RESUME ANESTESI OK SENTRAL RSUD DR SAIFUL ANWAR MALANG

1 dr. Rudy Vitraludyono, Sp. An 2 dr. Ruddi Hartono, Sp. An 3 dr. Taufik Agus Siswagama, Sp. An 4 dr. Djudjuk Rahmad Basuki, Sp. An, KAKV,PJT dr. Djudjuk Rahmad Basuki, Sp. An, KAKV

OK JAM NAMA BILLING JK UMUR RUANG DIAGNOSIS RENCANA TINDAKAN DPJP RESIDEN ASA ANESTESI KET
dr. Taufik
Agus ASA 2 Keganasan post
1 Anna lutfiati /11351404 L 48th R9 Ca cervix brachiterapy BAR/PRA/CID RA SAB
Siswagama, kemoterapi
Sp. An
dr. Taufik
OK 1 Agus ASA 2 Keganasan post
2 Tukini 11360185 P 60th R4 Ca cervix brachiterapy BAR/PRA/CID RA SAB
DIGESTIF Siswagama, kemoterapi
Sp. An
dr. Taufik ASA 3 Geriatri, keganasan,
susp. lung tumor S TxNxMx st IV Agus Atelektasis paru kiri, Ht
3 Sarkadi 11374346 L 79 th R24b FOB CID GA LMA
ks 50-60 dd abses paru Siswagama, stage 1, anemia 10,3,
Sp. An hipoalbumin 2,75

1 Supini 11401254 P 51th 17 Tumor recti 1/3 distal t4bn0m0 Colonoscopy LA

2 Djoko susilo 11401354 L 53th Ugd Ca recti 1/3 distal txnxm0 Colonoscopy LA
OK 2
DIGESTIF dr. Taufik
Agus KIN/PRO/PRA ASA 2, hipertensi stage II (TD
3 Edy tirto 11401134 L 69th 17 Hil d reponnible Hthr RA SAB
Siswagama, /CID : 180/90) on tx
Sp. An
dr. Taufik
Agus
4 Fahmi 11398809 L 3th Melati Rectal bleeding ec polip recti Colonoscopy PAV
Siswagama,
Sp. An
dr. Taufik
Crippled hypospadias + chordee Redo chordectomy +
Agus MAY/HAR/PR
1 Tegar sejati 11321289 L 7th 15 + urethrocutaneos fistule + penoscrotal transposition i.n ASA 1 pediatri GA intubasi
Siswagama, O/CID
scrotum bifidum johansson i
Sp. An

dr. Taufik
Recidive caruncula + urinary
OK 3 Panendoscopy i.n caruncula Agus MAY/HAR/PR ASA 2, HT stage 1 140/90,HF
2 Siti komariyah 11391623 P 60th 6 retention on catheter + RA SAB
UROLOGI exicion Siswagama, O/CID stage B FC 1, stable CAD,
hypoalbumin + hhd + esbl
Sp. An

dr. Taufik
Urethroscopy + laparoscopic
Crippled hypospadias + bilateral Agus
3 As'ad joko 10193871 L 38th Dahlia testis exploration i.n PAV
udt Siswagama,
orchiopexy i.n orchiectomy
Sp. An

Left proximal ureteral stone +

dr. Taufik
left dj stent in situ + left
Left urs + left dj stent re- Agus MAY/HAR/PR ASA 3, geriatri (64th), AKI st
1 Romli 11391607 L 64th 19 nephrocutaneous fistule + right RA SAB
insertion Siswagama, O/CID 1
upper lower pole renal stone +
Sp. An
ckd stage iv

OK 4
UROLOGI
 dr. Taufik
OK 4 Left radical nephrectomy + Agus MAY/HAR/PR ASA 2, keganasan susp renal Post Op
2 Edy cahyono 11358552 L 44th 21 Renal tumor t2bn1m0 GA epidural
UROLOGI lymph node dissection Siswagama, O/CID cell Ca, HT st II (TD 160/100) Back ICU
Sp. An

Right lower pole renal stone +

Right eswl + right dj stent
3 Dasum 11391623 P 60th 17 right dj stent insitu + left lower LA
removal
pole renal stone

dr. Taufik
Agus
1 Suyoto 11398898 L 61th Dahlia Ckd stg v on hd + malfungsi capd Aff capd PAV
Siswagama,
Sp. An

ASA 3, moderate cholangitis

class B (moderately severe
OK 5 dr. Taufik
liver disease dgn CPS : 8),
EKSTIRPASI Moderate cholangitis + Explore cbd + Agus KIN/PRO/PRA
2 Halima 11401009 P 35th 18 hiperbilirubinemia (Bil T/D/I : GA Epidural
cholelithiasis cholecystectomy + ioc Siswagama, /CID
5,17/3,87/1,3), transaminitis
Sp. An
(OT/PT : 60/139), anemia
(9,3)

dr. Taufik
Posterior fusion
Primary bone tumor vertebrae Agus
3 Niamah 11398809 P 53th Dahlia instrumentation PAV
cervical 1-2 Siswagama,
occipitocervical
Sp. An
ASA 2, hipertensi stage 2 on
dr. Taufik
treatment(TD 130/70 tx
ekstirpasi angiofibroma CN D/ Agus BAR/NOF/LIL
1 Prapti 11371127 P 48th angiofibroma CN D valsartan 80mg, bisoprolol GA intubasi
Nasoendoskopi Siswagama, /CID
2.5mg-0-0, adalat oros 0-0-
Sp. An
OK 6 THT 30mg)
dr. Taufik
tumor CN S/ (squamous Agus BAR/NOF/LIL
2 Toni 11397976 L 34 th eksisi tumor CN S ASA 1 GA Intubasi
papilloma) Siswagama, /CID
Sp. An
dr. Taufik Asa 2 keganasan ,post
Cacervix IIB + post kemo NACT
Agus kemoterapi (Carboplatin,
OK 7 OBG 1 mustika 11386050 P 49 th R9 carbopaclitaxel 3 seri poor respon Radikal Histerektomi NDI/NOF/CID CSE
Siswagama, paclitaxel), anemia 9,1, HF
+ anemia
Sp. An stB fc 1
chronic menorrhagia + post SOD
+ histerotomi ablasi ai kista dr. Taufik
ASA 2 HT St I on treatment
cokelat bilateral + post inj tapros Agus
OK 8 OBG 1 Dwi Astutik 11256206 P 36TH R10 Histeroskopi NDI/NOF/CID (amlodipin, lisinopril) 120/80, GA TIVA
6 siklus + post COC 6 siklus + Siswagama,
obesitas class I
post lutenik 3 siklus + post inj Sp. An
DMPA 3 siklus
dr. Taufik
ASA 2 Gravida, Hepatitis B
G1P0000Ab000 gr 37-38 mgg T/H Agus
2 Dewi ayu 11371127 P 23 th R10 SCTP NDI/NOF/CID (HbsAg reaktif, Hbe Ag RA SAB
+ HbsAg (+) + HbeAg (+) Siswagama,
positif)
Sp. An
 dr. Taufik
OK 9 BEDAH Hirschsprung disease post Agus
Moh. Syamil 11309975 L 3th 15 Potong stump ZII/LIL/CID Asa 1 Pediatrik GA Intubasi
ANAK duhamel procedure hari ke 11 Siswagama,
Sp. An
ASA 3 SOP cerebri
dr. Rudy meningioma, peningkatan
Post op
1 Andayani 11390328 P 54th 18 Sop cerebri ec meningioma Eksisi tumor Vitraludyono, VID/JUN TIK, keganasan, tetraplegia, Ga intubasi
ICU
Sp. An penurunan kesadaran GCS
423-424
OK I NS
ASA 3 SOP cerebri susp
dr. Rudy meningioma, peningkatan
Sop cerebri 345 ec meningioma +
2 Miati 11400108 P 59th 6 Vp shunt Vitraludyono, VID/JUN TIK, edema cerebri, Ga intubasi
hydrocephalus
Sp. An penurunan kesadaran GCS
345
dr. Rudy
Non union r neck femur cf ASA 3, geriatri, HT St 1
1 Nasiti 11400776 P 24th R.17 P-s femur Vitraludyono, BIM/VID/JUN RA SAB
subtrochanter r femur (150/70), HF ST B Fc 1
Sp. An
OK II ORTHO
dr. Rudy
Unon r olecranon post k wire Syme reduction+remove k HAM/BIM/
2 Sri juliati 11373351 P 51 th R.17 Vitraludyono, ASA 1 GA LMA
insertion+joint stifness ( wire JUN
Sp. An

dr. Rudy
HAM/BIM/JU
1 Milati 11378743 P 24 th R.17 R pcl rupture Pcl reconstruction Vitraludyono, ASA 2 Obesitas BMI 34.4 RA SAB
N
Sp. An
OK III ORTHO
dr. Rudy ASA 2 Pediatri 6 tahun, CKR
2 Azni indra 11400476 P 6 th R,15 Cf l neck femur Screw insertion Vitraludyono, BIM/VID/JUN 456 tanpa perdarahan tanpa GA Intubasi
Sp. An edema cerebri H-7

OK IV MATA 1

dr. Rudy ASA 3, HF st C fc 2, CAD riw

Tumor mamma d susp ganas
1 Sumiamah 11400654 P 59th 20 Eksisi tumor vc kp mrm d Vitraludyono, AMI 2016, HT st 1 terkontrol, GA intubasi
t2n1m0 ONY/YES/JUN
Sp. An overweight

OK V ONKO
ASA 3, Keganasan metastase
dr. Rudy paru dan vertebrae th 4-5,
Tumor mamma s susp ganas
2 Lis mainah 11400945 P 45th 18 Open biopsy Vitraludyono, YES/VID/JUN hiponatremi 121 on koreksi , GA TIVA
t4bn1m1 (paru tulang)
Sp. An anemia 9.3, azotemia renal
(ur/cr 51.30/1.75)

ASA 3 keganasan, HT
dr. Rudy uncontrolled (170/100),
GA intubasi
1 Sunarsih 11401298 P 41th 18 Scc lidah t2n0m0 Hemiglossectomy Vitraludyono, BIM/YES/JUN tanpa lab dan ekg, obesitas
nasal
Sp. An BMI 34, kemungkinan sulit
OK VI ONKO intubasi

dr. Rudy
Lymphadenopaty reg colli d susp ASA 3, geriatri, susp
2 Wardijah 11400079 P 67th 21 Open biopsy Vitraludyono, YES/VID/JUN GA LMA
nhl keganasan, DM, riw alergi
Sp. An
 ASA 2 riwayat CKS,
dr. Rudy
OK VII Fracture zmc d + fracture maxilla kmungkinan sulit intubasi
1 Muchlisin 11401793 L 21th 19 Rekonstruksi wajah Vitraludyono, ONY/VID/JUN GA intubasi
PLASTIK non lefort s + trauma occuli d
Sp. An
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

Ca cervix

brachiterapy

ASA 2 Keganasan post kemoterapi

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Ca cervix

brachiterapy

ASA 2 Keganasan post kemoterapi

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

susp. lung tumor S TxNxMx st IV ks 50-60 dd abses

paru

FOB

ASA 3 Geriatri, keganasan, Atelektasis paru kiri, Ht

stage 1, anemia 10,3, hipoalbumin 2,75

GA LMA

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Tumor recti 1/3 distal t4bn0m0

Colonoscopy

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Ca recti 1/3 distal txnxm0

Colonoscopy

0
 Err:509

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Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Hil d reponnible

Hthr

ASA 2, hipertensi stage II (TD : 180/90) on tx

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Rectal bleeding ec polip recti

Colonoscopy

0
 #NAME?

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Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Tegar sejati

Crippled hypospadias + chordee +

urethrocutaneos fistule + scrotum bifidum

Redo chordectomy + penoscrotal transposition i.n

johansson i

ASA 1 pediatri

GA intubasi

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Recidive caruncula + urinary retention on catheter +

hypoalbumin + hhd + esbl

Panendoscopy i.n caruncula exicion

ASA 2, HT stage 1 140/90,HF stage B FC 1, stable

CAD,

RA SAB

0
 0

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 0

Crippled hypospadias + bilateral udt

Urethroscopy + laparoscopic testis exploration i.n

orchiopexy i.n orchiectomy

0
 #NAME?

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Romli
Left proximal ureteral stone + left dj stent in situ +
left nephrocutaneous fistule + right upper lower pole
renal stone + ckd stage iv

Left urs + left dj stent re-insertion

ASA 3, geriatri (64th), AKI st 1

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Renal tumor t2bn1m0

Left radical nephrectomy + lymph node dissection

ASA 2, keganasan susp renal cell Ca, HT st II (TD

160/100)

GA epidural

Post Op Back ICU

 Err:509

Identitas

Diagnosis

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Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

Edy cahyono

Right lower pole renal stone + right dj stent insitu +

left lower pole renal stone

Right eswl + right dj stent removal

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Ckd stg v on hd + malfungsi capd

Aff capd

0
 Err:509

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Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Moderate cholangitis + cholelithiasis

Explore cbd + cholecystectomy + ioc

ASA 3, moderate cholangitis class B (moderately
severe liver disease dgn CPS : 8), hiperbilirubinemia
(Bil T/D/I : 5,17/3,87/1,3), transaminitis (OT/PT :
60/139), anemia (9,3)
GA Epidural

0
 #NAME?

Identitas

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Tindakan

Status Fisik
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Anestesi

Keterangan
 #NAME?

Niamah

Primary bone tumor vertebrae cervical 1-2

Posterior fusion instrumentation occipitocervical

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

angiofibroma CN D

ekstirpasi angiofibroma CN D/ Nasoendoskopi

ASA 2, hipertensi stage 2 on treatment(TD 130/70 tx
valsartan 80mg, bisoprolol 2.5mg-0-0, adalat oros 0-
0-30mg)

GA intubasi

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

tumor CN S/ (squamous papilloma)

eksisi tumor CN S

ASA 1

GA Intubasi

0
 #NAME?

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Dwi Astutik

Cacervix IIB + post kemo NACT carbopaclitaxel 3

seri poor respon + anemia

Radikal Histerektomi
Asa 2 keganasan ,post kemoterapi (Carboplatin,
paclitaxel), anemia 9,1, HF stB fc 1

CSE

0
 Err:509

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Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!
chronic menorrhagia + post SOD + histerotomi
ablasi ai kista cokelat bilateral + post inj tapros 6
siklus + post COC 6 siklus + post lutenik 3 siklus +
post inj DMPA 3 siklus
Histeroskopi
ASA 2 HT St I on treatment (amlodipin, lisinopril)
120/80, obesitas class I

GA TIVA

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

G1P0000Ab000 gr 37-38 mgg T/H + HbsAg (+) +

HbeAg (+)

SCTP
ASA 2 Gravida, Hepatitis B (HbsAg reaktif, Hbe Ag
positif)

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Hirschsprung disease post duhamel procedure hari

ke 11

Potong stump

Asa 1 Pediatrik

GA Intubasi

0
 0

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 0

Sop cerebri ec meningioma

Eksisi tumor
ASA 3 SOP cerebri meningioma, peningkatan TIK,
keganasan, tetraplegia, penurunan kesadaran
GCS 423-424

Ga intubasi

Post op ICU
 0

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 0

Sop cerebri 345 ec meningioma + hydrocephalus

Vp shunt
ASA 3 SOP cerebri susp meningioma, peningkatan
TIK, edema cerebri, penurunan kesadaran GCS
345

Ga intubasi

0
 0

Identitas

Diagnosis

Tindakan

Status Fisik
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Anestesi

Keterangan
 0

Non union r neck femur cf subtrochanter r femur

P-s femur

ASA 3, geriatri, HT St 1 (150/70), HF ST B Fc 1

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Unon r olecranon post k wire insertion+joint stifness

(

Syme reduction+remove k wire

ASA 1

GA LMA

0
 #NAME?

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Milati

R pcl rupture

Pcl reconstruction

ASA 2 Obesitas BMI 34.4

RA SAB

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Cf l neck femur

Screw insertion
ASA 2 Pediatri 6 tahun, CKR 456 tanpa perdarahan
tanpa edema cerebri H-7

GA Intubasi

0
 Err:509

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Tindakan

Status Fisik
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Anestesi

Keterangan
Err:509

#REF!

0
 #NAME?

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 #NAME?

Sumiamah

Tumor mamma d susp ganas t2n1m0

Eksisi tumor vc kp mrm d

ASA 3, HF st C fc 2, CAD riw AMI 2016, HT st 1
terkontrol, overweight

GA intubasi

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Tumor mamma s susp ganas t4bn1m1 (paru tulang)

Open biopsy
ASA 3, Keganasan metastase paru dan vertebrae th
4-5, hiponatremi 121 on koreksi , anemia 9.3,
azotemia renal (ur/cr 51.30/1.75)

GA TIVA

0
 #NAME?

Identitas

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Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Sunarsih

Scc lidah t2n0m0

Hemiglossectomy
ASA 3 keganasan, HT uncontrolled (170/100),
tanpa lab dan ekg, obesitas BMI 34, kemungkinan
sulit intubasi

GA intubasi nasal

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Lymphadenopaty reg colli d susp nhl

Open biopsy

ASA 3, geriatri, susp keganasan, DM, riw alergi

GA LMA

0
 #NAME?

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 #NAME?

Muchlisin

Fracture zmc d + fracture maxilla non lefort s +

trauma occuli d

Rekonstruksi wajah
ASA 2 riwayat CKS, kmungkinan sulit intubasi

GA intubasi

0
 Err:509

Identitas

Diagnosis

Tindakan

Status Fisik
Manajemen
Anestesi

Keterangan
 Err:509

#REF!

Ckd stg v on routine hd

Av shunt

0
 Err:509

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Anestesi

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 Err:509

#REF!

Thymectomy
Asa 4 sepsis perbaikan, gagal napas on ventilator,
miastenia gravis on terapi, effusi pleura kanan,
atelektasis total paru kiri, anemia 8,5, azotemia
prerenal ur cr 108,2/0,76
GA per traceostomy

Backup ICU
 #NAME?

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Status Fisik
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Anestesi

Keterangan
 #NAME?

Holik

Pseudoaneurysm reg cubiti d

Repair pseudoaneurysm

0
 0

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Anestesi

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0

0
 0

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0
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