Morning Report

Tuesday, 03 October 2023

 OR KG 6-3 Urology
dr. R. Besthadi Sukmono, Sp.An-KAR / Chacha - Habel - Vito
1. 65 Y / F / 4648815
Diagnosis : Kidney transplant candidate
Procedure : Left laparoscopic living donor nephrectomy
Status : ASA 2
Geriatric 65 years old, Frailty Scale 2, managing well
• Without airway difficulty
Plan : GA - Quadratus lumborum block
Post-op : Ward
 OR KG 6-3 Urology
dr. R. Besthadi Sukmono, Sp.An-KAR / Chacha - Habel - Vito
2. 52 Y / M / 4538834
Diagnosis : Prostate adenocarcinoma, moderate to severe bilateral hydronephrosis, thrombocytopenia,
hypoalbuminemia.
Procedure : Cystoscopy, bilateral Retrograde pyelography, double J stent insertion up to nephrostomy
Status : ASA
• Prostate adenocarcinoma with history of chemoradiotherapy. Clinically unable to lie supine,
dyspnea, limited activity. CXR: Multiple lytic-blastic lesions in both hemithoracic costae, visualized
right-left humerus, and right-left scapula, DD/ metastatic.
• Urinary tract infection in acute kidney injury dd acute on chronic kidney disease due to suspected
urinary tract obstruction. Clinically looking drowsy, without signs of fluid overload, BP 93/73
mmHg, HR 102x/minute, UO >0.5 mL/kgBW/hour, Ureum/Creatinine 98.4/1.3, on Cefoperazone 2 x
1000 mg IV
• Thrombocytopenia 56,000
• Hypoalbuminemia 2.2
• Without airway difficulty

Plan : GA
Post-op : Ward
 OR KG 6-3 Urology
dr. R. Besthadi Sukmono, Sp.An-KAR / Chacha - Habel - Vito
3. 60 Y / F / 4674823
Diagnosis : Left moderate-severe hydronephrosis, cervical carcinoma IIIc, type 2 diabetes mellitus, hypertension, obesity,
acute kidney injury dd acute on chronic kidney disease, urinary tract infection
Procedure : Cystoscopy, left Retrograde pyelography, left double J stent

Status : ASA 2
• Stage IIIb cervical carcinoma with history of chemotherapy 1x, external radiation 25x and internal radiation 4x.
Clinically without abdominal distension, without birth canal bleeding, without therapy.
• Hypertension, BP 155/83 mmHg, HR 82x/minute, clinically FC 1, METs 4, able to lie supine, without
dyspnea/chest pain. CXR: Cardiomegaly with aortic elongation and calcification. ECG: sinus, normoaxis,
without BBB/LVH/ST-T changes. Echo: global normokinetic, mild MR, normal LV diastolic and systolic
function(EF 61.7%), normal RV systolic function (TAPSE 31.6), on Amlodipine 1x10 mg PO.
• Grade 2 Obesity, BW 95 kg, BH 170, BMI 32.8, STOP Bang Score 3 intermediate risk OSA
• Geriatric 60 years old, Frailty scale 3 managing well
• Without airway difficulty

Plan : Spinal

Post-op : Ward
 OR KG 6-3 Urology
dr. R. Besthadi Sukmono, Sp.An-KAR / Chacha - Habel - Vito
4. 61 Y / M / 4735230
Diagnosis : Urinary retention of prostate due to dd Benign prostatic hyperplasia, urinary tract infection
Procedure : Transperineal prostate biopsy
Status : ASA 2
• Controlled hypertension, BP 152/93 mmHg, HR 64x/minute. Clinically FC 1, METs >4, able to lie
supine, without dyspnea and chest pain. ECG: CXR: without radiologic abnormalities of the heart,
on Amlodipine 1x10 mg PO
• Urinary retention with suspected urinary tract infection due to prostate tumor dd benign prostatic
hyperplasia on urinary catheter. UO >0.5 mL/kgBW/hour, Ureum/Creatinine 36.4/1.1, without
therapy
• Geriatric 61 years old, Frailty scale 3, managing well
• Without airway difficulty

Plan : Spinal
Post-op : Ward