KORAN DIVISI BEDAH PLASTIK

SABTU 17 SEPTEMBER 2016

LONTARA 3

L3AD
K1B6

M. Haerul Ihsan
24/01/1994
22 th
770217
MRS: 3/9/2016

Fraktur Zygoma
Dextra
Fraktur mandibula
dextra

DPJP:
Dr.dr. A. J. Riewpassa,
Sp.B, Sp.BP
L3 AB
K1 B1

Rusli
20/8/1979
37 tahun
771377
MRS: 09-09-2016

Fraktur mandibula
(proc alveolaris)

DPJP:
dr. A.J Riewpassa,
Sp.B Sp.BP

L3 AB
K2B2

Obedyermias
20-01-1991(25thn)
766691
MRS : 13-9-2016
DPJP :dr. , Sachrawaty,
Sp. B, Sp. BP

Ulkusregio gluteus
dextra
POH 5 debridement

Lab 30/8/16
WBC: 14.75
HB: 12.1
RBC: 3.98
HCT: 35.0
PLT: 282
SGOT: 47
SGPT: 39
GDS: 123
Lab9/9/2106
WBC : 16,9
RBC :5,17
Hb : 16,0
PLT : 223
Pt/Aptt: 9,9/21
INR: 0,95
Gds: 96
Ur/cr: 23/0,.74
Got/Gpt: 33/28
N/K/Cl:
142/4.1/105

IVFD RL 28 tpm
Ceftazidim 1 gr/12 j
Ketorolak 1 amp/8j
Ranitidin 1 amp/8j

-IVFD RL 28 tpm
-ceftazidime 1
gr/12jam/iv
-ranitidin 50
mg/12jam/iv
-metamizole 300
mg/8jam/iv
Rawatluka
Rencana
ORIFsenin
19/9/2016

MSCT kepala 3
dimensi non
kontras
(13/9/2106)
-Fraktur pada
corpus mandibula
sisi kanan
(processus
alveolaris) dengan
sruktur gigi area
tersebut yang
tidak intak
-Sinusitis
maxillaris bilateral
disertai rhinitis
chronic
Foto kepala
Ap+lateral(9/9/20
16)
-Fraktur os nasal
Suspek fraktur
proc. Alveolar os
maxilla dan atap
-Suspek
hematoorbita
dextra sinus
frontal

IVFD RL 28tpm
Ranitidin 50mg/8j/iv
Novalgin amp/8jam/iv
Ceftazidime1gr/12j/iv

L3 AB
K2 B3

Kaswi
1-7-1965 (51thn)
MRS 16-9-2016
768666

Skin defect

DPJP: dr.fonny josh

L3 AB
K2B5

L3 AB
K3 B1

Florensius
sukrisno
31/3/1995
21 tahun
770945
MRS : 10/9/2016
DPJP :
Dr.dr.Fonny Josh,
Sp,BP, RE(K). B.
Mikro

Skin defect
regional ocipital ec
luka bakar listrik

ST. HADIJAH POH 2

25/02/2016
Labioplastyec.Lab
0 Tahun, 6 Bulan, 16
iognatopalatoschi
Hari
zis unilateral
770537
completedextra
MRS: 10/09/2016
DPJP:
Dr. dr. Fonny Josh,
Sp.B, Sp.BP-RE(K)

Lab 10/9/2016
WBC: 5.39
HB: 14,1
RBC: 5,67
HCT: 45,2
PLT: 228
SGOT: 20
SGPT: 18
GDS: 92
Ur/cr : 14,0,96
Na/K/Cl :
146/3,5/109
Laboratorium
(02/09/2016)
WBC : 11,7
RBC : 4,26
HB
: 10,9
PLT : 387
PT
: 10,7
APTT : 29,0
INR
: 1,00
GDS : 70
Ur/Cr : 17/0,20
SGOT : 36
SGPT : 21
Na/K/Cl :
143/5,1/107

- IVFD RL 15 tpm
- Ceftriaxone
200mg/12jam/iv
- Ranitidine
10mg/12jam/iv
- Paracetamol
100mg/8jam/iv

- GV harike 3

Foto Baby Gram

(02/09/2016)
- Tidaktampakkelainan
radiologikpadafoto
Baby Gram ini

L3AB
K3 B4

SYAMSIYAR Multiple Fraktur

20/01/2002
Maxillofacial
14Tahun, 7 Bulan,
26 Hari

Laboratorium
(14/09/2016)
WBC: 12,2
RBC : 4.74

- Rencanaoperasi
- Menunggujadwal
operasi

771733
MRS:15/09/2016

HB
: 12,4
PLT : 373
PT: 10.3
APTT :24.7
INR
: 0.96
GDS : 92
Ur/Cr : 10/0,40
SGOT: 15
SGPT : 10
Na/K/Cl :
143/3,9/104

DPJP:
Dr. dr. Fonny Josh,
Sp.B, Sp.BP-RE(K)

L3AB
K4B3

Hj.Sitti
05/06/1969
(47 tahun)
768726
MRS:02/09/2016
DPJP:
Dr.dr.Fonny Josh,
Sp.BP, RE(K),
B.Mikro

POH IV Release
kontraktur left arm
manus

Lab (14/09/2016)
WBC: 6.5
RBC: 3.59
HGB: 10.1
HCT: 31
PLT: 142

IVFD RL 28 tpm
Ceftazidime 1gr/12j/IV
Ranitidin 1amp/8j/IV
Ketorolac 1amp/8j/IV
Metronidazole
500mg/8j/IV

Operasi release
kontraktur + flap
e.c, kontraktur left
arm
(tgl 13/09/2016)

Lab (04/09/2016)
PT/APTT: 9,8/25.7
INR: 0.94
GDS: 139
Ur/Cr: 32/0.59
SGOT/SGPT: 15/15
HBsAg : Non
reactive
Albumin: 5.2
Na/K/Cl:
147/3,9/107

GV per 3 hari

Foto manus Sinistra

AP/Obliq
(05/09/2016)
Kesan :
- Kontraktur
metacarpopalangeal
joint digiti II-IV dan
PIP digiti I-V
-Disuse osteoporosis
Foto thorax PA
(05/09/2016)
Kesan :
Tdk tampak kelainan
pd foto thorax
L3 AB
K5 B3

Wandi
14/01/1998
679861
MRS : 06/09/2016
DPJP :
Dr.dr.Fonny Josh,
Sp,BP, RE(K). B.
Mikro

POH 4 Aff Plate

Maxilla

Lab 06/09
WBC: 9,8
HGB: 16,5
PLT: 282
PT: 10,4
APTT: 25,1
INR: 0.97
SGOT:21
SGPT:25

IVFD RL 28 tpm
Injeksi ceftriaxone
1 gr/12jam/iv
Injeksi ranitidine
50 mg/12jam/iv
Ketorolac 1
amp/8jam/iv
Bila demam ekstra
paracetamol 1
gr/bolus
Betadin chimer 3x

L3 AB
K5 B4

Ashadi
22/04/1990
771079
MRS: 07/9/2016

POH 7 ORIF
Maxillafacial
+ Craniotomi
debridement

DPJP:

L3 AB
K5 B5

Wahyudin
15/08/1988
771543
MRS : 11/09/2016

Maxillofacial
injury

DPJP : Dr. Sachraswaty,

SpB, Sp.BP

ULB

MuhJufri Dg
Ngempo
42 tahun
MRS : 08/09/2016
DPJP :dr. A. J.
Rieuwpassa, SpB,
SpBP-RE(K)

Post debridement +
fasciotomy e.c
electrical burn
injury

sehari
GV/2hari
Terapisesuai TS
BedahSaraf

Lab 7/9
WBC: 16,25
HGB: 14,5
PLT: 229
PT: 11,4
APTT: 31,7
INR:1,10
SGOT:28
SGPT:25

Lab (11/9/2016)
WBC :11,6
RBC : 5,42
Hb : 16,0
HCT:46,4
pLT :207
Pt/aptt : 9,5/25,1
Inr : 0,91
Gds:113
Ur/cr: 37/1,00
Got/Gpt: 21/35
Na/k/cl: 143/3,6/103

Lab (08/09/2016)
HGB 15,7
RBC 4,92
WBC 18,5
PLT 229
GDS 146
SGOT/SGPT 459/79
Ur/Cr 32/0,78

ULB

Gondrong Dg
Tawang
47 tahun
MRS : 10/09/2016
DPJP :
drSachrawaty, Sp.B,
Sp.BP

Electrical burn
injury 20%
hipoalbuminemia

Lab (10/09/2016)
HGB 15,3
RBC 5.00
WBC 21,97
PLT 234
SGOT/SGPT
664/395
Ur/Cr 41/0,88
Albumin 3,0

IVFD RL 28 tpm
Injeksi ceftriaxone 1
gr/12jam/iv
Injeksi ranitidine 50
mg/12jam/iv
Novalgin 1
amp/8jam/iv
Rencana operasi
senin 19 september
2016

IVFD RL 30 tpm
Ceftazidime
1gr/12jam/IV
Metronidazole
500mg/8jam/IV
Ranitidine
50mg/8jam/IV
Ketorolac
30mg/8jam/IV
Inj. Vit C
400mg/12jam/IV
Ondansentron
4mg/12jam/iv
O2 via nasal kanul
IVFD RL 28 tpm
Ceftriaxone
1gr/12jam/IV
Metronidazole
500mg/8jam/IV
Omeprazole
40mg/8jam/IV
Ketorolac

Diet TKTP
Rawat luka
Awasi
produksi urin

Awasi
produksi urin
+ warna urin
Diet TKTP

ULB

Muhammad Nasir
24 tahun
MRS : 29/08/2016
DPJP : Dr. dr.
Fonny Josh, Sp.BP,
RE(K), B.Mikro

POH 7 skin graft

luasec. Electrical
burn injury

Lab (08/09/2016)
HGB 10,1
RBC 3,80
HCT 21,1
WBC 7,9
PLT 200

30mg/8jam/IV
Albumin 3x1 caps

IVFD RL + drip
Neurobion
1amp/24jam 28
tpm
Cefixime
100mg/12jam.iv
Metronidazole
500mg/8jam/IV
Albumin 3x1
caps

Diet TKTP