EQ/TS

 Name : Elmawaty
 Sex : Female
 Age : 63 y.o
 Med.Rec : 1102831
 Room : RKBC
 Diagnosis : Post DJ-stent
 Pro : cystoscopy + Aff DJ-stent
 Coex history : ( + )
 Allergy history ( - )
 History of asthma ( - )
 Surgical history ( + )
3 times, with general anesthesia and regional anesthesia without
complication
 History of diabetes ( + )
was diagnosed since 11years ago,
The Highest Blood Sugar Score’s 600 mg/dL, daily BSS between 100 and 200
mg/dL
Treatment : Novorapid 12IU 3x, levemir 12IU once daily
End-Organ target : Peripheral Neuropathy
 Hypertension ( + )
was diagnosed since 1,5 month ago
The Highest BP : 170/100 mmhg
Treatment with amlodipine 10mg once daily
end-organ target : cardiomegaly, Renal failure
o Sense : Compos mentis
o BP : 170/90 mmHg
o HR : 120x/menit
o RR : 20x/menit
o T : 36.5 ºC
o SpO2 : 99% with free air
 Head : Light Reflect ( + / +)
conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
Laboratory test ( 29/10/2019)

 Hb : 12.1
 Leucocyte : 4.010
 Trombocyte : 356.000
 Ht : 34
 BSS : 268
 Na/K : 147/3.1
 Ur/Cr : 36/0.93
 Chest X-ray
20/1/2019
Result : Cardiomegaly

 Electrocardiography
7/10/2019
Sinus Tachycardia
ASA II RA Spinal
 Name : Tahrin
 Sex : male
 Age : 37 yo
 Room : RPK / Room 10
 Med.rec : 1127065
 Diagnosis : Stricture of urethra
 Pro : Sache
Scheduled for aff cystostomy, any other symptoms -, urine +, dyspnoe -

 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( + )
Cystostomy on may 2019 with General anesthesia without problems, Post-
operative care’s in GICU for 8 days
 History of diabetes ( - )
 History of hypertension ( - )
o Sense : Compos mentis
o BP : 120/80 mmHg
o HR : 89x/min
o RR : 18x/min
o T : 36.5 ºC
o SpO2 : 99%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
Laboratory test (02/09/2019)
• Hb : 12,2
 Ht : 31
• Leucocyte : 10.560
• Trombocyte : 267.000
• Ur/Cr : 32/0.84
• CT/BT : 10.0/2.0
ASA I RA Spinal
 Name : Danish
 Sex : male
 Age : 8 yo
 Room : RBP / Room 6
 Med.rec : 1070437
 Diagnosis : Hypospadia
 Pro : Urethroplasty
Orificium Urethra eksternal’s not on the tips of the penis after birth, cough -,
sneezing -, rhinoroe -, fever -, seizure -

 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( + )
November 2018, and April 2019 for hypospadia with GA, Problems -
o Sense : Compos mentis
o HR : 89x/min
o RR : 20x/min
o T : 36.5 ºC
o SpO2 : 99%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
Laboratory test (24/10/2019)
• Hb : 14
 Ht : 40
• Leucocyte : 11.180
• Trombocyte : 402.000
• CT/BT : 10.0/2.0
ASA I GA LMA
 Name : Susdiana
 Sex : female
 Age : 61 yo
 Room : RKBC / Room 2
 Med.rec : 1137250
 Diagnosis : Ureterolithiasis Dextra
 Pro : URS Dextra
Feel pain in the back, colic +, and dysuria +
Dyspnoe -, chest pain –
Menopause + 15 years

 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( + )
Cholecystectomy in 2010 with General anesthesia without problems
 History of diabetes ( - )
 History of hypertension ( - )
o Sense : Compos mentis
o BP : 120/80 mmHg
o HR : 78x/min
o RR : 18x/min
o T : 36.5 ºC
o SpO2 : 98%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
Laboratory test (24/09/2019)
• Hb : 8,9
 Ht : 31
• Leucocyte : 6.880
• Trombocyte : 276.000
• Ur/Cr : 13/1,37
• CT/BT : 10.0/2.0
 ECG (1/10/2019)
Normal Sinus Rhythm
 Chest x-ray (26/8/2019)
Dilation of aorta
Cardiomegali, Bronchopneumonia
ASA I RA Spinal
 Name : Sumarna
 Sex : male
 Age : 56 yo
 Room : RPK
 Med.rec : 1140904
 Diagnosis : Nefrolithasis dextra + hypertension
 Pro : PCNL Dextra
Felt pain in the back since 3 month, colic +, and dysuria +
Dyspnoe -, chest pain –
Metscore > 4

 Coex history ( + )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( - )
 History of diabetes ( - )
 History of hypertension ( + )
Highest BP’s 150/90, treatment with amlodipine 5 mg once daily
o Sense : Compos mentis
o BP : 150/90 mmHg
o HR : 99x/min
o RR : 18x/min
o T : 36.5 ºC
o SpO2 : 98%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
Laboratory test (1/10/2019)
• Hb : 14,4
 Ht : 43
• Leucocyte : 7.960
• Trombocyte : 255.000
• Ur/Cr : 39/1,28
• CT/BT : 9.0/1.0
• BSS : 89
 ECG (2/10/2019)
Normal Sinus Rhythm
 Chest x-ray (1/10/2019)
Normal C-xray
BNO (19/9/2019)
Multiple stone in the right kidney
ASA II GA
 Name : Eko
 Sex : male
 Age : 58 yo
 Room : RPK
 Med.rec : 1149126
 Diagnosis : Gross Hematuria ec. Susp Carcinoma
Vesica urinaria + HT + post CVD NH
 Pro : Cystoscopy, TURB if necessary
Bloody urine since 1 week ago, with catheter, urine +, dyspnoe -, chest pain -

 Coex history ( - )
 Allergy history ( - )
 History of asthma ( - )
 Surgery history ( - )
 History of diabetes ( - )
 History of hypertension ( - )
o Sense : Compos mentis
o BP : 140/80 mmHg
o HR : 78x/min
o RR : 18x/min
o T : 36.5 ºC
o SpO2 : 98%
 Head : conjungtiva anemis(-/-) Sclera Icteric (-/-)
 Neck : Mass (-)
 Thorax :
cor : SI&SII reguler, murmur (-), gallop (-)
Pulmo : Vesikuler (+/+), ronkhi (-/-), Wheezing (-/-)
Abdomen : Bowel Sound (+)
Extremity : edema -/-, CRT <3’
 Motorik dextra 3, sinistra 5
Result hemiplegia dextra
Laboratory test (20/11/2019)
• Hb : 12,1
 Ht : 9,5
• Leucocyte : 4.740
• Trombocyte : 236.000
• Na/K : 139/3,0
• Ur/Cr : 56/1,0
• CT/BT : 9.0/1.0
• BSS : 96
 ECG (20/10/2019)
AV Block grade 1, old myocard infarction
 Chest x-ray (19/11/2019)
Normal C-xray
ASA II GA LMA