ORTHOPAEDI, Sabtu 15 Desember 2018

RIS/GAS/CID/DON/YOS/RDA/LAZ/GIL/IBY/SAQ LHB/JRM/FID/ALF/JNA

Ruan No BED NAMA Usia RM NON ORTHO MRS STATU OP TINDAKAN PLAN BIAY RABER LAB PP DPJP
g DIAGNOSIS S A DS

ICU 1 14 Herlambang 55 01425292 Tetraparese LMN type ec susp Tetraparese ec Kons Pre op Open bipsi local Ro BPJS NEuro 11/12 Hb 12.2 AL 16.4 AE 3.91 AT 392 YOS RVA
polymyositis polimyositis ulan humerus HCT 36 OT 27 PT 39 Alb 2.9 LDH 336 CRP
Ventilator associated 6/12 D 2 alkali fosfatase 204
pneumonia Bone
survey
2 17 Ngatiman 40 01387398 Cervical radiculopathy bilateralc4-5- 13/12 Pre op 1/12 Pro key hole BPJS RDA RVA
Pindah flb 9 6 post acdc4-5 foramenectomy c4-5, c5-6
k/p laminektomi k/p
stabilisasi

3 15 Catur 36 01441143 OF Tibia Fibula S post OREF Anemia 1/12 konserv DSU hari rabu jika cathlab Raber Jamsos BTKV GIL RVA
Susp. Aneurisma A.tibialis anterior atif gagal langsung naik OK BTKV tek CT 15/12 Hb 8.1 hct 24 AL 14.2 AT 355 AE
Transfusi angiografi 2.77
PRC 16/12 gds 100 cr 0.7 ur 24 na 129 k 3.4 cl
94 ca 1.06
RGB 4 J Nn.Piscalita 16th 01442260 CF Clavicula (D) 1/3 Tengah Allman COS GCS E2V2M5 11/12 Pre op - ORIF elektif (18/12/2018) BPJS B.Saraf 11/12 hb 9,5 al 11.2 at 191 pt 15,2 aptt YOS RVA
Grup I 24,7 gds 132 ur 31 cr o,6
CF Shaft Femur (D) 1/3 Tengah
Winquist Hansen III

5 D Edi 42 01442042 CF clavicula (D) 1/3 tengah allman COS GCS E3V4M5 9/12 pre op -Imobilisasi dengan arm Bedah BPJS 9/12 hb 14,7 al 19,2 at 207 pt 12,9 aptt YOS RYN
group 1 Oedem cerebri sling saraf 23,7 gds 128 cr 0,7 ur 24 na 138 k 3,7 cl
Fr. Kompresi VC6 Frankel D -ORIF elektif 104

Ag 1 6 4D Paimin 48 01437025 Destruksi Proximal humeri (s) Susp Pneumoia 26/11 Konsul Tidak perlu mri pro four Paru 10/12 Hb 10.9 HCT 33 AL 26.3 AT 160 AE YOS RYN
MBD PPOK quarter amputation 3.74 Na 132 K 4 Ca 1.06
Bone Survey Multiple lesi litik Clavicula
(d), Ulna (S),
11/12 na 132 k 4 cl 1.06
HCU 7 H Sri Sejati 39 01442465 OF Radius ulna 1/3 tengah GA grade COR GCS e3V5M6 13/12 Post op BPJS 12/12 hb 11,8 ht 37 al 20,9 at 449 pt 12.2
NEUR I aptt 25,3 gds 140 ur 18 cr 0,6 na 138 k
OF supracondylar femur (D) 3,1 cl 107
O
comminutive type GA grIIIA 16/12 hb 12.1 hct 38 al 14.5 at 193 ae
4.51
8 L Ariyanto 32 01441128 CF Clavicula (S) 1/3 lateral Allman COS GCS E2V2M5 30/11 pre op Cito Debridement + Bedah 1/12 hb 8.5 hct 25 leu 17.3 trom 121 gds YOS RVA
grup II type II SDH R. Frontal Immobilisasi Pedis dg Saraf 101 alb 2.4 na 134 k 4.7 inr 1.18
OF Ankle (S) Lauge - Hansen SA I GA SAH Bootslab 3/12 hb 9.7 hct 27 leu 15.3 trom 107
grd II post debridement Immobilisasi Clavicula dg 7/12 hb 9.6 hct 31 al 12.1 at 365 ae 3.47
Arm Sling 8/12 hb 10.5 hct 32 al 14.0 at 385 ae 3.45
ORIF elektif
MEL 2 9 5G An Amanda Cahya 8 01442768 CF Clavicula (D) 1/3 tengah allmann COR GCS E4V5M6, Fr 14/11 Pre op ORIF elektif Umum B Saraf 14/12 Hb 11.8 hct 35 AL 17.3 AT 310 AE RVA

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 group I Linear os temporal 3.97 GDS 137

HCU 10 B Viki S 12 01435684 AIS lenke IV Post koreksi deformitas 11/12 Post op 13/12 13/12 hb 9, hct 30 al 10,3 at 216 ae 3.46 GIL RVA

mel
2

Mel 11 16C Mustaniroh 67 Paraplegi inferior UMN type setinggi Dyspneu ec Ca paru 6/12 Pre op Paru BPJS 14/12 Hb 9.1 hct 28 AL 14.3 AT 300 AE YOS RVA
Th 12 ec MBD 3.14 GDS 156 OT 184 PT 248 ur 28 cr 0.4
3 Na 128 K 4.0 Cl 97
Imunologi (4-12-18) Anti TB (-) CEA 21,35
NSE 22,62
12 17C Dwi Ekatani 47 01440860 Septic arthritis genu dekstra dengan PAD, CHF NYHA III, OMI 13/12 Konsul BPJS Interna 13/12 Hb 9.3 Hct 31 AL 17 AT 285 AE 3.5
DM tipe II anterior, PJK, DM tipe II, GDS 182 OT 18 PT 5 Cr 1.3 Ur 71 Na 130 K
Obese 4.1 Ca 1.1
13 604A Sutardi 52 01440837 Fr kompresi VL1 frankel E 28/11 Post op Body Jacket Bpjs 28/11 hb 11,6 al 7,9 at 171 pt 13,5 aptt Gil RVA
Flb CF calcaneus (D) essex lopresti type ORIF Calcaneus 27,6 gds 147 ot 25 pt 17alb 4,1 cr 1 ur 22
6 c (14/12/2018) na 137 k 3,7 cl106
CF calcaneus (S) essex lopresti type c 10/12 MRI (+)
14 604C Suhartono 61 01441140 Paraparese inferior UMN type ec. Susp. Ca buli 1/12 Work THR long stem cemented Konsul 27/11 hb 10.6 hct 32 leu 7000 trom 371 GIL RVA
MBD up biomet hari senin urology led 1: 81 LED 2: 94 CRP (-) alkali fosfatase
CF patologis femur S 1/3 proximal ec MRI 918 ur 33 cr 0.49 SGOT 32 SGPT 13
MBD torakolu 3/12 hb 9.4 hct 29 leu 7.8 trom 230 pt
mbal 14.7 aptt 28.3 inr 1.200 gds 113 na 124 k
dengan 3.2 cl 100 HbSag NR
kontras
15 605A Ali Mahmud 43 01442675 CF patella dekstra 14/12 Pro ORIF elektif 14/12 Hb 13.7 Hct 40 AE 4.41 Cr 0.8 Ur 26
Na 133 K 3.8 Cl 9.6

16 607D Nur sidiq 27 01431389 Post orif pinning ai crush Skin kontraktur 11/12 Post op Roi+tata laksana skin b.plastik bpjs 8/9 hb 10 al 9,6 at196 GIL RYN
injury.manus D kontraktur 12/12 Hb 14.3 AE 5.97 Alb 4.3 Cr 0.8 Ur
19 Na 136 Cl 109
17 612A Ferry 32 01403396 Osteomyelitis kronis femur (D) post 10/12 post op BPJS 6/12 hb 12,4 al 8,9 at 649 led 1 2 led 2 GIL RYN
orif post ROI + debridement+ kultur 5pt 17 aptt33afp 202 hs crp 9,75
Ro femur ap/lat 13/12 malunion fraktur
1/3 media os femur kanan, kalus +,
osteomyelitis
18 613C kromo 81 01433873 CF patologis proximal femur d ec Post op 12/12 HA long stem cemented BPJS 12/11 hb 8,3 al 14,6 at 80 na 131 k 5,4 ca YOS RYN
susp MM post HA cemented Konsul khom + Open 1,05
Reduction + Skin traksi 7hr 5/12 hb 11.7 hct 34 leu 9.2 trom 167 pt
15.7 aptt 33.8 inr 1.300 na 134 k 4.3 cl
105 HbSa NR
Flb 9 19 901A Irfan fauzi 22 01439697 CF pelvis young burgess LC type 3 Ruptur Lien grade III 17/11 Post op 17/11 C-clamp Perawata bpjs B.digest 13/12 Hb 12.3 Hct 37 AL 9.8 AT 636 AE RDA BJ
dengan hemodinamik tidak stabil post laparotomi 11/12 ORIF n post op 4.04
post ORIF eksplorasi + splenektomi Ro pelvis 13/12 fraktur di ramus pubis
superior bilateral et inferior kiri dengan
terpasang internal fiksasi,aposisi dan
alignment cukup
20 901C Arip Yulyanto 28 01441003 OF lateral condyl femur D GA grade 30/11 Post op 30/11 Post Debridement + ORIF Usul UMU 12/12 Hb 12 Hct 37 al 9.2 AT 511 AE 3.96 RDA RVA
IIIA dengan bone loss 13/12 ORIF CF galeazi Poliklinis M Alb 3 Cr 0.7 Na 129 K 1.16
OF lateral condyle tibia D GA grade
IIIA dengan bone loss ro wrist joint ap/lat terpasang internal
Open degloving reg. Genu D fiksasi di 1/3 distal os radius kanan, garis
CF distal radius D extend to fraktur +, aposisi dan alignment baik
intraartikular (Galeazi variant)
Ruptur LCL knee D
ORTHOPAEDI, Sabtu 15 Desember 2018

RIS/GAS/CID/DON/YOS/RDA/LAZ/GIL/IBY/SAQ LHB/JRM/FID/ALF/JNA

21 904C Tarno 28 01441175 - OF tibia fibula S 1/3 distal grade Post laparatomi 2/12 Post op 2/12 Cock up splin hari ini blpl Perawata BPJS B.Digestif 10/12 Hb 12.8 Hct 38 AL 8,6 AT 247 AE RDA RVA
gustillo anderson IIIA post OREF eksplorasi ai. Peritonitis 11/12 n post op 3.93 AL 3.7 Cr 0.7 Na 131
- CF Humerus (D) 1/3 Distal dengan generalisata ec. TTA
butterfly fragment, dengan lesi hemodinamik tidak foto antebrachii ap/lat 12/12 : terpasang
n.Radialis high lession stabil ec laserasi hepar ORIF pada 1/3 tengah os radius et os ulna
kanan, garis fraktur + kalus formation +,
- CF Radius Ulna (D) 1/3 Tengah zone 7-8
aposisi dan alignment baik
Comminutive Type post ORIF
22 905E Suryadi 48 01441838 SCI Incomplete type Setinggi C5 7/12 Pre op MRI Cervical Ro umum 11/12 Hb 12.1 HCT 35 AL 8.8 AT 215 AE YOS RVA
Frankel C dynamic 4.06 AL 3.4 Cr 0.8
MRI
Ro cervical ap/lat : fr kompresi dan
listhesis (-) spondylosis servikalis,
paraservikal muscle spasm

23 906E sugiyarto 33 01442417 Close periprostetic fracture shaft 12/12 Pre op Imoblisasi dgn skin traksi BPJS 12/12 hb 12,6 al 11,0 at 281 pt 12,5 aptt RDA BJ
femur (D) post orif intercondyler ROI –re ORIF elektif 26,9 gds105 sgot 20 sgpt 26 ureum 20 cr
femur 0,8 na 20 k 3,8 cl 108

Ro femur ap/lat fr komplit pada 1/3

mediodistal os femur kanan dengan
fragmen fraktur distal contracted dan
displaced ke lateral
24 907A Yumrotul 34 01442046 - CF Clavicula (D) 1/3 Lateral Allman - Fraktur Costa 2.5.6.7 9/12 Pre op - imobilisasi distal radius BTKV Umum 12/12 Hb 9.5 hct 28 AL 8.3 AT 180 AE 3.19 YOS RYN
Group II (D) Postetior Simple dengan Long Arm Slab
- OF Distal Radius (D) Colles Type, - Fraktur Costar 3.4 (D) - Imobilisasi Clavicula
Frykman I, Gustillo-Anderson Grade Posterior Segmental dengan Armsling
II - EDH Temporal psot - ORIF elektif (join op
Craniotomi evakuasi BTKV)
(19/12/2018)
25 907B Rakum 68 01441097 Dislokasi Hip joint (S) post HA Anemia 30/11 Pre op Konsul interna susp MM. ct Bpjs 3 5/12 hb 8.7 hct 27 leu 9.6 trom 456 cr 0.8 RDA RVA
Bipolar scan 3d pelvis evaluasi ur 26
acetabulum 10/12 Alb 2.6 glob 3.2 protein total 5.8
26 907D Sumiyatun 49 01026887 CF Clavicula (S) 1/3 tengah Almann 15/12 Pre op Pain management BPJS 15/12 Hb 12.7 hct 37 AL 11.3 AT 383 AE RVA
group I Imobilisasi dengan arm 3.95 PT 13 APTT 28.8 GDS 99 Na 134 K 4.4
sling Cl 96 HbsAg nonreg
ORIF elektif dengan small
bone plate +
interfragmental screw
RO thorax
27 907E Teguh Yulianto 22 01442021 - CF Intercondyler Femur (D) 9/12 Post op 9/12 Distal femoral AMSA 7 BPJS 9/12 Hb 13 al 16,3 at 245 ae 4,04 pt 13 RDA RYN
Comminutive Type Extend to Shaft Pre op HOLE TANPA LOCKING aptt 25 gds 87 alb 4,6 cr 0,8 ur 41 na 135
- OF Phalang Distal Digiti I Pedis (D) jadwal rabu mingdep k 3,5 cl 101 hbsag nr
Comminutive Type dengan vascular
compromised, GA grade II
- OF Shaft Metatarsal I Pedis (D)

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 Comminutive Type, GA grade II
- OF Shaft Metatarsal IV dan V Pedis
(D) Oblique Type, GA grade II
28 908C Joko Prasetyo 39 01441190 FR kompresi VL I frankel E 2/12 Work Pro body jacket Ct scan BPJS 2/12 hb 14.7 hct 42 leu 10.1 trom 195 alb RDA RVA
up torakolu 4.3 na 134 k 4.1 cl 104 HbSag NR Cr 0.7 Ur
mbal + 3D 23
13/12 Hb 14/2 AL 4.3 AT 274 AE 4.72 Cr
0.8 Alb 4 Na 132 K 4.2 Cl 9.5
29 908D Slamet 70 01440971 CF intertrochanter femur S Hipertensi grade II 29/11 Post op 8/12 Orif elektif Work up BPJS urology 29/11 hb 11.6 hct 35 leu 12.1 trom 193 YOS RYN
Drop foot susp. Sciatic nerve palsy Riwayat DM tipe II Pindah bangsal diagnosis gol darah A HbSag NR
Post HA cemented 4/12 hb 12.1 hct 33 leu 12.1 trom 302 alb
Hematuri ec. Susp. Ca 3.1 CRP 16.30
buli 10/12 Hb 10.7 Hct 32 AL 16.1 AT 544 AE
3.36 Alb 3 Na 128 K 3.3 Cl 9.2
30 908 E Yono Nurjono 63 01438587 LST L3-4, L4-5, L5-S1 14/12 Pre op Dekompresi, PLIF + PSF BPJS LAB belum jadi (15/12) RVA
31 909C Intan 13 01441549 PBT r. distal femur S susp. Anemia 5/12 Perbaik Hip disartikulasi BPJS 9/12 Hb 8.9 Hct 29 AL 11 AT 494 AE 3.27 Rda BJ
Osteosarcoma an KU OT 30 PT 34 Cr 0.4 Ur 22
32 909E An Awan Kurnianto 10 01439309 PBT R Femur Dekstra proksimal 12/12 Ro pelvis BPJS 12/12 Hb 11.7 Hct 38 AL 7.1 AT 441 AE RYN
4.9 OT 23 PT 20 Cr 0.4 Alb 3.9 Ur 21 Na
136
33 910C An Muhammad 3 01442048 CF Shaft Femur (S) 1/3 tengah 9/12 Pre op Pro hemispecs tunggu Umum 9/12 hb 11,4 al 24 at 470 pt 13,8 aptt 29,4 LAZ RYN
Yusuf Winquis- Hansen I Oblique type jadwal cr 0,3 ur 31
Fo femur: fr komplit 1/3 tengah os femur
kiri cum contractionem cum
angulationem soft tissue swelling
34 910E An Naufal Isnan 1 01442049 CF supraconylar humerus (S) 9/12 post op BLPL senin hari ini medikasi Umum LAZ RYN
Aff drain
35 912B haryatno 52 01442251 CF Clavicula (S) 1/3 Tengah Allman Fr. Costae (S) 3,7,8 11/12 Pre op Pro ORIF clavicula join TS BPJS 10/12 hb 11,1 al 6,3 at 185 ae 3,64 pt LAZ
Grup I Posterior Simple BTKV 12,9 aptt 25,9 gds 80 cr 1,1 ur 40 na 132 k RYN
CF scapula (S) Zdravkovic and Fr. Costae (S) 4,5,6 4,3 cl 103
Damholt Type III Posterior Displaced ro scapula: fr komplit os scapula kiri
36 I Nursanti 23 01441824 - Lateral Flexion Fracture C4-5 Allen 6/12 Pre op MRI Cervical BPJS 11/12 hb 11.6 hct 37 al 8.4 at 236 ae 4.09 YOS RVA
ROI Ferguson Type II pt 12.7 aptt 25 gds 92 albumin 3.7 cr 0.5
- CF Phalanx Media Digiti III Manus ur 24 na 136 k 4.4 cl 102 hbsag non
(S) transverse type reaktif

MRI 13/12