I

Name
: Mrs. C
BB: 60 kg

Age
: 55 years old
TB: 155 cm
th

Admission date : May, 10 2016

:

Diagnose : Spinal stenosis L4-L5, L5-S1

Procedure : Posterior stabilization

Anamnesis

Complain : low back pain since 5 years ago

Hypertension (+) controlled with amlodipin 1x5mg, DMII (-), allergy (-), asthma (-)
Physical examination

Airways
: Clear , Mallampati 1, Dentures (-)

Breathing : RR 16 tpm, Ves (+/+) Rh (-/-) Wh (-/-)

Circulation : HR 88 x/menit TD: 150/80 Cor: BJ 1 > BJ 2 reguler

Brain
: GCS : 15

Local state : a.r waist: inflamation signs (-), pain (+), limited ROM
Adjuvant examination

Lab (27/4/2016) : Hb (11,9 ) Ht(36) Leu(8,6) Trom(268) CT/BT (7/2) Ur/Cr(45/0,93) KGDS(107)

CXR
: Cor and Pulmo within normal limit

ECG (2/5/16)
: Normal ECG
Conclusion
ASA II with controlled hypertension + anemia (11,9)
Planning
: General anesthesia

This morning BP: 140/90

MORNING REPORT
OR VIII
Wednesday, May 11th 2016

II

Name
: Mrs. N
BB: 70 kg

Age
: 61 years old
TB: 155 cm

Admission date : May, 10th 2016

:

Diagnose : Spinal stenosis L3-L4, L4-L5 + spondyloithiasis L4-L5

Procedure : Posterior stabilization

Anamnesis

Complain : pain in left thigh since 4 months ago

Hypertension (-), DMII (-), allergy (-), asthma (-)

Physical examination

Airways
: Clear , Mallampati 1, Dentures (-)

Breathing : RR 20 tpm, Ves (+/+) Rh (-/-) Wh (-/-)

Circulation : HR 88 x/menit TD: 140/90 Cor: BJ 1 > BJ 2 reguler

Brain
: GCS : 15

Local state : a.r waist: pain (+),

Adjuvant examination

Lab (26/4/2016) : Hb (13,1 ) Ht(39) Leu(6,3) Trom(234) CT/BT (7/2) Ur/Cr(42/-) KGDP(100)

CXR (26/4.2016) : Cor and Pulmo within normal limit

ECG (2/5/16)
: SR, HR 86 bpm, LAD
Conclusion
ASA II with hypertension gd 1
Planning
: General anesthesia

III

Name
: Mrs. K
BB: 50 kg

Age
: 58 years old
TB: 165 cm
th

Admission date : May, 10 2016

:

Diagnose : Spondylolithiasis L4-L5

Procedure : Posterior decompression + posterior stabilization

Anamnesis

Complain : low back pain and pain in legs since 3 months ago

Hypertension (-), DMII (-), allergy (-), asthma (-)

Physical examination

Airways
: Clear, Mallampati 1, Dentures (-)

Breathing : RR 22 tpm, Ves (+/+) Rh (-/-) Wh (-/-)

Circulation : HR 96 x/menit BP: 130/80 Cor: BJ 1 > BJ 2 reguler

Brain
: GCS : 15

Local state : a.r thorax posterior: lump (+), pain (+), limited ROM
Adjuvant examination

PPLab (26/4/2016): Hb (12 ) Ht(36) Leu(12,2) Trom(338) CT/BT (7/2) Ur/Cr(26/0,71) KG2PP(97)

CXR
: Cor and Pulmo within normal limit

ECG
: SR, HR 97 bpm
Conclusion
ASA II with controlled hypertension +leucositosis (12200)
Planning
: General anesthesia

IV

Name
: Ms. R
BB: 75 kg

Age
: 16 years old
TB: 160 cm
th

Admission date : April, 20 2016

:

Diagnose : Tumor vertebra Th II-III frankel A

Procedure : Tumor exsiscion + posterior stabilizaton

Anamnesis

Complain : weakness and anesthesia in lower extremity since 1 years ago

Hypertension (-), DMII (-), allergy (-), asthma (-)

Physical examination

Airways
: Clear, Mallampati 1, Dentures (-)

Breathing : RR 20 tpm, Ves (+/+) Rh (-/-) Wh (-/-)

Circulation : HR 92 x/menit BP: 100/60 Cor: BJ 1 > BJ 2 reguler

Brain
: GCS : 15

Local state : a.r cruris : paraplegia (+), anesthesia (+)

Adjuvant examination

Lab (1/5/2016)
: Hb (12,5 ) Ht(38) Leu(9,9) Trom(424) CT/BT (7/2) Ur/Cr(15/0,40) KGDS(80)

CXR
: Cor and Pulmo within normal limit
Conclusion
ASA II with overweight (BMI 27)
Planning
: General anesthesia