Mr. Gunawan Sugita/M/65 y.

o / BPJS / MR : 1557447
Admission : 17-10-2016 Time :06.30 WIB
INA CBG :
DPJP : Dr. dr. Januar, Sp.PD., SpJP.

PS : Chest pain
AK :
patients came with complaints of chest pain since 13 hours prior to admision. Chest pain
is felt when the patient rest> 30 minutes. As overlain heavy objects and radiating down
the arm and jaw. Pain is not relieved by rest or take medication. complaint accompanied
by a cold sweat. Patients were first experiencing chest pains similar to three months ago
and went to the doctor heart and said to suffer from coronary heart disease, two months
ago performed angiography and advised for CABG surgery. Patients scheduled for
surgery on 3 October 2016. The history of high blood pressure (+) since 5 years ago
routine treatment, smoking (+), high cholesterol (-).
 PHYSICAL EXAMINATION

Generalis Status :
Consciousness : Compos Mentis
Vital Sign : BP = 130/80 mmHg, P = 66 x/mnt,
RR = 18 x/mnt T = 36.5 C
Head : Conjungtival not anemic, sclera not icteric
Neck : JVP +2 cm H2O
Cor : Kardiomegali (+), Heart sound : S1S2, H2P2 > regulary
normal, S3S4 (-) murmur (-)
Pulmo : VBS R=L Rh-/-, Wh -/-
Thorax : Symmetrical shape and movement , VBS ka = ki, rh -/-,
wh -/-
Abdomen : Soft, Flat, bowel sound(+)normal, tenderness (-),
rebund (-).
Ektremitas : edema -/-, CRT < 2
 Laboratory finding

Laboratory 17/10/2016 Laboratory 17/10/2016

PT 9,6 Troponin 0.16
APTT 26,7
INR 0,88
Hb 13,7

Hct 46
Leukocyte 7.200
Platelet 197.000
Sodium/potassiu 140/4.4
m
Ur/cr 26/0,64

Mg 2,9

Timely Blood 89
Sugar
INA CBG: K-1-50-II MODERATE ANAL PROCEDURE IDR. 11.918.196
How Would You Evaluate The Patient ?
How Would you Prepare This Patient
for Anesthesia and Surgery ?
For Elective Surgery, How do You Manage the
anticoagulant
DEEP VEIN THROMBOSIS (DVT) prevention ?
surgery patients with severe sepsis, with impaired
hemostasis and coagulation system .... what needs to be
prepared?
Hemostatic in use in neurosurgical operation?
Elective surgery patients will be, but are using aspirin or
oral anti-coagulants. what should we do? stop aspirin for
how long, what about anticoagulant ? Can we stop?
THANK YOU