MORNING REPORT

PROGRAM STUDI ANESTESIOLOGI DAN

TERAPI INTENSIF

06 Maret 2023

PEMBIMBING dr. Fachrul Jamal, SpAn-TI, Subsp. TI(K)

dr. Teuku Yasir, SpAn-TI, Subsp. TI(K)
Dr. dr. Zafrullah Khany Jasa, SpAn-TI, Subsp. NA(K)
dr. Muhammad Iqbal, SpAn-TI
Chief Of Chief Aoelia
Chief Kamar Operasi …….
Chief Critical Care ……..
Chief Poliklinik/Ambulatory …….
Chief Emergency/METS ………
OKA VII (Bedah Orthopedi)

DPJP: dr. Azwar Risyad, SpAn-TI

5 Rencana Anestesi
 OK VII (Bedah Orthopedi)
DPJP: dr. Azwar Risyad, SpAn-TI
Pre Op: dr.Arshad/Juanda-faqih/Dedi On Duty : Audi/Juanda-Putra-Ira
No Nama Diagnosa Prosedur ASA Tatalaksana Post Op
1 TKR
CL, Pr, 55 Th OA Knee Joint Dextra II Spinal Anestesi Ruangan
08.40 dr. Armia, SpOT

2 Close Fracture Metacarpal ORIF General Anestesi –

MH, Lk, 21 Th I Ruangan
11.30 5 Manus Dextra dr. Onarisa, SpOT LMA

3 Fr. Interochanter Right Bipolar Arthroplasty

A, Pr, 51 Th III Spinal Anestesi HCU
16.00 Femur dr. Irsan, SpOT

Morbus Hansen With Median Nerve Compression

4 General Anestesi –
MB, Lk, 32 Th Median Nerve Entralment + Release II Ruangan
19.15 LMA
Flexor Contracture Pip Joint dr. Irsan, SpOT

Neglected Posterior
5 keletal Traksi
M, Lk, 23 Th Dislocation Caput Femur I Spinal Anestesi Ruangan
20.00 dr. Subhan, SpOT
Dextra
 OK VII (Bedah Orthopedi)
DPJP: dr. Azwar Risyad, SpAn-TI
Pre Op: dr.Arshad/Juanda-faqih/Dedi
No Nama Diagnosa Prosedur
) ASA
On Duty : Audi/Juanda-Putra-Ira
Tatalaksana Post Op
ASA II
- Hipertensi stage I, TD : 141/89 mmHg, METs
4, klinis: nyeri dada (-), sesak (-), berdebar
(-), mudah lelah (-), murmur (-), gallop (-),
EKG : Sinus ritme QRS rate 78 bpm, CXR
1
TKR Cardiomegali (-), Th/ -Leukositosis 10.770 Spinal
08.40 CL, Pr, 55 Th OA Knee Joint Ruangan
dr. Armia, SpOT mm/3 Anestesi
Dextra
Saran :
- Pertahankan TD <150/90 mmHg
- Amlodipin 1x5mg
- Lorazepam 1x0,5mg
 OK VII (Bedah Orthopedi)
DPJP: dr. Azwar Risyad, SpAn-TI
Pre Op: dr.Arshad/Juanda-faqih/Dedi On Duty : Audi/Juanda-Putra-Ira
No Nama Diagnosa Prosedur ) ASA Tatalaksana Post Op

2 Close Fracture ORIF ASA I General

11.30 MH, Lk, 21 Metacarpal 5 - Lab dalam batas normal Anestesi – Ruangan
Th Manus Dextra dr. Onarisa, SpOT - Tanpa penyulit airway LMA

ASA III
- Destroyed lung kiri dengan bronkiektasis,
susp TB paru, klinis sesak (-), batuk (-) ,
demam (-) , RR: 24x/i, SpO2 95-96% RA,
VES (+/menurun), Rh (-/-), Wh (-/+), CXR :
Atelektasis paru kiri e.c massa paru kiri dd
infeksi, CT Scan :Destroyed lung kiri
Bipolar
dengan bronkiektasis, TB paru dengan
3 Arthroplasty
A, Pr, 51 Fr. Interochanter single nodul di paru kanan kesan
16.00 Spinal
Th Right Femur tuberkuloma, Th/-- HCU
dr. Irsan, SpOT - Anestesi
DM type 2, GDS 321 mg/d, Th/ Novorapid
3x 10IU, Lantus 1x20IU
- Anemia Hb 9,3 g/dL
- Instabilitas suhu post transfusi 37,7 C, Th/-

Saran :
- Regulasi GDS target < 200mg/Dl
- Koreksi anemia target Hb > 10 g/dL
- Koreksi suhu target 36,5-37,2 C
3
3
 OK VII (Bedah Orthopedi)
DPJP: dr. Azwar Risyad, SpAn-TI
Pre Op: dr.Arshad/Juanda-faqih/Dedi
No Nama Diagnosa Prosedur
) ASA
On Duty : Audi/Juanda-Putra-Ira
Tatalaksana Post Op
ASA II
- Hipertensi stage I, TD : 142/81 mmHg,
METs 4, klinis: nyeri dada (-), sesak (-),
berdebar (-), mudah lelah (-), murmur (-),
Morbus Hansen gallop (-), EKG : (-), CXR Cardiomegali (-),
Median Nerve
4 With Median Th/-
Compression - General
19.15 MB, Lk, 32 Nerve Entralment Morbus Hansen pengobatan bulan ke 8 Th/
Release Anestesi – Ruangan
Th + Flexor MDT MB
- Leukositosis 15.450 /mm3 LMA
Contracture Pip
dr. Irsan, SpOT
Joint
Saran :
- Pertahankan TD target < 150/90 mmHg
- Amlodipin 1x5mg
- Lorazepam 1x0,5mg
4
 OK VII (Bedah Orthopedi)
DPJP: dr. Azwar Risyad, SpAn-TI
Pre Op: dr.Arshad/Juanda-faqih/Dedi On Duty : Audi/Juanda-Putra-Ira
No Nama Diagnosa Prosedur
) ASA Tatalaksana Post Op

Neglected Posterior keletal Traksi ASA I

5 M, Lk, 23 - Spinal
Dislocation Caput Lab dalam batas normal Ruangan
20.00 Th - Anestesi
Femur Dextra dr. Subhan, SpOT Tanpa penyulit airway