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MORNING REPORT

OK III
Rabu, 25 Mei 2016
Patient 1
Name : Ms. W Weight: 45 kg
Age : 61 years old Hight: 150 cm
Diagnose : Prolaps utery grade III
Procedure : Trans Vaginal Hysterectomy

Anamnesis
Complaints : The patient has come with chief complaint with pain in stomach since 2 months ago.
Medical history : HT (+), DM(-), Asma (-), Alergi (-)
Physical examination
Airways : Clear , Mallampati 1, denture (-) , obstruction (-)
Breathing : RR 20 x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : TD: 150/110 mmHg, HR: 72 x/minute, cor: BJ 1 > BJ 2
Brain : GCS : E4 M6 V5 : 15 , no parese
Localis state: pain ar abdomen with stiffness

Adjuvant examination
- ECG (23/05/2016) : Sinus Rhythm, HR: 55 bpm, with mild tolerance for op
- Rontgen (19/05/2016) : cor and pulmo in normal limit
- Lab :

Conclusion : ASA IIi with not Controlled Hipertension (150/110)


Planning : General Anestesi
Patient 2
Name : Ms. CA Weight: 54 kg
Age : 35 years old Hight: 155 cm
Diagnose : Kista Ovarium
Procedure : Laparatomy

Anamnesis
Complaints : patien came with chief complain swelling in stomach since 3 months ago.
Medical history : HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airways : Clear , Mallampati 1, denture (-) , obstruction (-)
Breathing : RR 18 x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : TD: 110/60 mmHg, HR: 78x/minute, cor: BJ 1 > BJ 2
Brain : GCS : E4 M6 V5 : 15 , no parese
Localis state: Swelling ar abdomen and immobile

Adjuvant examination
- Rontgen(19/05/2016) : cor and pulmo in normal limit
- Lab (13/05/2016) : Hb (14,3), Ht (44), Leu (6,6), Trom (240), CT/BT (7/2),
Ur/Cr (19/0,67), KGDS (97), KG2PP(131), CA 125 (21,76)

Conclusion : ASA II + Hyperkalemi


Planning : Spinal Anestesi
Patient 3
Name : Ms. N weight : 61 kg
Age : 42 years old hight : 150 cm
Diagnose : Molahidatidosa
Procedure : curretage

Anamnesa
Complaints : patien came with chief complain pain in stomach post curratage at 21/4/2016
Medica history : HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airways : Clear , Mallampati I, denture +) , obstructioni (-)
Breathing : RR 18 x/menit Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : TD: 110/60 mmHg, HR: 76 x/menit, cor: BJ 1 > BJ 2
Brain : GCS : E4 M6 V5 : 15 , no parese
Localis state: pain ar abdomen
Adjuvant examination
Rontgen (20/05/2016) : in normal limit
Lab (23/05/2016) : Hb (13,2), Ht (39), Leu (12,0), Trom (337), Ureum (19), creatinin
(0,70), Na(145), K(3,4), Cl(102), albumin(430), KGDS(109), TSH(109), T4 Total(94,00),T3
Total(1,03)
ECG (24/05/2016) : Sinus rhythm with HR 86 bpm,
Conclusion : ASA II + Leukositosis
Planning : Spinal Anestesi
Patient 4
Name : Ms. NJ Weight: 86 kg
Age : 36 years old Hight: 158 cm
Diagnose : G4P3 pregnant in 37-38 weeks BSC 1 Time
Procedure : SC

Anamnesis
Complaints : patien came with chief complain pain in stomach.
Medical history : HT (-), DM(-), Asma (-), Alergi (-)
Physical examination
Airways : Clear , Mallampati 1, denture (-) , obstruction (-)
Breathing : RR 18 x/minute Ves (+/+) Rh (-/-) Wh (-/-)
Circulation : TD: 120/70 mmHg, HR: 84x/minute, cor: BJ 1 > BJ 2
Brain : GCS : E4 M6 V5 : 15 , no parese

Adjuvant examination
- USG(20/05/2016) : head in PAP
- Lab (20/05/2016) : Hb (11,0), Ht (33), Leu (10,1), Trom (157), CT/BT (3/8),
KGDS (80), Na (141), K(4,2), Cl(105),SGOT/SGPT(16/11)

Conclusion : ASA II + Anemia + Pregnant


Planning : Spinal Anestesi