MORNING REPORT

operating theathre 7
Wednesday, January, 4, 2017
Dr. dr. Zafrullah Khany Jasa, Sp An,
KNA
 Patient 1

NLM, : male, 56 th day, weight: 72 kg, length: 157 cm

Diagnose: LUTS ec vesicolithiasis
Procedure : lytotripsy

Anamnesis
complaint: pain urination
Physical examination
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 20 x/minute, ves (+/+) Rh (-/-) wh (-/-)
Circulation : HR 60x/minute, Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Roentgen (31/12/16): Cor: cardiomegali, pulmo: congestive lung.
EKG (30/12/2016): sinus rhythm, HR 66 x/I
USG Ren (29/12/2016): Nefrolithiasis bilateral, hidronefrosis grade 2
sisnistra
USG prostate (28/12/2016): cystisis
Lab ( 27/12/16) : hb(16,7) ht(50) E(5,3) L(9,5) T(215) Na(145) K(4,4) Cl(114)

Conclusion : ASA III with AKI (cr 1,60) + Hepatitis B + HHD

Planning : Spinal Anesthetic
Post op : NICU
Roentgen December, 31th 2016
EKG December, 30th 2016
 USG Ren & Prostate
December, 28th 2016
 Patient 2

NLM, : female, 68 years, weight: 65 kg length: 165 cm

Diagnose: Hidronefrosis dextra + Hidroureter dextra
Procedure : URS + lytotripcy + DJ stant

Anamnesis
complaint:
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 19 x/minute, ves (+ /+) Rh (-/-) wh (-/-)
Circulation : HR 78x/minute, Bp: 170/100 mmHg Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Thorax Roentgen (5 /12/16): cor and pulmonal in normal condition
EKG (20/12/2016): LVH
BNO-IVP (30/11/2016): hidronefrosis grade III dextra, hidroureter dextra
with suspect ureterolitiasis dextra distal
Lab ( 24/12/16) : hb(13,1) ht(39) E(4,1 ) L(5,9) T(224) Na(146) K(3,7) Cl(111)

Conclusion : ASA III with CHF fc I-II ec HHD,

HHD (B/P: 170/100, on teraphy tanapres 1x5 mg,
amlodipin 1x5 mg, HCT 1x25 mg)
Planning : Spinal
Post op : ward
Roentgen
EKG
 Patient 3

NLM, : male,60years, weight: 60kg length: 160cm

Diagnose: nefrolithiasis multiple dextra + ureterolithiasis dextra + AKI stage 3 post renal
Procedure : URS + litotripsi

Anamnesis
complaint: low back pain dextra
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 20 x/minute, ves (+/+) Rh (-/-) wh (-/-)
Circulation : HR 88 x/minute, Bp: 140/90 mmHg Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Thorax Roentgen (20/12/2016): cor and pulmo in normal range
USG Abdomen(19/12/16):
EKG (28/12/2016): iskemik anterolateral
Lab ( 29/12/16) : hb(10,8) ht(33) E(4,0 ) L(9,3) T(411) Na(141) K(4,3) Cl(111),
GDS (107), Ur (43), Cr (1,30)

Conclusion : ASA III with AKI pre renal (ur: 43, cr:1,30),
CHF FC I-II ec HHD, hypertension stage 1 ( 140/90 mmHg),
anemia (hb: 10,8)
Planning : Spinal
Post op : ward
Roentgen
USG
 Patient 4

NLM, : female, 71 th day, weight: 50 kg, length: 155 cm

Diagnose: Gross hematuria ec suspect tumor buli
Procedure : cystoscopy + RPG + Biopsi / TURBT

Anamnesis
complaint: right abdominal pain
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 20x/minute, ves (+/+) Rh (-/-) wh (-/-)
Circulation : HR 68 x/minute, BP: mmHg Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Roentgen (22/12/2016): cor and pulmo in normal range
CT scan ( 28/12/2016) : cysticys, suspect mass in adnexa sinistra
USG ren (28/12/2016): hydronefrosis sinistra
Abdominal plain (28/12/2016): suspect nefrolitiasis dextra
Lab ( 30/12/2016) : hb(9,5) ht(30) E(4,7) L(5,7) T(309) Na(139) K(3,5) Cl(108),
ur(21). Cr (0,80), GDS (129)

Conclusion : ASA II with anemia (Hb 9,5), geriatri

Planning : spinal
Post op : ward
BNO
CT Scan
USG
 Patient 5

NLM, : male, 32 th day, weight: 70 kg, length: 165 cm

Diagnose: BPH
Procedure : TURP

Anamnesis
complaint: bloody urine
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 20x/minute, ves (+/+) Rh (-/-) wh (-/-)
Circulation : HR 91 x/minute, BP: 130/90 mmHg Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Roentgen ( 14/12/2016): cardiomegali with LVH
EKG (15/12/2016 ) : LVH
USG vesika(24/12/2016) : cystitis with BPH
Lab (15/12/2016 ) : hb() ht() E() L() T() Na() K() Cl()

Conclusion : ASA III with HHD (140/80 mmHg)

Planning : spinal
Post op :ward
 Patient 6

NLM, : female,36years, weight: 85kg length: 163cm

Diagnose: ureter stone proximal dextra
Procedure : ureterolitotomy

Anamnesis
complaint: low back pain dextra
Airway : clear,mallampati 1, denture (-) obstruction (-)
Breathing : RR: 21 x/minute, ves (+/+) Rh (-/-) wh (-/-)
Circulation : HR 91 x/minute, Bp: 140/90 mmHg Cor: BJ1 > BJ2, regular, murmur (-)
Adjuvant Examination
Thorax Roentgen ( 21/12/2016 ): cor and pulmo in normal range
USG vesika urinaria (21/12/16): in normal range
BNO(21/12/2016): reterolitiasis sinistra
EKG (21/12/2016): rhythm sinus
Lab ( 21/12/16) : hb(13,3) ht(39 ) E(4,6 ) L(7,8) T(371) Na(141) K(3,5) Cl(106),
ur (28), cr (1,17)

Conclusion : ASA II with hypertension stage 1 ( 140/90 mmHg)

obesity grade 1
Planning : General
Post op : ward
Rontgen
USG
THANK YOU