BEDAH PLASTIK

MINGGU, 11 November 2018

FDH/RAH/ARV/MOW/ATH/ALF/IBY/IHI/INA/DRI
RUANG BED PJ DPJP NAMA U MRS DIAGNOSIS STATUS PLAN BIAYA LAB

I ALF AM M. Ari Nuryanto 13 9/11 Pre op Diet cair, oral hygiene, ORIF elektif Maxilla ( BPJS III 9/11 Hb 14.2 Ht 41 AL 19.8 AT 263 AE 5.03 Goldar AB PT 13.6 APTT 30.3
Fr. Maksila (S) adoption plate), INR 1.060 Cr 0.6 Ur 13 Na 140 K 5.2 Cl 1.21 HbsAg NR
Bedah Saraf
Bedah Saraf
COS Konservatif, Awasi KU/VS/GCS

GCS E3V4M6, EDH R. Frontobasal 8cc,

Pneumatocele R. Frontal (S), Fr. Basis Cranii

Fossa Anterior
G AM Yeti dwinda N 10/11 Pre op BPJS III 10/11 HB 12.1 HT 37 LEU 14.1 TRO 292 PT 14 APTT 27.2 GDS 127 UR 14
01438909 bedah syaraf Konservatif CR 0.6 NA135 k 4.6 cl 14 HBSAG NR
ROI
COB GCS E2V1 (ett) M4, difuse axonal injury,

oedema serebri, fr. basis cranii fosaa media

bedah plastic

fr. zygoma type tripod (S) , fr. arch zygoma, fr. Orif elektif rima orbita (orbital plate, zygoma
maxilla ( adoption plate)+ MMF arch barr,
rima orbita inferior, vulnus excoriasi R. facial vulnus rawat luka terbuka dengan moist

bedah ortho

fr. scapula sin MOBILE arm sling

A ALF AM Anis Putriani 17 7/11 Pre Op Diet Cair BPJS III 7/11 10.7 Ht 32 AL 15.9 AT 202 AE 3.42 Goldar B PT 13.4 APTT 27.9
01438605 Multiple Vulnus terhecting R. Facialis, Fr Maksila Oral Hygiene INR 1.040 Cr 0.4 Ur 9 Na 138 K 3.6 Cl 1.11 HbsAg NR
(D/S), Fr. Rima orbita inferior (D/S), Fr. Os ORIF Elektif (Adaptation plate + Orbital Plate)
Repair vulnus elektif
Nasal, Trauma Occuli Rawat vulnus excoriasi dengan moist

Bedah Saraf Bedah Saraf

COS GCS E2V4M5, Oedem Cerebri, Contusional Konservatif

hemorrhagic R. Frontal, Fr. Sinus Frontalis

Dinding anterior-posterior
C ALF AM AMFRAN ARIF 15 10/11 Pre op Diet cair, oral hygiene, ORIF ( plate screw, BPJS I 8/11 PT/ QPTT 14.7/ 30.3 INR 1.170 NA 137 K 4.5 CL 108 HBSAG NR
bedah plastic MMF)
multiple vulnus terhecting R. facial, fr. os

frontalis. fr. zmc , fr. os nasal

bedah syaraf
HCU
COS E3V4M5, oedem cerebri, pneumatocele

J AM AN. LATIVUL 13 10/11 Pre op Diet cair, oral hygiene. UMUM 10/11 HB 11.6 HT 34 LEU 20.8 TRO 282 PT/ APTT 12.7 33.1 UR/CR
FALLACH bedah plastic Orif elektif maksila ( adoption plate), rima 19/0.5 HBS AG NR
fr. tripod (s), fr maksila (s), fr. rima orbita orbia+mandibular plate+MMf (arch barr)

inferior (s), fr. segmental mandibulla 9 fr.

angulus mandibula (d)+ f. corpus mandibula)

bedah syaraf
MRS , konservatif
COR E4C4M6, oedem cerebri, fr.linear os

frontal, ICH R frontal

bedah ortho
 Pain management dan cito debridement + OREf
OF supracondylar femur (s) extend to

intraarticular GA IIIA post wound toilet, close

epyphisiolysis distal femur (S) SH IV, OF tibia

segmental GA IIIA post wound loitelt, CF angkle

(s) webber)
L ALF AM Shidiq Basofi R 24 5/11 Pre op Diet cair Umum III 8/11 Hb 9.3 Ht 28 AL 12.4 AT 241 AE 3.46
01438355 Fr. maksila (D), fr. rima orbita inferior (S), fr. Oral hygiene 6/11 Hb 10.2 Ht 31 AL 13.0 AT 204 AE 3.66 Alb 2.8 Na 133 K 4.5 Cl 1.09
maksila (S)+ fr. zygoma (S) ZMC (S), fr. Pro ORIF elektif (adaption plate+mandibulla 5/11 Cr 1.0 Ur 31 Hb 12.1 Ht 35 AL 10.9 AT 243 AE 4.24 Goldar AB PT
plate +arch barr) 13.2 APTT 26.5 INR 1.020 HbsAg NR
simfisis segmental mandibula, vulnus sudah Bedah Saraf
Konservatif
dijahit R Submandibula Awasi KU/VS/GCS/Lateralisasi
Bedah Saraf Bedah Digestif
COR GCS E4V5M6 Bedrest Total
Oedem Cerebri CT Scan Abdomen kontras
Bedah Digestif Cek DR3 serial /12jam
Trauma tumpul abdomen dengan hemodinamik stabil Awasi KU/VS/Tanda akut abdomen

7 ALF AM Poniman TS 79 8/11 Combustio ledakan gas grade II 33% Pre op Cito debridement BPJS III 8/11 Hb 14.8 Ht 43 AL 33.7 AT 326 AE 5.45 Goldar A PT 13.0 APTT 28.4
01438779 Susp trauma inhalasi Evaluasi laring durante OP INR 1.000 GDS 254 Alb 3.8 Cr 0.9 Ur 50 Na 136 K 3.4 Cl 105 HbsAg NR
Konsul BTKV untuk pemasangan CVP 8/11 Hb 13.1 Ht 39 AL 21.4 AT 195 AE 4.93 Alb 2.5 Na 133 K 4.0 Cl 109
Evaluasi produk urin dan CVP 9/11 Alb 3.1
ICU
Bedah TKV
Perbaiki KU
Nebulizer
Pasang CVC
5F INA AM Tiyasih 44 1/11 Post wound bed preparation ai necrotic wound R. Post op Perawatan Post op BPJS III 10/11 Hb 8.1 Ht 25 AL 10.6 AT 188 AE 3.01 Alb 2.0
01437802 Abdomen-Lumbal 9/11 Hb 9.6 Ht 30 AL 8.3 AT 145 AE 3.69 Alb 2.5
MEL 1 8/11 Hb 9.3 Ht 30 AL 10.3 AT 147 AE 3.51 PT 21.1 APTT 31 INR 1.900
GDS 145 SGOT 43 SGPT 16 Cr 0.4 Ur 66 Na 133 K 3.9 Cl 109 Alb 2.0
2/11 Hb 11.3 Ht 34 AL 27.1 AT 211 AE 4.02 Alb 2.8
610B ATH DE A.Haris Affandi 47 29/10 Maloklusi, Fr Rima orbita superior (D), Fr rima orbita Pre op Pro ORIF tunggu jadwal, tidak join op BPJS 7/11 Hb 10.9 Ht 33 AL 10.6 AT 361 AE 3.69
01437346 lateral (S), Fr Nasal, Fr maxilla (D/S), Fr arch 5/11 Hb 11.5 Ht 33 AL 8.0 AT 255 AE 4.03
zygoma (S) B. Saraf 4/11 Hb 9.4 Ht 26 AL 8.2 AT 221 AE 2.94 GDS 97 Alb 3.0 Cr 0.5 Ur 27
B. Saraf Konservatif Na 138 K 3.3 Cl 109
COR GCS E3V5M6 B. TKV 29/10 Hb 11.7 Ht 36 AL 14.4 AT 233 AE 4.08 Goldar B PT 14.0 APTT
Diffuse Axonal Injury Pro ORIF Costae Elektif 27.5 INR 1.100 GDS 146 Cr 0.7 Ur 30 Na 138 K 3.9 Cl 1.15 HbsAG NR
FLB 6 Fr. Linier Os Frontal B. Orthopaedi
SDH R Temporal Imobilisasi dengan U Slab
B. TKV ORIF Elektif
Fr. Costae III, IV, V (S) Posterior Simple Closed Reduction + Imobilisasi dengan Thumb
B. Orthopaedi Spica
CF Intercondylar Humerus (D)
CF Dislokasi CMC Joint Digiti I Manus (D)

702B Sumartini 39 8/11 Tumor mandibula (S) susp. maligna Pre op Konsul untuk rekonstruksi, tunggu jadwal BPJS III 6/11 Hb 11.8 Ht 37 AL 6.8 AT 278 AE 4.32 PT 14 APTT 28 INR 1.130
FLB 7 Pro Hemimandibulektomy operasi dari onko GDS 95 SGOT12 SGPT 6 Alb 4.0 Cr 0.6 Ur 17 Na 136 K 3.7 Ca 1.04 HbsAg
NR AntiHCV NR
901C ALF AM Arianjas 19 31/10 Post thick STSG regio colli , thin STSG regio Post op Perawatan post op BPJS III 7/11 Hb 9.9 Ht 31 AL 12.1 AT 229 AE 3.9 Alb 3.2
01435988 scrotum, femur (D/s), dorsum pedis (S) ai vulnus 6/11 Hb 11. 2 Ht 38 AL 9.2 AT 256 AE 4.00 Alb 3.1
granulosum regio colli , abdomen, scrotum, femur Medikasi tiap hari 5/11 Hb 10.6 Ht 33 AL 6.3 AT 233 AE 3.72CFDX
(D/S), dorsum pedis (D/ S) + bone expsosed 1/11 Hb 9.8 Ht 29 AL 7.6 AT 334 AE 3.28 Goldar O PT 13.0 APTT 26.7
INR 1.000 GDS 89 Alb 3.4 Cr 0.7 Ur 36 Na 136 4.3 Cl 102 HbsAg NR
902 C DRI DE Nofiani 32 4/11 Pre Op Rekonstruksi + ORIF Maxilla (D) Umum III 4/11 hb 10.9 ht 35 al 5.9 at 333 ae 5.52 gds 110 na/k/ cl 141/3.7/107
01437920 Fr. Maxilla (D), Fr Rima Orbita Lateral (D), Fr 1/11 Hb 10.8 Ht 32.4 AL 8 AT 290
Arch Zigoma (D) Bedah Saraf
Konservatif
 Awasi KU/VS/GCS/Lateralisasi
902D IBY AM Suminem 45 30/10 Post STSG +Post Wound Preparation ai necrotic Post Op Perawatan post op BPJS III 5/11 hb 12.0 ht 35 al 7.0 at 262 ae 3.91 pt/aptt 12.1/40.1 inr 0.910 gds
01436167 wound R Pedis (D) Post debridement + Jahit Primer 2/11 132 alb 3.9 na 137 k 4.2 cl 108
DPH 1 Post op 6/11 30/10 Hb 13.5 Ht 40 AL 10.0 AT 410 AE 4.71 Goldar O+ PT 12.6 APTT
28.0 INR 0.980 GDS 100 SGOT 18 SGPT 12 Cr 0.7 Ur 32 Na 134 K 4.7 Cl
109 HbsAg NR
902 E DRI AM Sunarni 66 6/11 Post Eksisional debridement + STSG ai Vulnus Post op Perawatan Post op BPJS III 8/11 hb 12.2 ht 38 leu 6.1 tro 263 ae 4.12 alb 3.8
01428463 Granulosum R. Calcaneus (S) 8/11 7/11 Hb 11.1 Ht 35 AT 262 Ur /Cr 22 / 0,7 alb 3.7 GDS 114
907 D IINA DE Emalia 14 8/11 Fraktur dentoalveolar Pre op ORIF ELEKTIF BPJS III 9/11 HB 13.3 HT 39 LEU 6.9 TRO AE 4.52 GDS 93 SGOT/PT 18/12 ALB
01436862 3.9 UR/CR 17/0.5 PT/APTT 12.7/ 29.4 INR 0.97
909D IBY DE Ria Ayu 20 17/10 Post stsg +Post Debridemen + NPWT + ai Open Pre op OK IGD Evaluasi dan medikasi STSG Umum 9/11 Hb 11.4 Ht 35 AL 10.7 AT 500 AE 4.05 Alb 3.3
01436115 degloving+skin and soft tissue loss 6/11 Hb 6.7 Ht 21 AL 5.5 AT 360 AE 2.47 Alb 2.5
Post Op 5/11 hb 11.2 ht 35 al 5.2 at 441 ae 4.06 PT/apt 13.9/ 27.7 gds 92 alb 3.3
30/10 ur/ cr 9/ 0.3 na 135 k 4.5 cl 102
17/10 29/10 Hb 11.0 Ht 33 AL 7.6 AT 534 AE 3.84
5/11 28/10 Hb 8.9 Ht 27 AL 6.3 AT 641 AE 3.17 GDS 108 Alb 3.2 Na 136 K
4.3 Cl 101
21/10 Hb 10.7 Ht 32 Leu 7.6 Trombo 356 Eri 3.69
18/10 Hb 8.4 Ht 26 Leu 8.7 Trombo 194 Eri 2.70 Alb 2.9
16/10 hb 8 al 7,8 at 133 pt 15 aptt 29,1 inr 1,2 gds 93 cr 0,5 ur 13
910B IHI DE Achmad Romadlon 16 4/11 Pre Op Pro Eksisi BPJS III 8/11 Hb 14.3 Ht 44 AL 9.2 AT 271 AE 5.09 Goldar O+ PT 14.2 APTT 33.1
01296919 Neurofibroma R. Facial INR 1.140 GDS 61 SGOT 20 SGPT 19 Alb 4.2 Cr 0.7 Ur 25 Na 140 K 4.7
Cl 113 HbsAg NR
29/10 hn 13.9 ht 41 al 11.1 at 308 ae 4.91 pt/apt 13.0 / 31.3 INR 1.GDS
89 alb 4.5 ur/cr 21/1.0 na/k/cl 137/3.9/109
910C DAN DE Inara Zahra Z 1 24/10 Umum 5/11 hb 14.8 ht 47 al 16.4 at 457 ae 5.98 alb 2.8 na/k/cl 133/4.7 /108
01436917 Post debridement ai Combustio Kuah Bakso 40% Post op Medikasi, rawat luka dengan burnazin plus + 1/11 hb 8.7 ht 27 leu 15.6 tro 536 ae 3.15 pt/aptt 12.9/ 21.5 INR 0.99
DPH 5 2/11 mebo GDS 100 alb 2.7 ur/cr 16/0.2 na/k/cl 136/3.2 101
5/11 26/10 Hb 10,0 Ht 30 Al 4,8 At 204 AE 3.55 GDS 97 SGOT 31 SGPT 14
Alb 2.7 Ur 10 Cr 0.3 Na 137 K 3.5 Cl 106
24/10 Hb 11.9 Ht 36 AL 8.7 AT 346 AE 4.20 Goldar B PT 12.9 APTT 29.7
INR 0.990 GDS 91 Cr 0.3 Ur 22 Na 135 K 4.8 Cl 103 HbsAg NR Alb 4.0
911D DRI AM Annisa Afna S 11 6/11 Post op Perawatan post op BPJS III 7/11 Hb 10.2 Ht 32 AL 9.2 AT 257 AE 4.22 Goldar A+ PT 12.8 APTT 24.6
01423959 bln Post palatoplasty ai Post labioplasty ai 9/11 INR 1.000 GDS 104 Alb 4.5 Cr 0.3 Ur 26 Na 137 K 5.0 Cl 113 HbsAg NR
labiognatoplatoschizis unilateral dextra komplit 5/7/2018 Hhb 10.8 Ht 34 al 9 at 288 ae 4.40 A+ PT 12.5 APTT 30.9 INR
0.900 Alb 4.4 Cr 0.3 Ur 30 Na 133 K 5.5 Cl 108 HbsAg NR
non syndrome
911E INA DE Zalfa Muzaid D 10 5/11 Post op Perawatan post op BPJS 6/11 hb 13.9 ht 41 al 7 tro 130 ae 5.22 pt 14.2 aptt 35.1 INR 1.140 GDS
01436592 Post Eksisi hemangiom 9/11 71 sgot/pt 32/16 alb 4.1 cre 0.4 ur 15 na 134 k 4.1 cl 112 hbsAg NR

1010A IHI AM Irawan 27 6/11 Fr. Arch zygoma (D), fr. Maksila (D), Pre op Oral hygiene BPJS 9/11 Hb 9.7 Ht 29 AL 8.8 AT 201 AE 3.28
01438349 Bedah Saraf Diet cair 6/11 Hb 7.5 Ht 22 AL 14.1 AT 223 AE 2.51
COR GCS E3V5M6 ORIF Elektif (Adaption Plate) + Repair Vulnus 5/11 hb 10.1 ht 29 al 18.7 at 241 ae 3.33 pt 13.8 aptt 28.3 inr 1.208 alb
Discontinuitas posterior wallsinus frontalis Bedah Saraf 3.5 ur 47 cr 1.0 na 132 k 3.8 cl 107 hbsag NR
Pneumatocel R. Frontal Konservatif
Contisuon Awasi KU/VS/GCS/Lateralisasi
al Hemoragik R. Frontal (D) Orthopaedi
Oedema Cerebri Paint management
Orthopaedi Cito debridement+ORIF Femur (Broad Plate) +
OF Shaft Femur (D) 1/3 Tengah, transverse type ORIF Lateral Condyle (Screwing+washer)
FLB 10
nondisplaced, GA grade II
CF Lateral Condyle Femur (D) Nondisplaced dengan
Hemarthrosis Knee (D)
1010 B ALF DE Lina Jumiati 21 2/11 Fr. Angulus mandibulla (D), fraktur maksila (D/S), Pro rekonstruksi dan ORIF BPJS 5/11 HB 10.8 HT 33 LA 7.7 AT 206 AE 3.69
01438027 fraktur rima orbita inferio (D) Pre op 3/11 hb 8.9 ht 27 al 10.5 at 252 ae 3.05
2/11 Hb 11.9 Ht 34 AL 13.7 AT 270 AE 3.79 PT 16.4 APTT 31.0 INR 1.340
MRSA POSITIF GDS 114 Cr 0.5 Ur 29 Na 142 K 3.4 Cl 112 HbsAg NR

1011B INA DE Syahrico Febrian P 17 31/10 Pre op PRO REKONSTRUKSI mandibula +MMF Umum III 8/11 Hb 12.9 Ht 38 AL 14.8 AT 393 AE 4.17
01437738 CF Angulus (D/S) Mandibula 6/11 hb 10.8 ht 33 al 12.5 at 298 ae 3.54 pt 14.1 aptt 27.0 inr 1.100 gds
Bedah Saraf Bedah Saraf 102 alb 3.8 cre 0.8 ur 26 na131 k49.9 cl161 hbsah NR
 Craniotomy Evakuasi EDH 3/11 hb 10.5 ht 30 leu 9.5 at 163 ae 3.31
EDH R Temporoparietal (S) Bedah Orthopaedi 2/11 Hb 8.1 Ht 26 AL 8.4 AT 148 AE 2.77
Bedah Orthopaedi Skin Traksi Femur (D) beban 5kg 31/10 Hb 8.3 Ht 26 AL 9.3 AT 130 AE 2.70 GDS 107 Alb 2.7 Na 140 K
CF Shaft Femur (D) 1/3 Tengah oblique displaced ORIF Femur Elektif + Evakuasi knee ligament 4.4 Cl 109
injury
WH tipe II Tunggu acc bedah saraf

Hemartrosis Knee (D) Ligamen Injury

1011E ALF DE Silah 44 30/10 Fr. Maksila (D), Fr. Rima Orbita Lateral (D), Fr. Rima Pre op Pro ORIF Rekonstruksi tunggu jadwal BPJS 3/11 hb 11.5 ht 34 al 6.4 at 104 ae 3.92
01437629 Orbita Inferior Konsul TS Mata, jawaban : tidak ACC raber. 1/11 Hb 8.7 Ht 26 AL 6.3 AT 74 AE 3.06
B. Orthopaedi tunggu acc bedah saraf 31/ 10 Hb 7.2 Ht 21 AL 12.6 AT 59 AE 2.46 GDS 114 Alb 1.7 Cr 0.5 Ur
CF Clavicula (D) 1/3 tengah Allman Group I 23 Na 140 K 3.8 Cl 110
B. Saraf B. Orthopaedi 31/10 Hb 7.5, Ht 22, AL 10.6 AT 79 AE 2.57 GDS 132 Alb 2.0 Na 136 K
Cidera Otak Sedang GCS E 2 V2 M5 Imobilisasi Arm Sling 3.4 Cl 110
EDH R. Parietotemporobasal (D) Pain management 30/10 Hb 10.5 Ht 32 AL 7.4 AT 144 AE 3.39 PT 12.2 APTT 27.3 INR
Fr. Linier Temporal (D) ORIF Elektif 0.930 GDS 99 Cr 0.5 Ur 16 Na 134 K 4.4 Cl 105 HbsAg R
EDH R. Temporal (S) B. Saraf
Hemiparese (S) Craniotomy evakuasi EDH
1013 C ALF DE Sri Wahyudi 41 3/11 Maloklusi, Fr. Maxilla (D/S), Fr. Rima Orbita Pre Op Diet cair BPJS III 3/11 Hb 12.5 Ht 37 AL 16.9 AT 237 GDS 142 Ur 29 Cr 0.8 Na 141 K 2.9
01438096 Inferior (S) Oral hygiene
Bedah Saraf ORIF Elektif
COS GCS E3V2M5 Bedah Saraf
Oedem Cerebri Awasi KU/VS/GCS/Lateralisasi
B. Orthopaedi B. Orthopaedi
CF Patella (S) lower pole Konservatif dan imobilisasi