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RSUP FATMAWATIKEPANITRAAN KLINIK
FKIK UIN SYARIF HIDAYATULLAH
NOMOR RM :_________________________NAMA :_________________________UMUR :_________________________JENIS KELAMIN : P/LKUNJUNGAN PRA ANESTESI
ANAMNESISKELUHAN UTAMA: ....................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT SEKARANG:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
RIWAYAT PENYAKIT YANG SEDANG/ PERNAH DIDERITA: Alergi: ........................ Asma Diabetes Melitus Hipertensi Infeksi saluran nafas atas:.......................... Stroke Obesitas Pemebekuan darah
RIWAYAT OBAT-OBATAN: Alergi obat:............................................................................................................................... Obat yang sedang di konsumsi: ............................................................................................... ..................................................................................................................................................
RIWAYAT ANESTESI:Riwayat Oprasi sebelumnya
Pernah / tidak pernah Tanggal:....................................................................................................................................... Jenis pembedahan:...................................................................................................................... Jenis anestesi: GA/RA/Lokal Komplikasi:........................................................................................................................................................................................................................................................................................
RIWAYAT PENYAKIT KELUARGA: Alergi: ........................ Asma Diabetes Melitus Hipertensi Pemebekuan darah
RIWAYAT KEBIASAAN/SOSIAL (yg mempengaruhi tindakan anestesi): Merokok Minum Alkohol
PEMERIKSAAN FISIKTANDA VITAL:
Kesadaran :....................................... Kesan umum :........................................ BB :....................................kg TB :....................................cm
TD :........................................mmHg Suhu :........................................°C Nadi :.................................kali/menit RR :..................................kali/menit
EVALUASI KESULIATAN INTUBASI
Pemeriksaan Leher dan kepala: Trismus : Keadaan gigi mulut:
Gangguan motorik N. V Spasme otot pengunyah Kesulitan membuka mulut
Hilangnya gigi Gigi palsu Maksila/ gigi maju Micronagtia Madibula menonjol Gerak TMJ terbatas
Leher: 3-3-2 Rules Gangguan mobilitas leher Trauma tulang belakang Leher pendek
Membuka mulut 3 jari 3 jari Jarak submental mandibula 2 jari jarak krikoid tiroid
Masa/ tumor Perbesaran KGB Deviasi trakea
KESIMPULANKemungkinan sulitan intubasi: YA/TIDAK ............................................................................................
Mallapati score
Pemeriksaan Jantung: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan paru: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan abdomen: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan Ekstremitas: Jari tabuh Sianosis Luka Infeksi kulit Edema
Pemeriksaan punggung: Deformitas vertebrae Infeksi
Status Neurologis: Status mental : ....................................................... Fungsi saraf kranial : I/II (RC, Visus)/III/IV/V/VI/VII/VIII/IX/X/XI/XII Kesadaran : E___ M___V___ Fungsi motorik sensorik: ..................................................
PEMERIKSAAN LABORATURIUMDarah rutin:
Hb : ....................................... Ht : ....................................... Leukosit : ........................................ Trombosit : ....................................... Eritrosit : ....................................... Diff count : .......................................
Fungsi Hati : SGPT : .................................................... SGOT : ....................................................
Fungsi Ginjal : Ureum darah : ...................................... Creatinin darah : .....................................
Gula Darah : ......................................................EKG:............................................................................................................................................
Spirometri: ...........................................................................................................................................
Echo: ..............................................................................................................................................................................................................................................................................................
Foto RX:..............................................................................................................................................................................................................................................................................................................
HASIL KONSUL BAGIAN LAINIPD:.............................................................................................................................................................................................................................................................................................................................
OBGYN:.......................................................................................................................................................................................................................................................................................................................
JANTUNG:...................................................................................................................................................................................................................................................................................................................
PARU:..........................................................................................................................................................................................................................................................................................................................
LAINLAIN:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................KESIMPULANLAYAK OPERASI : YA/TIDAKASA : 1 2 3 4 5 6 E Dengan:................................................................
PERHITUNGAN KEADAAN DAN KEBUTUHAN CAIRAN Nama: ____________ BB:_____kg EBV (D/A: 70ml/kgbb B: 80ml/kgbb N: 90ml/kgbb)Jmlh Tranfusi darah (D >15 % EBV)WH:(Hbx – Hbpasien) x BB x 6=.....mlPRC:(Hbx – Hbpasien) x BB x3=......ml