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FK UIN SYARIF HIDAYATULLAH JAKARTA

NOMOR RM : _________________________NAMA : _________________________UMUR : _________________________JENIS KELAMIN : P/LDPJP : _________________________KUNJUNGAN PRA ANESTESI

Tanggal: Ruangan: Pemeriksa: .............................................ANAMNESISKELUHAN UTAMA: ....................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT SEKARANG:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT YANG SEDANG/ PERNAH DIDERITA:

Alergi: ........................ Asma Diabetes Melitus Hipertensi Infeksi saluran nafas

atas:.......................... Stroke Obesitas Pemebekuan darah

Penyakit paru : ..............................................

Penyakit jantung : ...............................................

Penyakit hati : ...............................................

Penyakit ginjal : ...............................................

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

Penyakit paru : ..............................................

Penyakit jantung : ...............................................

RIWAYAT KEBIASAAN/SOSIAL (yg mempengaruhi tindakan anestesi): Merokok Minum Alkohol

Narkotika Obat obatan penenang

PEMERIKSAAN FISIKTANDA VITAL:

Kesadaran :....................................... Kesan umum :........................................ BB :....................................kg

TD :........................................mmHg Suhu :........................................°C Nadi :.................................kali/menit

TB :....................................cm RR :..................................kali/menitEVALUASI KESULIATAN INTUBASIPemeriksaan 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:_____kgEBV (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