Morning Report

Wednesday, 16 August
2023
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
1. 20 Y / M / BW 70.2 kg / 4695302
Diagnosis : Neglected fracture of frontal, right zygomaticomaxillary complex, nasal and sagital palatum
Procedure : Nasal augmentation with diced cartilage and scar revision
Status : ASA 1
• Without airway difficulty
Plan : GA
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
2. 19 Y / F / 4666237
Diagnosis : Bilateral zygomaticomaxillary complex fracture, right nasoorbitoethmoidal type 2 fracture, left
anterior-sided alveolar parasagittal fracture
Procedure : Open reduction internal fixation
Status : ASA 2
Bilateral zygomaticomaxillary complex fracture, right lateral type 2 nasoorbitoethmoidal fracture, left
anterior lateral alveolar parasagittal fracture, clinically without signs of active bleeding, without
facial crepitation, brain CT without contrast: Comminuted fracture of the right ethmoid sinus wall
involving the right lamina papyracea, anterior and medial walls of bilateral maxillary sinuses,
bilateral nasal bone, reaching the processus alveolaris of the left maxilla os, with some bone
fragments reaching the cutis-subcutis of the right maxillary region, right periorbita, and bilateral
nasal, right inferior orbital rhomboid comminuted fracture with herniation of right orbital fat into
right maxillary intrasinus, may correspond to blow-out fracture, left zygomatic arch comminuted
fracture, without therapy.
• On tracheostomy

Plan : GA
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
3. An. 4 Y / M / 4623104
Diagnosis : Fibrolipoma of right hand
Procedure : Excision Biopsi
Status : ASA 2
Anemia Hb 10.1
• Without airway difficulty
Plan : GA
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
4. 54 Y / F / BW 60 kg / 4710351
Diagnosis : Left frontoorbital defect, history of wound dehiscence in WHO grade II recurrent sphenoorbital sinistra meningioma post craniotomy
tumor removal, closed defect with bipedicled flap, split thickness skin grafts, debridement, subdural empyema drainage, and
transpositional flap

Procedure : Defect closure with split thickness skin grafts

Status : ASA 3
Wound dehiscence, left subdural empyema frontotemporal, cerebrospinal fluid leakage on history of tumor re-removal,
ethmoidectomy, maxillectomy, and exenteration of due to left sphenoorbital meningioma WHO grade II, clinically with motoric
aphasia, impaired higher cortical function, left central n. VII paresis, GCS E4M6Vaphasia, BP 96/66 mmHg, HR 93 x/minute, without
sign of acute intracranial pressure elevation, CT Brain with contrast (30/7/23): Left ethmoid sinus posterior wall, left maxillary sinus
posterior wall, left sphenoid sinus posterolateral side, left carotid space, and left temporal fossa with left temporal bone and left
sphenoid sinus posterolateral wall destruction, decreased, Subdural hygroma in the left frontoparietotemporal region urging the left
side cerebral hemisphere medially, with surrounding emphysema, cerebral edema with midline shift to the right by 0.6 cm
(previously 1.3 cm). Defects in the left frontoparietotemporal bone, left lateral lamina papyracea, a portion of the superolateral wall
of the left maxillary sinus, and left cavum orbita, stqa, resection defect of the left frontoparietotemporal lobe parenchyma causing
dilation of the left anterior and posterior cornu lateralis ventricles, stqa, isodense lesion with rim enhancement in left masticator
space, stqa, VP shunt from defect in right temporal os with tip in right lateral ventricle posterior cornu, stqa, on Levetiracetam 2x750
mg PO.
• History of supraventricular tachycardia intraoperatively, clinically without dyspnea, able to lie supine, BP 96/66 mmHg, HR
93x/minute

Plan : GA

Post-op : HCU
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
5. An. 17 Y / M / 4715089
Diagnosis : Asites masif pada suspek hepatoblastoma dd/ Budd-Chiari Syndrome dd/ metabolic liver disease
Procedure : drainase dan biopsi hepar
Status : ASA

Plan :
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
6. An. 7 Y /
Diagnosis : Suspek kolestasis intrahepak ec suspek Viral Infecons, dd hemangioma infanl hepar relaps -
Hepatosplenomegali ec suspek hemangioma infanl hepar relaps - Riw hepatektomi segment 5-7 dan
kolesistektomi ec hemangioma infantil (usia 1 bulan) - Suspek hipertensi porta
Procedure : core biopsy
Status : ASA

Plan :
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
7. An. 2 M / M / 4711661
Diagnosis : Laringomalasia, Paralysis of vocal cords and larynx
Procedure : Bronchoskopi
Status : ASA

Plan :
Post-op : Ward
 OR CCC Plastic
dr. Aldy Heriwardito, Sp.An-KAKV / Devani - Karina - Tomo - Sasti - Ezra
8. An. 1 Y /
Diagnosis : hipospadia
Procedure : Staged urethroplasty
Status : ASA

Plan :
Post-op : HCU
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
1. 59 Y / F / 1742025 / JKN
Diagnosis : Intraocular lense dislocation left eye
Procedure : Vitrectomy, explant intraocular lens, exchange intraocular lense (iris claw retropupil posterior) left
eye
Status : ASA 3
Moderate-severe persistent asthma, triggered by dust, insects (cockroaches), flu, with a history of
arrest due to severe asthma attack in 1976, the symptoms appear depending on the trigger, the
last exacerbation 1 day ago, on Salmeterol and Fluticasone propionate maintenance twice a day,
inhalation Ipratropium bromide, Fenoterol hydrobromide, Salbutamol.
• Without airway difficulty

Plan : MAC up to sedation

Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
2. 67 Y / F / 4714966 / JKN
Diagnosis : Chronic primary angle closure glaucoma left eye, primary angle closure right eye, immature senile cataract both
eyes
Procedure : Phaco intraocular lens both eyes

Status : ASA 3
Epilepsy since 2011, clinically with a history of tonic clonic seizures of about 5 minutes, last seizure 2 years ago,
on Divalproex Sodium 2x500 mg PO, Trihexyphenidyl HCl 2x2 mg PO, Kalium L Aspartate 3x500 mg PO, NaCl
capsule 3x500 mg PO.
Parkinson since 2019, clinically with intentional tremor, moderate assisted mobilization, dyskinesia, on Donepezil
hydrochloride 1x10 mg PO, Lamotrigine 1x50 mg PO, Citicoline 3x500 mg PO, Escitalopram 1x10 mg PO
Hypertension, BP 152/89 mmHg HR 75 x/minute, clinically without dyspnea/chest pain, able to lie supine, FC and
METs difficult to assess, CXR: Aortic elongation, without radiologic abnormalities of the heart and lungs,
thoracic scoliosis to the right side, without ECG results, without echo results, on non-routine Candesartan 1x8
mg PO.
Geriatric, frailty scale 5, mildly frail
• Without airway difficulty

Plan : GA

Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
3. An. / F / 4732448 / JKN
Diagnosis : Aggressive posterior retinopathy of prematurity both eyes stage,3 stage on right eye
Procedure : Retcam, avastin injection in both eyes and laser indirect ophthalmoscopy in both eyes 2-4 weeks
later
Status : ASA 3
Premature neonates inadequate for gestational age, 30 weeks of gestational age, 37 weeks of
preconceptional age, birth weight 1700 gram, current weight 2555 grams, history of ventilator use
during postnatal care in NICU, with retinopathy of prematurity without apnea of prematurity,
clinically active, HR 124 x/minute, SpO2 98% room air, without echo results.
Anemia Hb 9.9
• Possibility of difficult airway cannot be ruled out

Plan : GA
Post-op : SCN back up ventilator
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
4. 2 Y 8 M / M / 4676362 / JKN
Diagnosis : Suspected cortical visual impairment, microcephaly and suspected corpus callosum dysgenesis,
suspected cerebral cortex malformation
Procedure : Examination under anesthesia of both eyes
Status : ASA 2
Microcephaly, clinically with developmental and visual impairment, able to say 1 word, begin to walk,
history of febrile seizure 1x in January 2023, CT scan (25/11/22) without calcification or intracranial
hemorrhage, suspected blake pouch cyst with bilateral ventricular dilatation, ventricle III, and
ventricle IV, without brain edema, suspected corpus callosum dysgenesis, suspected cerebral
cortex malformation, on occupational and speech therapy, on Risperidon 1x0.25 mg PO.
• Possibility of difficult airway cannot be ruled out

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
5. 4 Y 1 M / F / 4630802 / JKN
Diagnosis : Post external dacryocystorhinostomy and lacrimal fistula reconstruction of left eye (5/4/2023) due toi
dacryocystitis with lacrimal fistula
Procedure : Removal of silicone tube
Status : ASA 2
History of prematurity without history of ventilator use, with labiognatopalatoschizis post labioplasty
and partial palatoplasty May 2022, currently still with cleft palate, sometimes drink exit through
the nose, not easily choked, with polydactyly and syndactyly, without other congenital
abnormalities, without echo results.
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
6. An. 5 Y / F / 4464541 / JKN
Diagnosis : Bilateral steroid induced cataract
Procedure : Cataract extraction, primary posterior capsulectomy , anterior vitrectomy, and right eye intraocular
lens
Status : ASA 2
Juvenile idiopathic arthritis, clinically with joint swelling, leukocytes 19.430, on Methylprednisolone
1x8 mg PO
Hypokalemia 3.1
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
7. An. 5 Y / F / 4711313 / JKN
Diagnosis : Left eye lens subluxation, right eye pseudophakia (post phaco intraocular lens + capsular tension ring
+ capsular tension segment), Marfan syndrome
Procedure : Right eye suture removal, left eye phaco intraocular lens
Status : ASA 2
Suspected Marfan syndrome, clinically without dyspnea, tall stature, elastic finger joints, Echo
(11/10/22): normal LV function, EF 67%, normal RV function, MR mild, PR mild, CXR (10/7/23):
Heart within normal limits, without therapy
• Possibility of difficult intubation due to Marfan syndrome

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
8. An. 6 Y / M / 4711406 / JKN
Diagnosis : Left eye pseudophakia after cataract extraction and left eye intraocular lens insertion
Procedure : Right eye ataract extraction and intraocular lense
Status : ASA 1
• Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
9. An. 13 Y / F / 4706700 / JKN
Diagnosis : Aftter v-y plasty, suspension of frontal, right eye tarsal fixation H+5 weeks due to blepharophimosis-
ptosis-epicanthus inversus syndrome
Procedure : V-y plasty, suspension of frontal, left eye tarsal fixation
Status : ASA 1
• Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
10. An. 15 Y / M / 4632538 / JKN
Diagnosis : Right eye Emulsified Silicone oil
Procedure : Right eye Silicone oil evacuation
Status : ASA 1
• Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
11. 18 Y / F / 4585976 / JKN
Diagnosis : Severe socket anophthalmia with right eye extropion
Procedure : Release sikatriks, skin graft, right eye proteses
Status : ASA 2
ECG (14/8/23): sinus aritmia, incomplete right bundle branch block, clinically without
palpitation/dyspneu/chest pain, BP 128/80 mmHg, HR 102 x/minute, RR 20 x/minute, without
therapy
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
12. 27 / M / 4692749 / JKN
Diagnosis : Total retinal detachment right eye, acquired immunodeficiency syndrome on anti retro viral, uvetis
posterior
Procedure : Scleral buckling, vitrectomy endolaser silicone oil right eye
Status : ASA 2
Acquired immunodeficiency syndrome on anti retro viral, clinically stable, CD4 <200 (July 2023), on
Tenofovir, Lamivudine, and Dolutegravir 1x1 PO
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
13. 18 Y / F / 4585976
Diagnosis : Severe socket anophthalmia with right eye extropion
Procedure : Release sikatriks, skin graft, right eye proteses
Status : ASA 2
ECG (14/8/23): sinus aritmia, incomplete right bundle branch block, clinically without
palpitation/dyspneu/chest pain, BP 128/80 mmHg, HR 102 x/minute, RR 20 x/minute, without
therapy
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
14. 27 / M / 4692749
Diagnosis : Total retinal detachment right eye, acquired immunodeficiency syndrome on anti retro viral, uvetis
posterior
Procedure : Scleral buckling, vitrectomy endolaser silicone oil right eye
Status : ASA 2
Acquired immunodeficiency syndrome on anti retro viral, clinically stable, CD4 <200 (July 2023), on
Tenofovir, Lamivudine, and Dolutegravir 1x1 PO
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
15. 43 / M / 4731770
Diagnosis : Right eye corneal ulcer with epithelized prolapse of iris due to fungal infection
Procedure : Periosteal graft of right eye
Status : ASA 2
Type 2 diabetes mellitus, clinically stable, fasting blood glucose 191, 2 hours post prandial blood
glucose: 234, on Metformin 3x500mg PO
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
16. 51 Y / M / 4690183
Diagnosis : Acute angle closure glaucoma mata kanan, primary angle closure mata kiri, graves ophthalmopathy
inaktif derajat sedang berat, retinopathy hipertensi grade 2, DM tipe lain et causa steroid induced,
hipertensi, dislipidemia
Procedure : Phaco intraocular lens mata kanan siapkan capsular tension ring
Status : ASA

Plan :
Post-op : Ward
 OR Kirana Ophthalmology
dr. Christopher Kapuangan, Sp.An-KAP / Fulki - Novi - Vina - Tiwi - Fakhri
17. 51 Y / F / 4714043
Diagnosis : Corneal perforation with right eye iris prolapse, pterygium on both eyes
Procedure : Right eye amniotic membrane transplant, camera oculi anterior reformation
Status : ASA 2
Incomplete right bundle branch block, clinically without dyspnea/chest pain, BP 132/80 mmHg, HR
82 x/minute, FC 1 METS>4, ECG (10/8/23) : sinus rhythm, 82 x/minute, regular, normoaxis, normal
P wave, PR interval 0,12s, QRS 0,10s, without ST-T changes, incomplete RBBB, without therapy
• Without airway difficulty

Plan : GA
Post-op : Ward