KORAN BEDAH PLASTIK

N O IDENTITAS PASIEN DIAGNOSIS TERAPI PALEM BAWAH

Senin, 26 November 2012

HASIL PEMERIKSAAN

Sarma P/17thn 566609 Dikonsul 03/10/2012 JKM Kmr 8/Bed 2

POH 30(tgl. 19/10/2012) biopsi eksisi soft tissue tumor nasal POH 23 (tgl 31/10/2012)

Hasnah P/40 thn/ MRS 19/11/12 Kmr 5 Bed 4

Hemangioma pada submandibula dan leher

PALEM ATAS LONTARA 1 ATAS BELAKANG LONTARA 1 BAWAH BELAKANG LONTARA 2 ONKOLOGI Tunggu jadwal Hasil PA 22/11/2012 rekonstruksi bila Hasil PA: tepi, lateral.medial, atas masih terdapat jaringan tumor.. margin bebas tumor Hasil PA (25/10/2012) Low grade fibromaxoid sarcoma dengan tepi dasar masih mengandung sel tumor. Hasil PA (04/09/2012) Malignant tumor kesan suatu sarcoma Hasil Lab (19/09/2012) CT 8, BT 3, PT 11,4, INR 0,95, APTT 25,2, Na 138, K 3,4, Cl 106, GDS 89, Ur 14, Cr 0,5, SGOT 20, SGPT 18, WBC 7,34, RBC 4,2, HGB 12,5, PLT 317 Rencana operasi hari Hasil Lab (10/11/2012) ini jumat, 23/11/2012 WBC: 8,15 RBC: 4,28 HGB: 11,2 HCT: 36,5 PLT: 320 CT 700 BT 2 00 PT 12,1 APTT 27,8 GDS 132 GDS 132 SGOT 10 SGPT 8 Hasil USG colour dopler Kesan: lesi hiperechoic pada region submandibular, cervical dan subaurikel kanan kesannya saling berhubungan dan kesan berasal dari vena jugularis kanan, pada color dopler tampak gambaran low flow. Multiple thyroid bilateral Hasil Laboratorium 16/11/2012 Hb 9,5 RBC 3,75 WBC 8,49 PLT 369 HCT31,0 CT 600 BT 200 GDS 104 Ur 20 Cr 0,6 SGOT 62 SGPT 43 Asam Urat 5,1 Elektrolit: N 143 K 43 Cl 113 LONTARA 2 DIGESTIF LONTARA 2 ORTHOPEDI Cefadroxil 2x500 Hasil Kultur 19/11/12 mg Kultur BTA (-) As. Mefenamat 3x500mg Sensivitas Antibiotik (9/10/2012) Vit Bcom 2x1 A : Proteus Morganii Vip albumin 3x2 tab Sensitif : Aztrenam, Cefepime, Fosfomicin GV+rawat luka/2hari Jadwal GV tanggal 21/11/12 GV/hari

Ninin Andriyani Sirathak/P/ 579031/7-9-1968

Ulkus dekubitus

Demmatamu L/40 thn 562777 MRS 04/08/2012 JKM Kmr 8/Bed 4

Ulkus decubitus Regio Lumbosakral+ Gluteus(D) et (S) Burst Frak. Vertebra Th VIIIIX

Muslimin L/22thn 570535 MRS 26/09/2012 Dikonsul 03/10/2012 UMUM Kmr 7B/Bed 6 Nahariah/P/45 thn/579102/MRS 17/11/12 Kmr.9 B.1 Herlinda P/15 thn 556307 MRS 26/06/2012 JKD Kmr 11/Bed 6

- POH 31 (tgl. 22/10/2012) Skin graft ec. Ulkus Decubitus at lumbosacral region - Ulkus Decubitus at lumbosacral region - Fail Skin Graft

GV + rawat luka/2 hari Jadwal GV Minggu 23/11/12 Lanjut terapi dari TS Ortopedi

Hasil Lab (04/11/20162) WBC 10,34 RBC 2,94 HGB 8,2, PLT 545; HCT 25,4 Sensivitas Antibiotik (9/10/2012) A : Proteus Morganii B : Pseudomonas aeroginosa Sensitif : Amikacin (S,S) Cefepime (R,S) Ceftazidime (R,S) Amikacin (S,S) Doxycyclin (S,R) Fosofomisin (S,R) Gentamicin (R,S) Novomiocin (S,S) Meropenem (S,S) Levofloxacin Amikacin (R,S)

Post op.debridemen schissun wound

GV tanggal 23/11/2012

Ulkus Dekubitus Regio Lumbosakral + Post Repair Bulibuli (08/09/2012)

Lab 19/11/2012 WBC 17,32 RBC 3,90 HB 11,2 HCT 33,4 PLT 333 CT/BT 700/300 PT/APTT 11,6/26,9 GDS 124 Ur/Cr 20/ 0,7 GOT 64 GPT 57 Na 143 K 4,5 Cl 108 LONTARA 2 UROLOGI Obat injeksi Hasil lab 9/11/2012 GV / 2 hari WBC 7,91 RBC 3,50 HB 9,1 HCT 29,3PLT 469 Mobilisasi miring kanan dan kiri GV sabtu 24/11/2012 LONTARA 3 KULIT Chordectomy Lab 13/11/2012 WBC: 12,61 RBC: 5,00 HGB: 12,3 HCT: 36,3 PLT: 402 CT 700 BT : 3 00 PT :10 APTT : 26,0 GDS : 91 Ur/Cr: 12/1,4 SGOT: 40 SGPT :19 Albumin : 4,2 Na : 136 K : 4,4 Cl : 104

Nasrul L/2 thn/ MRS 19/11/2012 JKM Km 1 Kartini Mene

Hipospadia POH 2

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Kontraktur bibir bawah POH 1

Contracture at the lower lip RL 24 tpm Hipopobac 2x10/12j/IV Ketorolac amp/8j/iv Ranitidin amp/8j/iv Cernevit amp/24j/drips GV hr ke 5 Diet lunak

Lab 22/11/2012 Hb 10,8 HCT 34,3 WBC 5,14 RBC 3,95 PLT 375 CT 700 BT 200

KORAN BEDAH PLASTIK

11 Yasir/L/17thn/ 577276/MRS 7/11/2012 JKM Km 2bed 1 Skin defect region frontal POH 5 Burn Hole GV dengan Mebo Cefixime 2x100 mg Vip albumin 2x1 tab Tunggu CT Rawat luka GV/2hari Rencana op hari senin Cefadroxil 2x1 As.Mefenamat 3x1 Ranitidin GV terakhir 18/11/12

Senin, 26 November 2012

Hasil Lab(6/11/2012) CT 800 BT 200 PT 11,6 aPTT 21,8 GDS 123 Ur 15 Cr 1,0 GOT 12 GPT 10 HBsAg /Anti HCV (-)/(-) WBC 7,92 RBC 4,90 HGB 15,7 HCT 45,4 PLT 387 MSCT Scan Non Kontras 09/11/12 Defect pada os frontoparietal (D) Lab (24/10/12) WBC 5,7; RBC 4,88, HGB 14,8; HCT 41,4; PLT 183; CT/BT 7/2; PT/APTT 10,2/22,6; GDS 77; UR/CR 18/07; Na 143; K 3,7; Cl 108; GOT/GPT 24/21; ALB 4,6

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Sedinta Simanjuntak P/ 38thn 575255 MRS 25/10/12 JKM Kmr 3/Bed 6 Gilda Sari Eka/4 thn/577380/ 8/11/12 ASK K1 B4 Murni/P/37 thn 565499 JKM MRS 3/11/12 Kmr 3 Bed 1 Hasriah/kamar 3/MRS 21/11/2012/8 tahun/JKM Akran 7bln 28 hr 22/11/2012 ASKES Wajib 579570 Kmr 1 bed 3

Skin defect region plantar pedis (D) Post Skin Graft hr 20 (1/11/12)

Contracture Collic ec Heat Burn Injury + keloid sternalis POH 5 Skin Graft Paraplegia due to susp. Fr. Vt. Thoracal VII-IX Ulcus decubitus femur sinistra Primigravida 7 bulan G1P1A0 Kontraktur poplitea sinistra

Cefixime syr 2 cth 1 Novalgin syr 3 cth 1 Rawat luka] Rencana op hari senin RL;Tutofusin 2;1 28 tpm Cefepim 1 gr/12j/iv Ranitidine 1 amp/8j/iv Ketorolac 1 amp/8j/iv GV terakhir 18/11/2012 Tunggu jadual operasi

Lab 9/11/2012 WBC 12,16, RBC 5,50, Hb 13,2, HCT 40,0, PLT 45,2, GDS 89, Ur/Cr 19/0,3, GOT/GPT 39/10, Protein total 7,4, Albumin 4,8, Globulin 2,6 Hasil Lab (03/11/2012) GDS 103, Ur 13, kr 0,5, GOT 20, GPT 14, Protein tot 6,6 , Na 141, K 4,9 Cl 110, HbsAg negative, Anti HCV negative, WBC 11,17, RBC 4,81, HB 12,2, HCT 37,6 ,PLT 419 CT 6, BT 2, PT 12,3 APTT 27,8, INR 1,0 Hasil lab 20-11-12 HBsAg ve antiHCV ve CT 800 BT 200 PT 10.5 aPTT 20.4 Na 135 K 4.1 C 108 GDS 122 Ur/Cr 13/0.6 GOT/PT 21/11 alb: 4,1 WBC 8,18 RBC 5,11 Hb 10,8 PLT 558

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Labiognatoschisis bilaeral

LONTARA 3 SARAF LONTARA 3 MATA 17 Tn. Syarif L/64 tahun 571046 MRS 09/10/2012 JKM Kmr 4/Bed 4 Randa L/38 thn 576999 MRS 11/11/12 Kmr 4 Bed 1 By Haddad L/6 bln 579239 MRS 22/11/12 Tn. Sugiman 580093/L/25 thn Jamkeda Maxillofacial injury + Fraktur Zigoma bilateral + Fr. Parasimpisis mandibula POH 31 Release Kontraktur ec. Kontraktur Reg. knee joint (S) (18/10/2012) - Asam mefenamat 3x1 - Cefadroxil 2x1 GV terakhir 19/11/2012 POH 4 Silikonoma As.mefenamat 3x1 Neurodex 3x1 Lab 5/11/2012 WBC 13,68, RBC 3,72, Hb 10,6, PLT 570, GDS 209, Ur 47, Cr 1,1, GOT 13, GPT 17, Albumin 3,8, Na 138, K 4,3, Cl 107 Hasil thorax PA Atherosceloris aortae Hasil Lab 5/11/2012 CT 700 BT 300 PT 10,6 GDS 105 Ur/Cr 20/1.0 SGOT 24 SGPT 41 Albumin 4,4

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Hasil Lab 21/11/2012 Ur/kr 14/0,2 GOT 27 GPT 15 Alb 4,1 N 134 K 4,9 KL 105 Hasil Lab 19/11/2012 WBC 11,5 HB 11,2 PLT 516 Hasil CT Scan Kepala Brain window : pneumocephal frontal Bone Window: Fr. Zigoma bilateral Fraktur nasal Hasil Laboratorium 23/11/2012 HgB 12,1 RBC 4,06 WBC 23,52 PLT 192 HCT 36,8 CT 700 BT 200 GDS 175 Ur 28 Cr 1,0 SGOT 26 SGPT 16 Elektrolit: N 144 K 4,1 Cl 108 Lab 24/11/12 WBC 21,04, RBC 4,53, HGB 14,4 HCT 42,0 PLT 278 CT 8, BT 4, PT 12,1 APTT24,4 GDS 123 Ur 28 Cr 0,8 GOT 266 GPT 261 N 143 K 4,4 KL 107

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Tn. Sardi L/18 thn/Umum MRS 24/11/12 Kamar 2 Bed 1

TCR GCS 15 + Maxillofacial Injury

Persiapan orif

LONTARA 3 THT LONTARA 3 BEDAH SARAF LONTARA 4 UNIT LUKA BAKAR - vip albumin 3x1 Hasil lab (03/11/2012) - Vit C 3x1 GDS 91; Ur 10; Cr 0.3; GOT 19; GPT 13; Alb 3,6; Na 142; K 4,3; Cl 107; - GV/rawat luka/2hari + WBC 12,42; PLT 628; Hb 12; Hct 37,8 mebo Stop duoderm dan suprasurb As. Mefenamat 3x250mg Fujimin 3x1 B com C 1x1 GV/ 2 hari Rawat luka 2x hari Hasil lab (08/11/2012) Ct/Bt 600/200, PT 11 kontrol 11,2, APTT 22,6 kontrol 25,5 Hasil lab (03/11/2012) WBC 5,70; RBC 4,90; HGB 13.7; HCT 41,3; PLT 333; GOT 43; GPT 41; Na 144; K 5,1; Cl 108; Ur 21; Cr 0,4

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Ariny Beauty Yaqina P/4 thn/ 567475 MRS 7/9/12 JKD Bed 1 Yasril Ananta L/11thn 571189 MRS 29-09-2012 Bed 3

Combustio Grade II A/B 27%

Combustio gr II A 17 % ec. Electrical Burn injury + Necrotic phalangs II & III pedis (D) POH 15 (09/11/12) amputasi jari multiple II dan III

KORAN BEDAH PLASTIK

24 M.Hidayatullah L/19 thn MRS 18/10/12 574577 Bed tambahan Electric burn injury POH 16 (09/11/2012) trans antebrachii (S) Tramadol 3x1 Neurodex 3x1 Fujimin 3x2 PCT 2x1 GV/2 hari Diet TKTP Rencana debridement hari senin tanggal 26/11/12 Cefixine 3x100mg Neurodex 3x1 Vip albumin 3x2 Gv 2x hari Neurodex Vit. C VIP albumin -Rawat Luka/ 2 hari + mebo - Vip albumin 3 x 2

Senin, 26 November 2012

Hasil lab (09/11/2012 Wbc 24,80, Hb 12,3, Rbc 4,26, Plt 747

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Sugianto/L/26th 576914 4/11/12 Umum Bed 4 Hamzah/L/26 thn/22-0912/569960 Syawal/L/7 thn/ 566363 MRS 22/10/2012 UMUM Bed 6

Electric Burn Injury 35%

Lab 10/11/12 GDS 140 Alb 2,3 WBC 13,34 RBC 4,76 Hb 13,6 HCT 42,1 PLT 255

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Electric Burn Injury Combutio Grade IIA/B 30%

Lab 03/11/2012 WBC 8,02; RBC 4,17; HGB 11,9; HCT 37,2; PLT 299;; GDS 112; Ur/Cr 21/0,5; GOT/GPT 35/49;; Alb 3,5; Na/K/Cl 144/4,3/109 Lab (20/10/2012) WBC 24,64; RBC 4,72; HGB 11,4; HCT 36,0; PLT 792; PT/APTT 11,4/23,5; GDS 161; Ur/Cr 21/0,8; GOT/GPT 25151; Prot.Total 5,2; Alb 3,2; Na/K/Cl 141/4,8/106

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Irwansyah L/28 thn 563404 JKM VIP 1 Basir Kadir L/44th 572815 inHealth VIP Utama Suyanti/28 thn/P/25-11-12/ JKD Febriansyah/28 thn/L/25-1112/Umum

Ulkus dekubitus

PCC RSUH ICU GV/hari

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-infark cerebri -ulkus decubitus reg.sakrum

Rencana mobilisasi kiri kanan / 2 jam Control gula darah Rawat luka per hari UGD

Hasil Lab 20/11/12 WBC 9,35 RBC 4,65 HB 9,5 HCT 31,0 PLT 447 GDS 91 Alb 2,4 Na 134 K 3,5 Cl 102 Ur/Cr 7/0,3 GOT/GPT 21/22 Hasil Lab 17/11/12 GDS 83 ur/cr 9/0,1 got/gpt 13/18 albumin 2,7 Na 143 k 3,8 cl 107 wbc 8,77, hb 9,7 plt 453 Hasil Lab 20/11/12 WBC 7,23 RBC 4,18 HB 12 HCT 35,4 PLT 268 GDS 99 Ur/Cr 27/1,1 GOT/GPT 19/25 Alb 4,2 Hasil AGD 17/11/12 Ph 7,52 p02 37,4 pCO2 38 SO2 49,4 HC03 28 Lab 25/11/12 WBC 18,45 RBC 4,12 HB 11,8 HCT 37 PLT 109 GDS 120 Na 143 K 4,3 Cl 110 Ur/Cr 21/0,5 GOT/GPT 269/40 CT 10 BT 4 PT 10,3 INR 0,9 _

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Vulnus Laserasi Frontal (S) Maxillofacial Injury

RL Ceftriaxone Ketorolac Ranitidin IVFD RL Ceftriaxone Ranitidin Ketorolac

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Maxillofacial Injury