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7/23/2019 Follow Up Pre
http://slidepdf.com/reader/full/follow-up-pre 1/1
FOLLOW UP PRE-OP VISITE ANASTESI
Nama : ................................. No. MR : .........................................
Umur : ................................. Diagnosa : .........................................
Alamat : ................................. Operasi : .........................................
Ruangan : ................................. Dokter : ........................................
SUBJEKTIF
Keluhan :
Riwayat HT (....), Riwayat DM (....), Riwayat Asma (....), Riwayat Alerg makanano!at (....), Riwayat
gangguan pem!ekuan "ara#(....), Riwayat anastesi se!elumnya Regional anastesigeneral anastesi.
Tgl..........., $atukpilek (....), riwayat pemakaian o!at%o!atan(....)
OBJEKTIF
Airway :
&alan na'as !ersi# (....), mallampati *+, Tiro%Mental Distane(TMD) .-m (...), $uka mulut * ari
(....), gigi goyang, ompong, palsu(.....), per!esaran tiroi" (.....), "e/iasi trakea (....)
Hasil Rontgen : .........................................................................................................................................
Breathin :
0esikuler (.........),w#ee1ing (........), r#onki (........), sesak (........), ekspansi paru simetris (........)
!ir"ulati#n :
22 Murni 3rregulerreguler, 4allop (.....), murmur (........), 5RT 6 "etikle!i#, sianosis (.....)
$a%il La&#rat#riu' :
H$ : ......... HT : .............. 7eukosit : ............. Trom!osit : .................. 4olongan Dara# : A $ O A$,
4D2 : ........., 24OT248T : ........... H!sAg : ............. Ureum : ............ 9reatinin : .............. Natrium :
............ 9alium : .............. 5alsium : ............... 94 : ............................................................................
(i%a&ility :
452 : .................................... 9esa"aran : ............................. 9U : .........................................
Tan)a Vital :
TD : ............. mmHg, N : ........................ ;m, RR : .............;m, T : .................<5 $$ : ...........kg
ASSES*ENT :
A2A 3 33 333 30 0 , 4eneral Anastesi ( 3ntu!asi 7MA T30A =ae Mask), Regional Anastesi
(2u! ara#noi" !lok epi"ural lokal)
PLANNIN+ :
8uasa ..........am, pasang in'us ........tpm, in'orm onsent ..............
9e!utu#an airan ..........................
Maintenane > ..........;........($$) >
8engganti puasa > .........;.........(M) >
2tressoperasi > ........;..........($$) >
Total >
8em!erian am 3, ( 88)?M?2O >
8em!erian am 33,(+ 88)?M?2O >
7ain%7ain : ....................................................................................................................................
(OKTER *U(A
FK UNILA-RSA,
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