Name : Nuraini

Date of Birth : 1976-06-17

Registration Number : 693540
Room : Lontara 3 AD
Operator : Azmi Mirah Zakiah, M.Kes, Sp.THT-KL
Assitant : dr. Rismayanti
Anesthesiologist : dr. Syamsu Hilal Salam, Sp.An
Assistant : dr. Halim
Type of anesthesia : General Anesthesia
Category of operation :elective
Pre-surgery diagnosis : Chronic Rhinosinusitis + Septal Deviation
Post-surgery diagnosis : Chronic Rhinosinusitis + Septal Deviation
Indication : Drainage
Name of operation : Fungsional Endoscopy Sinus Surgery (FESS)
Pathology Examination : No
Date
6-1-2015

Started
8.45

Finished
10.45

Duration
2.00

Complication : None
Bleeding : 20 cc
Post-op care : Room
Operation Report
1. Patient lied on General Anesthesia, Endotracheal Tube attached
2. Decontaminatin operation area with betadine, strerilized doek
attached
3. Make SMR procedure
- Infiltrate mucocutaneus junction area using
lidocain:epinephrine 1 : 100.000
- Incision about 3 mm from landmark area, elevation on
mucopericondrium dan mucoperiosteum
- Remove deviation on septal area, bleeding control
4. Make FESS procedure
- Uncinetomi dextra sinistra
- MMA dextra sinistra
- Konkotomi concha media dextra sinistra
- Konkotomi concha inferior dextra
5. Suturing wound incision using sandwich stitching on septal using
vycril 3.0
6. Bleeding control, bleeding (-)
7. Attached boorzalf tampon dextra sinistra 2:1

8. Operation finished, bleeding during operation 50 cc

Name : Nuraini
Date of Birth : 1976-06-17
Registration Number : 693540
Anamnesis
S : Patient came with planned to operation. Cephalgia suffered since a
year ago. No rinore, sometimes. Nasal obstruction positive epistaksis
negative , blood stained rinore negative , post nasal drips negative,
tinnitus negative, otalgia negative, loss of hearing negative, odinifagi
negative disfagi negative, disfoni negative, odinofoni negative
O:
Ear : Membran Thimpany intact
Nose :
Concha hypertrophy
Mucosal hyperemia
Septal deviation positive
Throat
T1-T1 Quiet
A : Chronic Rhinosinusitis
P:
Operation plan FESS + SMR
On Tuesday 6-1-2015
-Informed consent
- Confirmed to OK
- Consult to anesthesiology department
- PRC preparation 2 bags
- Fasting 8 hours before operation
Premedication :
Ceftriaxone 1gr/IV (skin test), 22.00, 06.00
Tranexamat Acid 500 mg/IV 22.00, 1 gr/IV, bolus slowly 6.00
Dexamethasone 5mg/IV, 22.00, 6.00

Date : 19-12-2014 14:30:53

RM : 693540
Name : Nuraini
Date of birth/Sex : 17-6-1979 Female
Address :
Clinical Condition : Palatum Neoplasm
Examination Type : Head MSCT (AX-Cor) non-contratst
Has been examined Head MSCT Scan without contrast axial reformat
coronal dan sagittal slice with the following result :

Looks pneumatitation concha media bilateral, enlargement on

concha nasalis, with asymmetric surface
- Looks nasal septal deviation to the right
- Osteomeatal complex right and left patent
- Unclearly looks on palatum region. Nasofaring area and
orofaring within normal limits
- No enlargement on lymph gland
- Scanned bones intact
Impression : Rhinitis chronic hipertrofikans with nasal septal deviation
to the right
Concha bullosa bilateral
Unidentificated pallatum mass
Suggestion : Head MSCT Scan with Contrats