women, 56 yo
• Weight 55 kg, Height : 150 cm
• Diagnose : fractur compresion vetebra lumbal 3-4 frankel
• Procedure : Posterior dekompresion + posterior stabilitation

• Anamnesis
- Complaints : low back pain
- Medical history : HT (+), DM(+), Asma (-), Alergic (-)

• Physical examination
- Airway : Malampati (1) , denture (-) , obstruction (-), neck : normal
- Breathing : RR 18x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
- Circulation : BP 140/80 mmHg, HR: 88x/minute, cor: BJ 1 > BJ 2
- Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm
• Adjuvant examination
- Thorax AP : cor & pulmo in normal limit
- Laboratorium (07/11/2016): Hb (7,5), Ht (24), Eri (2,8), Trombo (571), L (7,6)
Na (140), Cl (102), Ur (35), Alb (2,72), KGD (67)

• Conclusion : ASA II with anemia (7,5) hypertension (140/80) on therapy

amlodipine 1x10 mg, DM type II controlled on insulin, hipoalbumin (2,72)
• Planning : correct HB > 10 g/dl, correct albumin >3,5
- General Anatesion
• Post Op : Ward
Patient 3
Mr. S , 38 yo
• Weight 50 kg, Height : 1605 cm
• Diagnose : TB spine V. Thoracal 8,9,10
• Procedure : Posterior dekompresion + posterior stabilitation

• complaints : low ekstremity weakness

- Medical history : HT (-), DM(-), Asma (-), Alergic (-)

• Physical examination
- Airway : Malampati (2) , denture (-) , obstruction (-), neck : normal
- Breathing : RR 20x/minute, Ves (+/+) Rh (+/+) Wh (-/-)
- Circulation : BP 90/60 mmHg, HR: 100x/minute, cor: BJ 1 > BJ 2
- Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm
• Adjuvant examination
- Thorax ap : bronchitis
- Laboratorium : hb (13,2),ht (42), Eri (5,3), trombosit (578),
leukosit (8,0), Na (143),K (3,8),Cl (103),ur (15) Cr (0.80)
- Conclusion : - Asa II with TB on therapy OAT 2nd weeks
trombositosis(578)
• Planning : General anesthesia
• Posting op : Ward
Patient 4
Mr. A, Men, 34 yo
• Weight 59 kg, Height : 175 cm
• Diagnose : TB spine Thorakal Lumbal
• Procedure : Posterior dekompresion + posterior stabilitation

• Anamnesis
- Complaints : low back pain
- Medical history : HT (-), DM(-), Asma (-), Alergic (-)

• Physical examination
- Airway : Malampati (1) , denture (-) , obstruction (-), neck : normal
- Breathing : RR 20x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
- Circulation : BP 110/60 mmHg, HR: 78 x/minute, cor: BJ 1 > BJ 2
- Brain : E4M6V5, Compos Mentis, Isokor (+/+) 3mm/3mm
• Adjuvant examination
- Thorax AP : cor & pulmo in normal limit
- Laboratorium : Hb (12,6), Ht (4,2), Eri (5,5), Trombo (476), L (7,5)
• Na (144), Cl (100), Ur (12),
• Cr (0,80), GDS (100)

• Conclusion : ASA II with TB On OAT 3nd month

• Planning : General anestesi
• Post Op : Ward
THANKS