GENERAL ANASTHESIA

LM KAMAL ABDURROSID
MIMI KURNIATI
NINI AZNIATI
DHAUATA YUDISTIRA

preceptor : Dr. H. Elya

Sp.An
CASE REPORT
Identity Patient
Name :
Age :
Adress :
Religion :
Status :
MR :
in hospital :
anamnesis
•Main complaint :
•Current History :
anamnesis
•Past medical history :

•Family history :
Examination Physical
General composure :
GCS:
BP : 130/80 mmHg
HR : 88 x /minute
RR : 20x /minute
temperature : 36,5C
SpO2 : 97%
Examination Physical
Head:
Normocephali
Conjungtiva : Anemic (-/-), Hyperemia (- / -)
sclera : icanchovyc (-/-)
pupil : isocor, round 3mm / 3mm, pupil Reflex (+/+)
Lips : Cyanosis (-)

Neck:
Limfonode enlargement : (-)
SCM muscle : active (-), hypertrophy (-)
Thyroid enlargement (-)
thorax
inspection:
respiratory movement symmetry
retraction (-)
Palpation:
Respiratory movement symmetry
tactile fremitus : + | + , symmetry
Percussion
Percussion notes: sonor / sonor
Auscultataion
Cast: S1 S2 regular, murmur (-) Gallop (-)
Pulmo: vesicular + / +, Rales - / -, wheezing - / -
abdomen
inspection:
Shape of the abdomen is flat, distension (-), Scars (-), Mass (-), pulsation of the abdominal aorta (-)
auscultation:
Bowel sounds (+) 16x / minute
Metallic sound (-)
Percussion:
distribution: tympany
palpation:
Pain pressure (-), Abdominal masses (-)
The liver and spleen are not palpable
extremity
Upper extremity Lower extremity
Warm acral : +/+ Warm acral : +/+
deformity : -/- deformity : -/
-
edema : -/-
edema
cyanosis : -/- : -/-
CRT: <2 seconds cyanosis : -/
-
CRT: <2 seconds
Babinsky test : (+)
ORL
Ear
part Ear right ear
Deformity (-), hyperemia (-),
auricle
edema (-)
Hyperemia (-), edema (-), fistula (-
Regional preaurikula ), abscess (-), tenderness tragus
(+)
Hyperemia (-), edema (-), fistula (-
Regional retroaurikula
), abscess (-), tenderness (-)
left ear
Deformity (-), hyperemia (-),
edema (-)
Hyperemia (-), edema (-),
fistula (-), abscess (-),
tenderness tragus (-)
Hyperemia (-), edema (-),
fistula (-), abscess (-),
tenderness (-)
 part Ear right ear left ear
cerumen (+), Edema (-),

cerumen (-), edema(-), hyperemia (-) hyperemia (-), furuncle (-), otorea

furuncle (-), secretions (-) (-)

acoustic meatus

Perforations (-), hyperemia (-), retraction (-), bulging (-),

secretions (-), retraction (-), bulging (-), perforation (-), cone of light (+),
cone of light (+), 5 o'clock position position hour 7
tympanic membrane
NOSE
Examination Nose Nose Right Nose Left
Nose outer Shape (N), inflammation (-), tenderness Shape (N), inflammation (-),
(-), deformity (-). tenderness (-), deformity (-).
rinoskopi anterior
vestibule N N
Basic cavity rice media Shape (N), mucosal hyperemia (-). Shape (N), mucosal hyperemia (-).
meatus rice media Mucosal hyperemia (-), secretions (-), Mucosal hyperemia (-), secretions
Konka media rice (N), mass (-), (-), Konka media rice (N), mass (-),
secretions (-). secretions (-).
 Examination Nose Nose Right Nose Left
rinoskopi anterior
meatus rice media Mucosal hyperemia (-), secretions (-), Mucosal hyperemia (-), secretions
Konka media rice (N), mass (-), (-), Konka media rice (N), mass (-),
secretions (-). secretions (-).
Meatus nasi inferior Mucosal hyperemia (-), edema (-), Mucosal hyperemia (-), edema (-),
Hypertrophy (-) Hypertrophy (-)
Konka inferior rice mucous hyperemia (+), Edema (- mucous hyperemia (+), Edema (-),
),hypertrophy (+) hypertrophy (+)
septum nasi Deviation (-), foreign objects (-), Deviation (-), foreign objects (-),
bleeding (-) bleeding (-)
THROAT
Part Information
buccal mucosa hyperemia (-), mass (-)
mucosal gear hyperemia (-), mass (-)

Hard palate and Palatu mole Hyperemia (-), mass (-)

pharyngeal mucosa Hyperemia (-), edema (-), mass (-), granules (-), ulcers (-)

tonsils (left right) Hyperemia (-), size T3-T3, kripte (+), detritus (-)
Laboratory
Parameter Normal Range
hb g / dl 12-16
WBC /ul 4000-10000
RBC million/ul 3.5-5
PLT /ul 150000-400000
HCT % 36-48
MCV fL 80-100
MCH pg 26-34
MCHC g / dL 32-36
Laboratory
Parameter Normal Range
urea mg / dl 10-50
creatinine mg / dl 0.6 to 1.1
SGOT U/l 0-40
SGPT U/l 0-41
GDS mg / dL < 160
sodium (serum) mmol / l 135-146
Potassium (serum) mmol / l 3.4-5.4
Chloride (serum) mmol / l 95-108
Ro Thorax
ECG
Head CT-scan
Head CT SCAN
Pre Assessment operative

diagnosis : chronic Tonsillitis

Surgery planning: tonsillectomy
Anesthesia planning: General Anasthesia
ASA Classification:
Operation
Date of Operation : 12/22/2018

Surgery:
Time of induction: 11:30 pm
Time of operation: 11:45 pm
Operation finish : 12:20 pm
Anasthesia finish: 12. 35 pm
Procedure of Operation
•Prepare the tools and drugs for general anesthesia
•Positioning the patient on the operative bed with supine position
•Premedication through IV line with midazolam (0.07 to 0.1 mg /kg): 0.07 to 0.1 x 70 kg = 4, 9-7 mg
(given mg)
•Analgetic through IV line:
fentanyl (2-150 mcg /kg): 2-150 x 70 kg = 140-10500 mcg (Given mcg)

•Induction through IV line:

propofol (2-2.5 mg /kg): 2-2.5 x 70 kg = 140-1175 mg (Given mg)

•Muscle relaxant through IV line:

atracurium (0.5-0.6 mg /kg): 0.5-0.6 x 70 kg = 35-42 mg(Given 30 mg)
cont '
• Oxigenation with a facemask in 3 minutes
• Put the endotracheal Tube number 6, 5, Confirmed the location of the balloon
and ET fixation
• maintenance O2 3 lpm, N2O 3 lpm, and sevoflurane
• Same ventilation with respiratory rate of the patient
• After the operation was finished, clean the airway with suction and give reverse
medication:
• neostigmine (0.04-0.08 mg /kg): 0.04-0.08 x 70 kg = 2,8-5.6 mg
• atropine (0.01-0.02 mg /kg): 0.01-0.02 x 70 kg = 0,7-1, 4 mg
Fluid
Preoperative: fluid for 8 complement fasting hours
2 cc x 8 hours x 70 kg = 1120 cc
intra-operative
Bleeding: ±20 cc
EBV: 75cc x 79 kg = 5250 cc
 EBL: 20 /5250x 100% = 0.38%
Bleeding <20% give crystalloid with ratio 3: 1  3xblood loss = 3x20 cc = 60
cc
Maintenance fluid during operation:2-4cc / kg / hours = 2 x 70 kg = 140 cc
 Total fluid intake intraoperative = 1120 + 60 + 140 =
- 3B KAEN 500 cc  20 TPM
- Fasting until full awareness
- Giving O2 masks 3 lpm to SpO2> 95%
- Injection of Paracetmaol 1 g / 6 hours