KORAN BEDAH PLASTIK

KORAN BEDAH PLASTIK Senin, 26 November 2012

NOIDENTITAS PASIENDIAGNOSISTERAPIHASIL PEMERIKSAAN

PALEM BAWAH

PALEM ATAS

LONTARA 1 ATAS BELAKANG

LONTARA 1 BAWAH BELAKANG

LONTARA 2 ONKOLOGI

1SarmaP/17thn

566609

Dikonsul 03/10/2012

JKM

Kmr 8/Bed 2POH 30(tgl. 19/10/2012) biopsi eksisi soft tissue tumor nasalPOH 23 (tgl 31/10/2012)Tunggu jadwal rekonstruksi bila margin bebas tumor

Hasil PA 22/11/2012

Hasil PA: tepi, lateral.medial, atas masih terdapat jaringan 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

2Hasnah

P/40 thn/

MRS 19/11/12Kmr 5 Bed 4Hemangioma pada submandibula dan leherRencana operasi hari ini jumat, 23/11/2012Hasil Lab (10/11/2012)

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

3Ninin Andriyani Sirathak/P/ 579031/7-9-1968Ulkus dekubitusGV/hariHasil 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

4DemmatamuL/40 thn

562777MRS 04/08/2012

JKMKmr 8/Bed 4 Ulkus decubitus Regio Lumbosakral+ Gluteus(D) et (S) Burst Frak. Vertebra Th VIII-IXCefadroxil 2x500 mg

As. Mefenamat 3x500mg

Vit Bcom 2x1

Vip albumin 3x2 tab

GV+rawat luka/2hari

Jadwal GV tanggal 21/11/12

Hasil Kultur 19/11/12

Kultur BTA (-)

Sensivitas Antibiotik (9/10/2012)

A : Proteus Morganii

Sensitif : Aztrenam, Cefepime, Fosfomicin

5MusliminL/22thn

570535MRS 26/09/2012

Dikonsul 03/10/2012

UMUM

Kmr 7B/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 OrtopediHasil Lab (04/11/20162)

WBC 10,34 RBC 2,94 HGB 8,2, PLT 545; HCT 25,4Sensivitas 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)

6Nahariah/P/45 thn/579102/MRS 17/11/12

Kmr.9 B.1Post op.debridemen schissun woundGV tanggal 23/11/2012Lab 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

8

HerlindaP/15 thn

556307MRS 26/06/2012

JKDKmr 11/Bed 6Ulkus Dekubitus Regio Lumbosakral + Post Repair Buli-buli

(08/09/2012) Obat injeksi

GV / 2 hari Mobilisasi miring kanan dan kiri GV sabtu 24/11/2012Hasil lab 9/11/2012

WBC 7,91 RBC 3,50 HB 9,1 HCT 29,3PLT 469

LONTARA 3 KULIT

9Nasrul

L/2 thn/

MRS 19/11/2012

JKM

Km 1Hipospadia

POH 2ChordectomyLab 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

10Kartini Mene

Kontraktur bibir bawahPOH 1Contracture 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

11Yasir/L/17thn/ 577276/MRS 7/11/2012

JKM

Km 2bed 1Skin defect region frontalPOH 5 Burn HoleGV dengan Mebo

Cefixime 2x100 mg

Vip albumin 2x1 tab

Tunggu CTRawat luka

GV/2hari

Rencana op hari seninHasil 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)

12Sedinta SimanjuntakP/ 38thn

575255

MRS 25/10/12JKMKmr 3/Bed 6Skin defect region plantar pedis (D)Post Skin Graft hr 20 (1/11/12)Cefadroxil 2x1

As.Mefenamat 3x1

Ranitidin

GV terakhir 18/11/12Lab (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

13Gilda Sari Eka/4 thn/577380/8/11/12ASK

K1 B4Contracture Collic ec Heat Burn Injury + keloid sternalisPOH 5 Skin GraftCefixime syr 2 cth 1

Novalgin syr 3 cth 1

Rawat luka]

Rencana op hari seninLab 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

14Murni/P/37 thn

565499

JKM

MRS 3/11/12Kmr 3 Bed 1

Paraplegia due to susp. Fr. Vt. Thoracal VII-IX

Ulcus decubitus femur sinistra

Primigravida 7 bulan G1P1A0RL;Tutofusin 2;1 28 tpm

Cefepim 1 gr/12j/iv

Ranitidine 1 amp/8j/iv

Ketorolac 1 amp/8j/iv

GV terakhir 18/11/2012Hasil 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

15Hasriah/kamar 3/MRS 21/11/2012/8 tahun/JKMKontraktur poplitea sinistraTunggu jadual operasiHasil lab 20-11-12HBsAg 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

16Akran

7bln 28 hr 22/11/2012

ASKES Wajib

579570

Kmr 1 bed 3Labiognatoschisis bilaeral

LONTARA 3 SARAF

LONTARA 3 MATA

17Tn. Syarif

L/64 tahun

571046

MRS 09/10/2012

JKM

Kmr 4/Bed 4POH 31 Release Kontraktur ec. Kontraktur Reg. knee joint (S) (18/10/2012) Asam mefenamat 3x1

Cefadroxil 2x1

GV terakhir 19/11/2012Lab 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 107Hasil thorax PA

Atherosceloris aortae

18Randa

L/38 thn

576999

MRS 11/11/12Kmr 4 Bed 1

POH 4 SilikonomaAs.mefenamat 3x1

Neurodex 3x1Hasil 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

19By Haddad

L/6 bln

579239

MRS 22/11/12

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 19/11/2012WBC 11,5 HB 11,2 PLT 516

20Tn. Sugiman

580093/L/25 thn

JamkedaMaxillofacial injury + Fraktur Zigoma bilateral + Fr. Parasimpisis mandibula 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 10830

21Tn. Sardi

L/18 thn/Umum

MRS 24/11/12

Kamar 2 Bed 1TCR GCS 15 + Maxillofacial InjuryPersiapan orifLab 24/11/12WBC 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

LONTARA 3 THT

LONTARA 3 BEDAH SARAF

LONTARA 4

UNIT LUKA BAKAR

22Ariny Beauty Yaqina

P/4 thn/ 567475

MRS 7/9/12JKD Bed 1Combustio Grade II A/B 27%- vip albumin 3x1- Vit C 3x1

- GV/rawat luka/2hari + mebo

Stop duoderm dan suprasurbHasil lab (03/11/2012)

GDS 91; Ur 10; Cr 0.3; GOT 19; GPT 13; Alb 3,6; Na 142; K 4,3; Cl 107; WBC 12,42; PLT 628; Hb 12; Hct 37,8

23Yasril Ananta

L/11thn

571189

MRS 29-09-2012

Bed 3Combustio 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 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 25,5Hasil 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

24M.Hidayatullah

L/19 thn

MRS 18/10/12

574577

Bed tambahanElectric burn injuryPOH 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 26/11/12Hasil lab (09/11/2012

Wbc 24,80, Hb 12,3, Rbc 4,26, Plt 747

25Sugianto/L/26th

576914

4/11/12

UmumBed 4

Electric Burn Injury

35%Cefixine 3x100mg

Neurodex 3x1Vip albumin 3x2

Gv 2x hariLab 10/11/12

GDS 140 Alb 2,3 WBC 13,34 RBC 4,76 Hb 13,6 HCT 42,1 PLT 255

26Hamzah/L/26 thn/22-09-12/569960Electric Burn InjuryNeurodexVit. C

VIP albuminLab 03/11/2012WBC 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

27Syawal/L/7 thn/566363MRS 22/10/2012

UMUMBed 6Combutio Grade IIA/B 30%-Rawat Luka/ 2 hari + mebo- Vip albumin 3 x 2

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

PCC

RSUH

ICU

28IrwansyahL/28 thn563404

JKM

VIP 1Ulkus dekubitusGV/hariHasil Lab 20/11/12WBC 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 21/22Hasil 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

29Basir Kadir

L/44th

572815

inHealth

VIP Utama-infark cerebri

-ulkus decubitus reg.sakrum

Rencana mobilisasi kiri kanan / 2 jam

Control gula darah

Rawat luka per hariHasil Lab 20/11/12WBC 7,23 RBC 4,18 HB 12 HCT 35,4 PLT 268 GDS 99 Ur/Cr 27/1,1 GOT/GPT 19/25 Alb 4,2Hasil AGD 17/11/12

Ph 7,52 p02 37,4 pCO2 38 SO2 49,4 HC03 28

UGD

30Suyanti/28 thn/P/25-11-12/JKDVulnus Laserasi Frontal (S)Maxillofacial InjuryRL

CeftriaxoneKetorolac

Ranitidin

Lab 25/11/12WBC 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

31Febriansyah/28 thn/L/25-11-12/UmumMaxillofacial InjuryIVFD RL

Ceftriaxone

Ranitidin

Ketorolac_

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