Morning Report

Monday, 06 February
2017
 OR 1 (Ortho)
dr. Andi Ade Wijaya, SpAn, KAP / Rifky - Halida
1. 38 yo / M / 4192150
Diagnosis : Malunion of the left shaft tibia fibula
Procedure : Refracturization and open reduction internal fixation (ORIF) plate and
screw
Status : ASA 2
Asymptomatic bradycardia HR 52x/m. EKG: sinus bradycardia, QRS
rate 49x/m. FC 1
Without airway difficulty
Plan : CSE
Post-op : Ward
 OR 1 (Ortho)
dr. Andi Ade Wijaya, SpAn, KAP / Rifky - Halida
2. 40 yo / F / 4163193
Diagnosis : Closed fracture of pelvis Marvin Tile C3 consists of: - Closed fracture of
right superior pubic rami - Left sacroiliac joint disruption - Closed
fracture of left superior and inferior pubic rami - Closed acetabular
fracture Judet-Letournel associated type T-shaped Closed fracture
dislocation of left femoral neck Garden type IV
Procedure : Open reduction internal fixation (ORIF) plate and screw (C-Arm)
Status : ASA 2
Elevated transaminase enzymes SGPT 83 SGOT 47
Leukocytosis 12.250/mm3
Without airway difficulty
Plan : GA
Post-op : HCU
 OR 2 (Transplant)
dr. Christopher Kapuangan, SpAn / Farah - Anggun - Bell
1. 1 yo / Girl / BW 10 kg / 4102048
Diagnosis : Biliary atresia
Procedure : Recipient of liver transplant
Status : ASA 3
Biliary atresia
Abdominal distension, Abdominal circumference 39 cm, with
venectation
Pancytopenia (Hb 9 g/dL, leukopenia 4500, thrombocytopenia 79000)
Elevated transaminase enzyme SGPT 158
Hypoalbuminemia 3.36
CMV infection on therapy of vagancyclovir 2x50mg po
Plan : GA-CVC-ABP
Post-op : PICU
 OR 2 (Digestive)
dr. Christopher Kapuangan, SpAn / Farah - Anggun - Bell
2. 22 yo / M / 4162122
Diagnosis : Enterocutan fistula with history of adhesiolysis laparotomy and tube
caeosteotomy due to perforated appendicitis and ileocaecal adhesion
Procedure : Exploration laparatomy and adhesiolysis
Status : ASA 4
Septic shock (blood pressure 122/71mmHg, heart rate 94x/m on
norepinefrin 0.05mcg/kg/minute, breathing on MOV PSIMV
6/8/5/45, SpO2 100%, temperature 37C, urine output
0.8mL/kg/hour, leukocytosis 46700, PCT 1.55 on D22 fluconazole
1x200mg iv+ D5 meropenem 3x2gram iv + D5 amikasin 1x1gram iv)
Post iatrogenic pneumothorax dueto CVC insertion WSD
Anaemia Hb 9.6 g/dL
Hypoalbuminemia 2.6
Plan : GA
Post-op : ICU ER
 OR 3 (Oncology)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Neil
1. 60 yo / M / 3780710
Diagnosis : Malignant Peripheral Nerve Sheath Tumors (MPNST) of the cruris
dextra region
Procedure : Wide excision + Frozen section
Status : ASA 2
Controlled type 2 diabetes mellitus RBG 217 on therapy of novorapid
3x14 unit, lantus 1x18 unit
Anaemia Hb 9.3 g/dL
Leukocytosis 13.040
Without airway difficulty
Plan : GA Epidural
Post-op : Ward
 OR 3 (Oncology)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Neil
2. 38 yo / F / BW 65 kg / 3783727
Diagnosis : Phyloides tumor of the right breast
Procedure : Simple mastectomy, if necessary radical mastectomy
Status : ASA 3
Sepsis (heart rate 127x/m, respiration rate 24-26x/m, leukocytosis
14.200, lactic acid 1.7, PCT 1.65, urine output > 0.5ml/kgBB/hour) on
therapy meropenem 3x1 gr IV (E2)
Anaemia Hb 9 g/dL on transfusion of 2 bags PRC
Hypoalbuminemia 1.62 on therapy of albumin 20%
Without airway difficulty
Plan : GA - CVC
Post-op : ICU
 OR 3 (Oncology)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Neil
3. 45 yo / F / BW 57 kg / 4175896
Diagnosis : Struma nodosa toxic
Procedure : Total thyroidectomy + frozen section
Status : ASA 2
Grave's disease on therapy of PTU 3x400mg, clinically stable and
euthyroid (FT3 2.970 FT4 0.16 TSHs 3.3)
Chest X ray : cardiomegaly CTR 59%. Echo: segmental hypokinetic, TR
mild, PR mild, MR mild. EF 70%, TAPSE 28.5mm. METS >7
Without airway difficulty
Plan : GA
Post-op : ICU
 OR 4 (ENT)
dr. Christopher Kapuangan, SpAn / Rifky - Tata - Anton
1. 22 yo / M / 4192895
Diagnosis : Ala nasi dextra stricture
Procedure : Ala nasi dextra reconstruction and concha auricular graft
Status : ASA 1
Without airway difficulty
Plan : GA
Post-op : Ward
 OR 4 (ENT)
dr. Christopher Kapuangan, SpAn / Rifky - Tata - Anton
2. 12 yo / Boy / BW 33 kg / 4120883
Diagnosis : Microtia grade I bilateral, ear canal atresia
Procedure : Auriculoplasty left ear, atresioplasty right ear
Status : ASA 2
Leukocytosis 15.200
Without airway difficulty
Plan : GA
Post-op : Ward
 OR 9 (ENT)
dr. Christopher Kapuangan, SpAn / Rifky - Tata - Anton
1. 50 yo / F / 4191183
Diagnosis : Sinonasal squamous cell carcinoma
Procedure : Medial maxillectomy
Status : ASA 2
Intermittent mild bronchial asthma, last episode was 2 weeks ago,
with fatigue as the trigger, resolves on resting, on therapy of oral
teosal at night
Stage I hypertension, blood pressure 140/90 mmHg, without therapy,
FC 1
Without airway difficulty
Plan : GA
Post-op : ICU
 OR 9 (ENT)
dr. Christopher Kapuangan, SpAn / Rifky - Tata - Anton
2. 54 yo / F / 4143949
Diagnosis : Non-Hodgkin lymphoma post-chemotherapy
Procedure : Tonsillectomy
Status : ASA 2
Controlled hypertension, blood pressure 140/90 mmHg, on therapy
of oral amlodipine 1x10mg, echocardiography: no cardiomegaly, FC1
Anemia Hb 10.8
History of chemotherapy 6 times, with regimen of vincrystin,
cyclopoapamide, doxorubicin, rifuximab, and prednisone, last
regimen was on December 2016
Without airway difficulty
Plan : GA
Post-op : Ward
 OR 5 (Vascular)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Ata
1. 56 yo / M / 4163381
Diagnosis : Diabetic left foot ulcer, osteomyelitis post redebridement and negative pressure wound
therapy (NPWT)
Procedure : Redebridement and negative pressure wound therapy (NPWT)

Status : ASA 3
Late onset hospital acquired pneumonia and pulmonary tuberculosis on Anti
Tuberculosis therapy category 1, rifampicin 1x450mg, INH 1x300 mg, respiration rate
24x/min, rales presents in both lungs area, wheezing presents in the right lung area,
SaO2 99%, with nasal canule 3 litres per minute, Chest X Ray : right perihillar fibrotic;
suprahillar, perihillar, and paracardial bilateral infiltrates; increased right suprahillar
density, blunt costophrenicus angle DD/ pleural effusion
Sepsis et causa diabetic ulcer of the left foot DD/ hospital acquired pneumonia, heart
rate 113x/minute, Lactate 2.6, Leukocyte 9360, temperature instability, on therapy of
ampicillin sulbactam E2 4x1.5g
Type 2 diabetes mellitus RBG 136, on therapy of humalog 3x6 U, lantus 1x8 U
Elevated level of direct billirubin 2.69, indirect billirubin 2.8
Hypoalbuminemia 2.73
Anaemia Hb 10.3 gr/dl
Plan : Femoropopliteal block

Post-op : HCU medical

 OR 5 (Vascular)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Ata
2. 49 yo / M / 4161462
Diagnosis : Diabetic foot ulcer post debridement
Procedure : Redebridement and negative pressure wound therapy (NPWT)
Status : ASA 3
Sepsis improvement, (HR 85x/min, without temperature instability,
leukocyte 4.720, procalcitonin 0.29, on therapy levofloxacin 1x400
mg, metronidazol 3x500 mg
Acute on Chronic kidney disease dd Chronic kidney disease stage III
(Ureum 141, creatinin 3.6, urine output >0.5cc/kgbb/jam
Controlled diabetes mellitus type 2, on therapy novorapid 3x6 unit
and lantus 1x8 unit
Controlled hypertension, on therapy of valsartan 1x160 mg dan
bisoprolol 1x5mg
Hypoabumin 2.35
Without airway difficulty
Plan : Femoropopliteal block
Post-op : Ward
 OR 5 (Vascular)
Dr. dr. Aida R. Tantri, SpAn, KAR / Agung - Ata
3. 51 yo / M / 4163551
Diagnosis : Diabetic ulcer pedis dextra post debridement

Procedure : Redebridement + negative pressure wound therapy (NPWT)

Status : ASA 3
Sepsis HR 103x/min, leukocyte 17.400, procalcitonin 1.63, lactate 2.8, on therapy
E10 moxyfloxacin 1x400 mg, E10 meropenem 3x500mg due to right foot diabetic
gangrene
Acute kidney injury dd/ acute on chronic kidney disease, ur/cr 75/1.9, urine
output: 0.674 cc/kgbb/hour
Non hemorrhagic stroke GCS E3M6V4-5, right hemiparesis on therapy of ascardia
1x80mg
Decrease level of consciousness due to non hemorrhagic stroke due to sepsis
Improvement of pneumonia, no cough, rales, nor wheezing present
Type 2 diabetes mellitus RBG 192, on therapy of novorapid 3x10 U, lantus 1x10 U
Hypoalbuminemia 2.54
Anaemia Hb 10.5 gr/dl
Plan : Femoropopliteal block

Post-op : Ward
 OR 6 (Thorax)
dr. Arif HM Marsaban, SpAn, KAA, KAP / Dira - Shendy - Kadek
1. 4 yo / Boy / BW 13.5 kg / 34689E5
Diagnosis : Pectus excavatum, dextrocardia
Procedure : Sternal turnover
Status : ASA 3
Cyanotic congenital heart disease, complete atrio-ventricular shunt
defect (CAVSD) post bidirectional cavo-pulmonary shunt (BCPS).
Clinical findings: bluish when fatigue, dyspnea on exertion, SpO2 82-
84% room air. Echo : dextrocardia, common AV valve, mild AV
regurgitation, large inlet to outlet VSD, severe PS, good biventricular
function EF 50%, BCPS flow good, no collateral. Conclusion : complete
atrio-ventricular shunt defect (CAVSD) + severe PS post bidirectional
cavo-pulmonary shunt (BCPS). CXR : dextrocardia + left paracardial
infiltrate
Plan : GA-CVC-ABP
Post-op : PICU
 OR 7 (Obgyn)
dr. Anas Alatas, SpAn, KAKV / Rifky - Uyun
1. 37 yo / F / 4182378
Diagnosis : High risk endometrium cancer
Procedure : Total hysterectomy salphingo-ovarectomy bilateral (HTSOB)
laparoscopic lympadectomy
Status : ASA 2
Stage I Hypertension (Blood pressure:146/81mnHg on therapy of oral
amlodipin 1x10 mg, chest x ray: calcified aorta, EKG: inverted T at
avL, FC I)
Plan : GA - Epidural
Post-op : Ward
 OR 8 (Neurosurgery)
dr. Anas Alatas, SpAn, KAKV / Dira - Nuri
1. 37 yo / F / 4182810
Diagnosis : Left parietal tumor
Procedure : Tumor removal craniotomy kraniotomi removal tumor
Status : ASA 2
Chronic elevation of intracranial pressure ec intracranial space
occupying lesion (SOL) (headache, blurry vision)
Hypertension BP 150/100 mmHg, without therapy
Obesity BMI 33 kg/m2, without obstructive sleep apnea (OSA)
Plan : GA-CVC-ABP
Post-op : ICU
 OR 10 (Neurosurgery)
dr. Pryambodho, SpAn, KAR / Dira - Linda - Mega
1. 57 yo / M / 4168818
Diagnosis : Hernia nucleus pulposus L3-4

Procedure : Laminectomy complex + C-arm

Status : ASA 3
Hypertensive heart disease (BP 140/80, echo : LA high normal hypertrophy
septal, hypokinetic segmental, AR mild, Aortic calcification RCC, MR mild, TR
mild, EF 40% tapse 17 mm, diastolic dysfunction grade II. EKG : inverted T at
avL, V3-V6 on therapy amlodipin 1 10 mg, valsartan 180 mg, bisoprolol 15
mg, clinically stable, FC I
Coronary artery disease post Percutaneous Coronary Intervention on therapy
clopidogrel 175 mg, aspilet 1100 mg (last consumed 2/2/2017)
Morbid obesity BMI 35 kg/m2, high risk of obstructive sleep apnea (OSA)
Without airway difficulty
Plan : GA - CVC

Post-op : ICU
 OR 10 (Neurosurgery)
dr. Pryambodho, SpAn, KAR / Dira - Linda - Mega
2. 70 yo / M / 3907176
Diagnosis : Residive hypofisis adenoma
Procedure : Recransphenoid removal tumor + C-arm
Status : Cancelled
 OR 11 (Transplant)
Dr. dr. Aida R. Tantri, SpAn, KAR / Vivi - Chrysa - Wiwid
1. 32 yo / M / 4191817
Diagnosis : Liver transplant donor
Procedure : Living Donor Liver Transplantation
Status : ASA 1
Without airway difficulty
Plan : GA - Epidural - CVC - ABP
Post-op : ICU
 OR 11 (Digestive)
Dr. dr. Aida R. Tantri, SpAn, KAR / Vivi - Chrysa - Wiwid
2. 67 yo / M / 4199254
Diagnosis : Intra-abdominal tumor suspect Gastrointestinal Stromal Tumor (GIST)
Procedure : Excision laparotomy
Status : ASA 2
Anaemia Hb 10.1 g/dL
History of pleural effusion post pleurocentesis (Chest X ray: fibrotic
appearance on both lower region of the lung, clinically stable, no
short of breath present
Chest X ray : cardiomegaly with calcification of the aorta, clinically
stable
Hypoalbuminemia 2.86
Geriatric patient 67 year old
Plan : GA - Epidural
Post-op : ICU
 OR 12 (Pediatric)
dr. Pryambodho, SpAn, KAR / Dira - Nindy
1. 13 yo / Boy / BW 30.2 kg / 4193411
Diagnosis : Hypospadia penoscrotal uretrocutan fistula
Procedure : Fistula repair
Status : ASA 1
Without airway difficulty
Plan : GA - Caudal
Post-op : Ward
 OR 12 (Pediatric)
dr. Pryambodho, SpAn, KAR / Dira - Nindy
2. 3 yo / Girl / BW 13 kg / 3812807
Diagnosis : Atresia ani fistel rectovestibular on-colostomy
Procedure : Posterior Sagittal Anorectoplasty (PSARP)
Status : ASA 2
Anaemia Hb 10.5g/dL
Acute tonsillitis, clinically infrequent cough no fever, on therapy of
oral ambroxol 10 mg and salbutamol 0.6 mg 3x/day
Chest X ray: Infiltrate on suprahiler bilateral and right paracardial,
clinically no dypnea, fever, rales, and wheezing
Plan : GA - Caudal
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
1. 49 yo / M / 4191808 (Private)
Diagnosis : Retinal detachment of the left eye
Procedure : Vitrectomy posterior + endolaser contilation
Status : ASA 2
Hypertension Blood pressure 138/76 mmHg, on therapy of oral
captopril 2x25 mg, amlodipine 1x5 mg, FC 1
Type 2 Diabetes Mellitus, RBG 87 mg/dL, on therapy: metformin
3x500 mg
Overweight BMI 29,2 kg/m2, OSA STOP BANG score 4 (intermediate
risk)
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
2. 45 yo / F / 4108625
Diagnosis : Proptosis non axial ocular sinistra ec atypical meningioma

Procedure : Enucleation + dermal fat graft (DFG)

Status : ASA 3
Hypertensive heart disease (blood pressure 161/86 mmHg, on therapy of oral captopril 2x25
mg, Chest X ray: cardiomegaly, CTR 56%, echo: global normORinetic, LV dilatation, concentric
LVH, moderate MR, mild PR, good LV and RV function (EF 76%, Tapse 26.2 mm), EKG T
inverted on II, III, avF, V4-V6, clinical findings: no dyspnea or chest pain, FC 1
Suspected meningioma with chronic elevation of intracranial pressure (head CT: proptosis
bulbi oculi ec extracranial heterogenic lesion with calcification at the sella-parasella region
which infiltrated left retrobulbar and left temporal lobe medial region, causing subfalcine
herniation to the right as far as +/- 1.1 cm dd/ meningioma), (MRI: large extra-axial mass
with dural tail at the left sella-suprasella-parasella region and left intracavum orbita, which
enlarged the superior orbitalis fissure, obliterated opticum chiasm, encapsulated the left
parasella vascular structure, left lateral ventricle, and third ventricle with subflcine
herniation to the right of about 1.3 cm and narrowing the left sphenoid and ethmoid sinus
suspect meningioma), history of seizure 1x on 2016, current clinical findings: stable, no
seizure, no sign and symptoms of intracranial pressure elevation, on therapy: keppra 2x500
mg)
Plan : GA-CVC-ABP
Post-op : ICU
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
3. 51 yo / F / 3683577
Diagnosis : Retinal detachment ocular dextra
Procedure : Vitrectomy and endolaser
Status : ASA 3
Hypertension BP 173/91 on therapy: ramipril 1x2,5 mg, FC 1, S1 and
S2 normal, systolic murmur at left and right 4th intercostal space,
grade 3/6, no gallop, EKG: pathological Q at lead I, avL. Clinical
findings: no dypnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea
Type 2 Diabetic mellitus, RBG 174 mg/dL, on therapy: glimepirid 1x1
mg
Anemia Hb 9,5 g/dL
Without airway difficulty
Plan : GA (advice: echo prior surgery)
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
4. 10 yo / Girl / BW 21 kg / 4185754
Diagnosis : Proptosis of the left eye e.c cavernosum hemangioma
Procedure : Exenteration of the left eye
Status : ASA 2
Anemia Hb 11.7 g/dL
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
5. 1 yo / Boy / BW 7 kg / 4130626
Diagnosis : Congenital cataract of the right eye
Procedure : Cataract extraction, Primary Posterior Capsulotomy (PPC), anterior
vitrectomy
Status : ASA 2
Atresia ani on colostomy, echo (19/10/2016): normal heart structure
and function
Leukocytosis 19070
Suspect Addison disease, hypocortisol 2.4, without therapy
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
6. 11 yo / Girl / BW 26.7 kg / 3705315
Diagnosis : Congenital glaucoma
Procedure : Tube reposition of the left eye
Status : ASA 2
Intellectual development disability
Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
7. 12 yo / Girl / BW 34.7 kg / 4182665
Diagnosis : Complicated cataract
Procedure : Cataract extraction, intraocular lens, Primary Posterior Capsulotomy
(PPC), vitrectomy anterior
Status : ASA 2
Anemia Hb 11.9 g/dL
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
8. 2 yo / Boy / BW 13.8 kg / 4178835
Diagnosis : Aniridia of both eyes
Procedure : Retinal camera (RETCAM) bilateral eyes
Status : ASA 1

Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
9. 64 yo / F / 4190114
Diagnosis : Proliferative diabetic retinopathy and cataract ocular dextra
Procedure : Vitrectomy, endolaser, scleral buckle (SB), silicon oil/gas
Status : ASA 3
Hypertensive heart disease, uncontrolled hypertension, blood
pressure 171/96 mmHg, heart rate 83x/m, SpO2 98%, cardiomegaly,
CTR 53%, FC I, on therapy of oral valsartan 1x160 mg, amlodipine
1x10 mg, bisoprolol 1x10 mg, clonidine 3x0,15 mg
Type 2 diabetes mellitus, RBG 238, on therapy: lantus 1x18 unit,
gliquidone 2x30 mg, acarbose 3x100 mg, trajenta 1x1 tab
Elevation of creatinine level 1.5, urine output >0.5 cc/kg/hour
Anaemia 11.8 g/dL
Geriatric 63 years old
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
10. 53 yo / F / 4110495
Diagnosis : Post vitrectomy endolaser and emulsification of silicon oil of the left
eye
Procedure : Silicon oil evacuation
Status : ASA 3
Hypertensive Heart Disease BP 150/100 mmHg, on therapy
amlodipine 1x10 mg, valsartan 1x160 mg, CXR: CTR 53%, with aortic
calcification
Type 2 diabetes mellitus, RBG 174 mg/dL, on novorapid 3x12 IU,
Lantus 1x14 IU
Anemia Hb 9,4 g/dL
Elevation of ureum level 55, creatinine level 1,66, urine output >0,5
cc/kg/hour
Obesity BMI 31,55 kg/m2, OSA STOPBANG score 3
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
11. 62 yo / M / 4193399
Diagnosis : Corneal rupture ocular dextra
Procedure : Corneal repair
Status : ASA 2
Cardiomegaly CTR 53%, clinically stable, FC 1
Geriatric 62 year old
Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
12. 63 yo / M / 4154919
Diagnosis : Aphakia ocular dextra
Procedure : 2nd implant of scleral fixation ocular dextra
Status : ASA 2
Hypertension, blood pressure 157/99 mmHg, on therapy of oral
ramipril 1x2.5 mg, FC 1
Leukocytosis 14520
Geriatric 63 years old
Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
13. 58 yo / F / 4189402
Diagnosis : Retinal ablasion of the right eye
Procedure : Vitrectomy and endolaser
Status : ASA 2
Hypertension, BP 170/80 on therapy captopril 3x12,5 mg, amlodipine
1x5 mg
Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
14. 63 yo / F / 3959499
Diagnosis : Lagophthalmos, paralytic extropion ocular sinistra
Procedure : Palpebra reconstruction
Status : ASA 2
Type 2 diabetes mellitus, controlled, RBG 129, G2PP 179, on therapy:
metformin 3x500 mg
History of mild intermittent asthma, last attack 4 years ago. trigger:
cough, dust, without therapy. Clinical findings: stable, without
dyspnea or wheezing
History of radiation 33x, on 2015, ec parotid tumor post
parotidectomy (2015)
CXR : infiltrate in bilateral upper lung, clinically stable, without cough
and dyspnea
Geriatric 62 year old
Without airway difficulty
Plan : GA
Post-op : Ward
 OR Kirana (Opthalmology)
dr. Jefferson, SpAn, KAKV / Jacky - Rara - Ucil - Claudia - Mange
15. 49 yo / M / 3944295
Diagnosis : Cicatrix lagophthalmos ocular sinistra
Procedure : Graft mucosa-buccal (GMB)
Status : ASA 1
Without airway difficulty
Plan : GA
Post-op : Ward
 OR CMU 3 (Plastic)
dr. Adhrie Sugiarto, SpAn, KIC / Ian - Manda - Ririn
1. 18 yo / F / BW 57 kg / 4193110
Diagnosis : Seborrhoeic nevus regio abdomen-flank dextra
Procedure : Nevus excision, shaving, and primary hecting
Status : ASA 1
Without airway difficulty
Plan : GA
Post-op : Ward
 OR CMU 3 (Plastic)
dr. Adhrie Sugiarto, SpAn, KIC / Ian - Manda - Ririn
2. 28 yo / M / 4193613
Diagnosis : Soft tissue tumor on penile region
Procedure : Tumor excision and primary hecting
Status : ASA 2
Elevated transaminase enzyme SGPT 68, clinically stable
Overweight BMI 29,7 kg/m2 with low risk of Obstructive Sleep Apnea
Without airway difficulty
Plan : Spinal
Post-op : Ward
 OR CMU 3 (Plastic)
dr. Adhrie Sugiarto, SpAn, KIC / Ian - Manda - Ririn
3. 30 yo / F / 4162090
Diagnosis : Non-vital skin and post-debridement of the sacrogluteal region and
split-thickness skin graft (STSG)
Procedure : Advanced split-thickness skin graft (STSG)
Status : ASA 3
Systemic inflammatory response syndrome (heart rate 120x/minute,
leukocytosis 16.600, without temperature instability
Anaemia Hb 9,9 g/dL
Thrombocytosis 817.000
Hypokalemia 2,93 mEq/L
Immobilisation et causa complete pelvic fracture, lateral position, on
negative pressure wound therapy, on therapy of heparin 7500
unit/24 hour
Without airway difficulty
Plan : GA
Post-op : Ward
 OR CMU 3 (Plastic)
dr. Adhrie Sugiarto, SpAn, KIC / Ian - Manda - Ririn
4. 66 yo / F / 4163754

Diagnosis : Burn injury grade II-III with total body surface area of 48%

Procedure : Excisional debridement and split-thickness skin graft (STSG)

Status : ASA 3
Improved sepsis, heart rate 100-107x/minute, blood pressure 139-140/60-70mmHg, temperature
36,5C, without temperature instability, leukocytosis 17.360, PCT 1.1, urine output 1.6cc/kg/hour, on
therapy of intravenous meropenem E3 3x1gr and Tygacyclin D2 2x50mg
Hospital acquired pneumonia, short of breath presents, respiration rate 24-28x/minute, rales present
on the base of right lung, no wheezing SpO2 98% on nasal canule 3 litres per minute, chest X ray:
perihillar and paracardial infiltrate on both lungs dd/ pneumonia, on therapy of intravenous
meropenem E3 3x1gr, Tygacyclin 2x50mg and Combivent nebule/8 hour
Decreased level of consciousness et causa metabolic, somnolen at the moment, dd/ acute confusional
state
Uncontrolled type 2 diabetes mellitus, RBG 250, on therapy of insulin drip 2 unit/hour and novorapid
correctional dose of 5 unit
Stage 1 hypertension, blood pressure 140/70mmHg, dyspnoe presents, respiration rate 24-28x/minute,
SpO2 98% on nasal canule 3 litres per minute, chest X ray: cardiomegaly with elongation of the aorta,
on therapy of intravenous lasix 2x20mg, oral amlodipine 1x10mg, and oral bisoprolol 1x5mg
Hypoalbuminemia 2.4
Geriatric patient 66 yo
Without airway difficulty
Plan : GA
Post-op : ICU ULB
 OR Urology
dr. Alfan Mahdi Nugroho, SpAn(K) / Zeta - Gumar - Lucya
1. 54 yo / F / BW 65 kg / 4190710
Diagnosis : Right kidney stone
Procedure : Mini right percutaneous nephrolitotomy
Status : ASA 2
Chest X ray : cardiomegaly, CTR> 50%, clinically stable, FC 1
Elevated ureum level 52
Anaemia Hb 11.4g/dL
Leukocytosis 12.290
Plan : Spinal
Post-op : Ward
 OR Urology
dr. Alfan Mahdi Nugroho, SpAn(K) / Zeta - Gumar - Lucya
2. 58 yo / F / BW 55 kg / 4103610
Diagnosis : Right kidney stone post percutaneous nephrolitotomy on right double J
stent
Procedure : Retrograde pyelogram if needed aff right double J stent
Status : ASA 2
Controlled hypertension, blood pressure 137/72 mmHg on therapy of
oral captopril 1x25 mg
Chest X ray : nodular calcification at apical of right lung, clinically
stable
Plan : Spinal
Post-op : Ward
 OR Urology
dr. Alfan Mahdi Nugroho, SpAn(K) / Zeta - Gumar - Lucya
3. 37 yo / M / BW 40 kg / 4193204
Diagnosis : Left kidney tumor T2bM0N1
Procedure : Open cytoreductive left nephrectomy
Status : ASA 2
Anaemia Hb 11.6 g/dL
Chest X ray: round opaque lesion on the upper side of left lung dd/
nodula
Abdominal CT-Scan: left kidney mass with size 15x17.7x17 cm
Left renal necrosis probably malignancy
Plan : GA - Epidural - CVC
Post-op : ICU
 OR Urology
dr. Alfan Mahdi Nugroho, SpAn(K) / Zeta - Gumar - Lucya
4. An. 2 yo / M / BW 13.9 kg / 4086295
Diagnosis : Epispadia, micro penis
Procedure : Repair epispadia
Status : ASA 2
History of febrile seizure on April 2016, temperature 39.9
Leukocytosis 14.450
Plan : GA
Post-op : Ward
 OR Urology
dr. Alfan Mahdi Nugroho, SpAn(K) / Zeta - Gumar - Lucya
5. 13 yo / Boy / BW 63 kg / 4005101
Diagnosis : Midshaft hypospadia
Procedure : Urethroplasty
Status : ASA 2
Obese BMI 30 kg/m2, history of snoring, STOP BANG score low risk
Elevated SGOT 33 / SGPT 46
Without airway difficulty
Plan : GA Pudendal block
Post-op : Ward
 RESUME
Total : 50
Cancelled :0
ICU : 11
ICU back up :0
PICU/NICU/ICCU : 2/0/0
PICU back up :0
HCU :1
HCU Neurosurgery :2
ICU Burn unit :1
Ward : 36
GA : 38
Epidural :5
CSE :1
GA combined :7
Peripheral block :4
TIVA :0
CVC :7
CVC preparation :0
ABP :4
ABP preparation :0
ODC :3
Spinal :3
Caudal :2
MAC :0