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MORNING REPORT

Operating Theatre 4
Wednesday, October, 19, 2016
dr. Rahmi Sp An

Patient 1
IN,male, 40 yo
Weight : 71 kg , Height : 162 cm
Diagnose
: jaundice obstruction ec CBD stone
Procedure : LE+extraction of stone +IOC +T-Tube
Anamnesis
Complaints : epigastric pain (+)
Medical history
: HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 19 x/minute, Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 120/90 mmHg, HR:72x/minute, cor: BJ 1 > BJ 2, reguler
Status lokalis :
ar epigastric region:
L : deformity (-), scar (-)
F : pain (+)

Adjuvant examination
Rontgen (14/10/2016) : cor and pulmo normal
EKG
12/10/16 : sinus ritme, heart rate 84 bpm
Lab (02/10/2016) : Hb (16,2), Ht (50), Eri (5,8), Leu (22,4), Trom (330), ur/cr
(16/0,9), KGDS 141, total billirubin/dirct (2,64/1,9), Na/K/Cl (139/3,4/103),
SGOT/SGPT (272/355)
Conclusion : ASA II with
- hipocalemia (3,4)
- leukositosis (22,4)
Planning
: General Anestethic
Post Op
: ward

Patient 2
DH, female, 45 yo
Weight : 55 kg ,Height : 155 cm
Diagnose : Jaundice obstruction ec CBD stone
Procedure : LE+ cholecystectomia+explore CBD + IOC T Tube
Anamnesis
Complaints : epigastric pain
Medical history
: HT (-) DM(-), Asma (-), Alergi (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 22x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 110/80 mmHg, HR: 110 x/minute, T : 39,3 C , cor: BJ 1 > BJ 2

Adjuvant examination
- Rontgen (18/10/2016) : -cor and pulmo normal
- Usg 17/10/16 : dilatation of ductus billiaris intrahepatic and ductus
choleducus ec CBD stone
- Lab (17/10/2016)
: Hb (10), Ht (32), Eri (3,8), Leu (32,2), Trom (439),
CT/BT (7/2), Ur/Cr (10/0,5), Na/K/Cl (138/2,9/ 100), KGDS 151, SGOT/SGPT
(32/29), tot billirubin/direct (7,24/4,6)
Conclusion : ASA III with susp SIRS with takikardi (110 bpm), hipertermi (39,3),
leukositosis (32,2), hipokalemia (2,9) hiperbilirubin (7,24)
Planning : GeneralAnestethic
Post op
: ward

Patient 3
N, male 63 yo
Weight : 50 kg ,Height
Diagnose : carcinoma recti 1/3 distal
Procedure : males procedure

: 165 cm

Anamnesis
Complaints : hematochezia and pain
Medical history
: HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 18x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : BP 150/70 mmHg, HR: 72 x/minute, cor: BJ 1 > BJ 2

Adjuvant examination
- Rontgen (25/08/2016) : -cor and pulmo normal
-Lab (12/10/2016)
: Hb (11,6), Ht (35), Leu (10,1), Trom (353), Ur/Cr
(22/1,0), Na/K/Cl (139/4,0/ 100), SGOT/SGPT (24/11), random glucose 90, bil
tot/direct (0,36/0,3), albumin (6,0), D-dimer 629,2, Ca 8,6
-EKG 18/10/16
: rytme sinus HR 76 bpm, with VAD, OMI
Conclusion : ASA II with Controlled Hypertention (150/90 mmHg), anemia (11,6) ,
VAD, OMI
Planning : General Anestethic, tranfusion PRC
Post op
: ICU

Patient 4
WD, female 43 yo
Weight : 65 kg , Height
Diagnose : jaundice obstruction ec CBD stone
Procedure : LE + by Pass Billiodigestive

: 155 cm

Anamnesis
Complaints : epigastric pain
Medical history
: HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airway : Clear , Mallampati (1) , denture (-) , obstruction (-)
Breathing: RR 20 x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : HR: 100 x/minute, TD 110/80 mmHg cor: BJ 1 > BJ 2

Adjuvant examination
- Rontgen (18/10/2016) : Cor and pulmo in normal limite
-Lab (13/10/2016)
: Hb (10,7), Ht (35), Leu (10,5), Trom (347), tot
bilirubin/direct (17,54/14,7) SGOT/SGPT (60/49) Na/K/CL ( 138/2,9/100), CT/BT
8/3
-EKG 14/10/16
: sytme sinus HR 62 bpm
-MRI non contras 11-10-16 : hydrops galblader with stenosis distal CBD ,
dilatation of proximal CBD, ductus cysticus , pancreas in normal limite
Conclusion : ASA III with anemia (10,7), hipocalemia (2,9)
Planning : General Anestethic
Post op
: ICU

TERIMA KASIH