RSUP FATMAWATI

KEPANITRAAN KLINIK
FKIK UIN SYARIF HIDAYATULLAH

KUNJUNGAN PRA ANESTESI

NOMOR RM
:_________________________
NAMA
:_________________________
UMUR
:_________________________
JENIS KELAMIN : P/L

Tanggal:
Ruangan:
Pemeriksa: .............................................

ANAMNESIS
KELUHAN
UTAMA: ....................................................................................................................
.................................................................................................................................
...............................................................................
RIWAYAT PENYAKIT SEKARANG:
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.....................................................................
.................................................................................................................................
.................................................................................................................................
..................................................................
RIWAYAT PENYAKIT YANG SEDANG/ PERNAH DIDERITA:
Alergi: ........................
Penyakit
Asma
paru
: ............................................
..
Diabetes Melitus
Penyakit
Hipertensi
jantung : .............................................
Infeksi saluran nafas
..
atas:..........................

Penyakit
Stroke
hati
: ............................................
Obesitas
...
Pemebekuan darah
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: ........................
Penyakit
Asma
paru
: ............................................
..
Diabetes Melitus
Penyakit
Hipertensi
jantung : .............................................
Pemebekuan darah
..

RIWAYAT KEBIASAAN/SOSIAL (yg mempengaruhi tindakan anestesi):

Merokok
Narkotika
Minum Alkohol
Obat obatan penenang
PEMERIKSAAN FISIK
TANDA VITAL:
Kesadaran
:............................
TD
:........................................
...........
mmHg
Kesan
Suhu :........................................
umum :.......................................
C
.
Nadi
BB
:..........................
:.................................kali/menit
..........kg
RR
TB
:..........................
:..................................kali/menit
..........cm
EVALUASI KESULIATAN INTUBASI
Pemeriksaan Leher dan kepala:
Trismus :
Keadaan gigi mulut:
Gangguan motorik N. V
Hilangnya gigi
Spasme otot pengunyah
Gigi palsu
Kesulitan membuka mulut
Maksila/ gigi maju
Micronagtia
Madibula menonjol
Gerak TMJ terbatas
Leher:
3-3-2 Rules
Gangguan mobilitas leher
Membuka mulut 3 jari
Trauma tulang belakang
3 jari Jarak submental
Leher pendek
mandibula
2 jari jarak krikoid tiroid
Masa/ tumor
KESIMPULAN
Kemungkinan sulitan intubasi: YA/TIDAK
Perbesaran KGB
.............
Deviasi trakea
...............................................................
................
Mallapati score

Pemeriksaan Jantung:
Inspeksi
: .................................................................................................
................................
Palpasi
: .................................................................................................
................................
Perkusi
: ..................................................................................................
...............................
Auskultasi : ..................................................................................................
...............................
Pemeriksaan paru:

Inspeksi
: .................................................................................................
................................
Palpasi
: .................................................................................................
................................
Perkusi
: ..................................................................................................
...............................
Auskultasi : ..................................................................................................
...............................
Pemeriksaan abdomen:
Inspeksi
: .................................................................................................
................................
Palpasi
: .................................................................................................
................................
Perkusi
: ..................................................................................................
...............................
Auskultasi : ..................................................................................................
...............................
Pemeriksaan Ekstremitas:
Pemeriksaan punggung:
Jari tabuh
Deformitas vertebrae
Sianosis
Infeksi
Luka
Infeksi kulit
Edema
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 LABORATURIUM
Darah rutin:
Hb
: ..............................
.........
Ht
: .............................
..........
Leukosit
: ...............................
.........
Trombosit : ................................
.......
Eritrosit
: ...............................
........
Diff
count : .....................................
..
EKG:.......................................................
...........
..............................................................
............
Echo: .....................................................
...........
..............................................................
............
..............................................................
............
..............................................................
............

Fungsi Hati :
SGPT : .........................................
...........
SGOT : ........................................
............
Fungsi Ginjal :
Ureum
darah : .....................................
.
Creatinin
darah : .....................................
Gula
Darah : ...............................................
.......
Spirometri: ............................................
................
...............................................................
................
Foto
RX:.........................................................
........
...............................................................
................
...............................................................
................
...............................................................
................

HASIL KONSUL BAGIAN LAIN

IPD:..........................................................................................................................
.................................................................................................................................
..................................................................
OBGYN:....................................................................................................................
.................................................................................................................................
..................................................................
JANTUNG:.................................................................................................................
.................................................................................................................................
.................................................................
PARU:.......................................................................................................................
.................................................................................................................................
..................................................................
LAINLAIN:.................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
...
KESIMPULAN
LAYAK OPERASI : YA/TIDAK
ASA
: 1
2
3
4
5
6
E
Dengan:................................................................
PERHITUNGAN KEADAAN DAN
KEBUTUHAN CAIRAN
EBV (D/A: 70ml/kgbb B: 80ml/kgbb N:
90ml/kgbb)

Jmlh Tranfusi darah (D >15 % EBV)

WH:(Hbx Hbpasien) x BB x 6=.....ml
PRC:(Hbx Hbpasien) x BB x3=......ml

Nama: ____________ BB:_____kg