REKAPITULASI PASIEN BEDAH PLASTIK RSUP HAM MEDAN

TANGGAL 13 FEBRUARI 2018

RB2A
N DPJP/ TGL MASUK TGL OPERASI
IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
O RUANGAN (HARI RAWATAN) (KETERANGAN)
13/12/2017 09/02/2018
Skin Avulsion o/t (R) Debridement Hb: 11,2
Leg + Post IVFD RL 14 gtt/i Leu: 11.790
dr. Emil,
Debridement + Post 09/01/2018 Cefadroxil syr 2x1 cth Plt: 351.000
Sp,BP-RE Rendi Saputra/ L/12 thn/ 28/11/2017
1. STSG + Post Debridement II Paracetamol 3x 250mg Albumin: 2.8
(3.2.4) 72.71.51
Contracture Release + konsul gizi anak KGDs: 155
Tendon Lengthening 16/01/2018 R/ STSG selasa Na/K/Cl: 132/2.8/98
a/i Contracture (R) STSG
Knee + Osteomyelitis

11/02/2018
IVFD Asering 20 gtt/i
Flame Burn Grade II- Hb: 10,7
Inj Ceftriaxone 1 gr/12 jam,
dr. Emil, III o/t face,bith hands, 02/02/2018 Leu:33.390
M. Dedi Anwar / L/ Inj Ranitidin 50 mg/12 jam
2. Sp.BP-RE both legs + 02/02/2018 Debridement Plt: 606.000
73.31.48 Inj Ketorolac 30 mg/8jam
(1.4.1) hipokalemia+ Albumin: 2.0
Koreksi Kalium
hipoalbumin KGDs: 81
Koreksi Albumin
BUN/Ur/Cr: 12/26/0,60
Na/K/Cl: 122/4,8/95
11/02/2018
Hb: 11,2
dr. Emil, Leu: 7.200
Fijai Saputra/L/22 02/02//2018
Sp.BP-RE (L) Corpus Mandible R/ X-ray panoramic jika Plt: 487.000
3 thn/73.29.40 02/02/2018 Wound Toilet +
(3.2.4) fracture pasien sudah transportable Albumin: 2.9
Primary Suture
KGDs: 70
BUN/Ur/Cr: 9/19/0,53
Na/K/Cl: 136/4.0/103
4 dr. Arya, Farwah (L) Parasymphisis 03/02/2018 IV RL 14 gtt/i 12/02/2018
Sp.BP-RE Halilah/L/19thn/73.31.9 Mandible Fracture Inj Ceftriaxone 1 gr/12 jam Hb: 12,2
(1.5.2) 9 Inj Ketorolac 30 mg/8 jam Leu: 7.820
Inj Ranitidin 50 mg/12 jam Plt: 341.000
Oral hygiene Albumin: 3,5

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 KGDs: 76
BUN/Ur/Cr: 11/24/0,74
R/ X-ray panoramic
Na/K/Cl: 135/4.4/105

RB2B
N DPJP/ TGL MASUK TGL OPERASI
IDENTITAS DIAGNOSIS TERAPI/RENCANA HASIL LAB
O RUANGAN (HARI RAWATAN) (KETERANGAN)
10/02/2018
Hb: 10,2
Leu: 14.760
Plt: 357.000
04/02/2018
07/02/2018
Zuraidah/P/62 Ca Mammae + Ulkus Na/K/Cl: 124/4,4/99
5 (3.6.2) (Konsul Bedah R/Rawat luka
thn/69.25.54 Dekubitus + Anemia
Plastik)

11/02/2018
Hb: 10,4
03/01/2018 Infus RL 20tpm Leu: 13.660
Post Flap
Flap + STSG Inj ceftriaxone 1 gram/12 jam Plt: 853.000
dr. LatisissmusDorsi +
(Rawat bersama Inj ketorolac 30 mg/8 jam Albumin: 3.0
UtamaSp.BP STSG a/i Wide
Elfina Soraya/P/44 28/12/2017 Onko dan BTKV) Inj ranitidin 50 mg/12 jam KGDs: 83
6. -RE Incision d/t
thn/72.48.68 Paracetamol 3x500 mg tab BUN/Ur/Cr: 5/11/0,48
(3.7.1) PhyloidesTumor
22/01/2018 Ganti balutan/2 hari Na/K/Cl: 135/4,4/104
Removal Sugg.
Repair flap asetilsistein 3x200 mg
Malignansi

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 11/02/2018
Hb: 10.0
Leu: 3.800
Open degloving (R) IVFD RL 20 gtt/i
20/01/2018 Plt: 213.000
dr. Emil, pedis + (R) metatarsal inj Ceftriaxon 1 gr/12 jam
Marliyah/P/56th/ ORIF metatarsal + Albumin: 2.3
7 Sp.BP-RE fracture + Post 20/01/2018 inj ranitidin 50 mg/12 jam
73.17.67 debridement + KGDs: 95
(2.5.3) debridement + Post inj ketorolac 30 mg/8 jam
primary suture BUN/Ur/Cr: 5/11/0,52
ORIF metatarsal Perawatan luka GV/ 3 hari
Na/K/Cl: 137/3,6/101

11/02/2018
Hb: 13,0
Leu: 8.060
Plt: 182.000
Cefadroxil 2x50 mg
Albumin: 3,9
dr. Emil, Mara Sutan Sinaloan Post ORIF a/i PCT 3x500 mg
KGDs: 79
8 Sp.BP-RE Siregar/ L/ 20 thn/ Parasymphisis 25/01/2018 Ranitidin 2x150 mg
BUN/Ur/Cr: 14/30/0,85
(3.5.5) 73.22.48 Mandible Fracture R/Foto Posisi Waters
Na/K/Cl: 139/4.0/104

RB3
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
11/02/2018
Hb: 12,8
18/01/2018 IVFD RL 14 tpm Leu: 9.600
Open (R) shaft tibia OREF tibia inj Ceftriaxon 1 gr/12 jam Plt: 556.000
Juanda
9. fibula fx type IIIb + 18/01/2018 inj ranitidin 50 mg/12 jam Albumin: 3,5
Dr. Frank, Putra/L/15th/72.97.13
close shaft femur fx (konsul dari 24/01/2018 inj ketorolac 30 mg/8 jam KGDs: 96
SP.BP-RE
orthopaedi) ORIF femur R/ soleus flap Rabu BUN/Ur/Cr: 12/26/0,51
(3.3.1)
Na/K/Cl: 136/4,0/105

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 12/02/2018
Hb: 12.2
IVFD Asering 20 tpm Leu: 9.490
dr. Utama, Flame burn grade IIB- Inj ceftriaxon 1 gr/12 jam Plt: 464.000
30/01/2018
10. SpBP-RE Nuriah/P/64th/73.26.78 IIA 38% o/t both arms, 30/01/2018 Inj ketorolac 30mg/8 jam Albumin: 2.4
(Debridement)
(3.5.3) abdomen, back, (R) Leg Inj ranitidin 50mg/12 jam KGDs: 93
R/Debridement hari ini BUN/Ur/Cr: 5/11/0,42
09/02/2018
Na/K/Cl: 135/3,4/101

Open degloving o/t (R) 12/02/2018

hand + Open 5th Hb: 9,8
Metacarpal (R) hand Leu: 9.800
fracture + Ruptur IVFD RL 14 tpm Plt: 610.000
dr. Frank, 31/01/2018
Armiden/L/72th/73.27.6 extensor digiti minimi Inj ceftriaxon 1 gr/12 jam Albumin: 2,8
11. SpBP-RE 31/01/2018 (Debridement +
6 tendon post debridement Inj ketorolac 30mg/8 jam KGDs: 60
(1.11) STSE)
+ STSG + post ORIF K- Inj ranitidin 50mg/12 jam BUN/Ur/Cr: 14/30/1.14
wire 5th Metacarpal + 06/02/2018
post Repair EDM Na/K/Cl: 137/3.9/106
tendon (R) hand

12/02/2018
Hb: 10.2
Leu: 11.920
Post debridement + IVFD RL 30 gtt/i Plt: 479.000
dr. Emil,
Hotmaida Sitorus/P/54 Marginal Eksisi a/I Inj Ceftriaxon 1 gr/12 jam Albumin: 2.7
12. Sp.BP-RE 02/02/2018
th/73.30.20 Open degloving o/t Inj Ketorolac 30 mg/8 jam KGDs: 94
(1.5.2)
forehead Inj Ranitidine 50 mg/12 jam BUN/Ur/Cr: 21/45/0.69
06/02/2018
Na/K/Cl: 135/3,9/103

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 07/02/2018
Hb: 13,6
Leu: 16.170
Plt: 476.000
dr. Emil, Sp. Contracture o/t digiti Release contracture R/ release contracture + skin Albumin: 3,7
Suan Tua Rambunan/L/9 06/02/2018 KGDs: 108
13. BP-RE 3,4,5 (L) Manus ec Burn + STSG graft
thn/ 73.12.35 Na/K/Cl: 141/4.4/103
(1.6.1) Injury (7/02/2018) (7/02/2018)
29/01/2018
BUN/Ur/Cr: 9/19/0.63

09/02/2018
Hb: 9.8
Leu: 9.860
Post debridement d/t Plt: 153.000
IVFD RL 30 gtt/i Albumin: 1.9
electrical burn 13% o/t
Apriyanto Pasaribu/L/21 Post Debridement Inj Ceftriaxone 1 gr/12 jam KGDs: 108
14. 1.9.1 both hands and legs +
thn/73.34.84 Post Fasciotomy Inj Ranitidin 50 mg/12 jam BUN/Ur/Cr: 7/15/0,44
Post fasciotomy d/t
Inj Ketorolac 30 mg/8 jam Na/K/Cl: 122/3,7/92
compartement syndrome

11/02/2018
Hb: 12.2
Leu: 11.880
dr. Utama, Plt: 496.000
Heru Pribadi/L/26 thn/ R/Foto panoramic
15 Sp.BP-RE Fraktur Mandibula 01/02/2018 Albumin: 3.3
73.29.50 (06/02/2018)
(2.2.2) KGDs: 119
BUN/Ur/Cr: 6/13/0,69
Na/K/Cl: 136/4.0/102

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 11/02/2018
Hb: 9.7
Dr. Emil, Electrical burn 1% o/t leuko: 13.440
Noprianto 11/02/2018 R/ Rawat luka dengan
16 Sp.BP-RE (L) hand post 11/02/2018 Plt: 217.000
Munthe/L/20th/73.38.51 debridement burnazine
(1.3.1) debridement BUN/Ur/Cr: 8/17/0,76
Na/K/Cl: 138/4,0/108
KGD: 128

HCU
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)

10/02/2018
Hb: 17,2
dr.Emil, Muhammad Flame burn grade II a-b leuko: 21.000
17 10/02/2018 11/02/1018
Sp.BP-RE Bilal/L/63th/73.38.31 + post debridement Plt: 258,000
BUN/Ur/Cr: 9/19/0,71
Na/K/Cl: 136/4,0/108
KGD: 106

ICU
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
12/02/2018
Hb: 23,6
Flame burn grade II-III leuko: 29,970
dr.Emil, Jonny Nasib
90% o/t face, chest, Plt: 217,000
18. Sp.BP-RE Parulian/L/42th/73.38.2 10/02/2018 11/02/2018
abdomen, back, BUN/Ur/Cr: 27/58/1,5
9
extremities Na/K/Cl: 140/5,5/110
KGD: 178
albumin: 1,8

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 RA4BS
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
19/01/2018
Hb: 11,7
leuko: 12.050
30/01/2018
RA4 BS Anak Zulfan/L/14 Segmental Mandibule R/Susul hasil CT-scan midface Plt: 312,000
19. (konsul ke
(Bed 1) thn/73.10.81 Fracture 3D (23/01/2018)
b.plastik)
Na/K/Cl: 133/4,5/99
(18/01/2018)
Albumin: 3,1

RA4
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
07/02/2018
Hb: 9,4
dr. Utama, Rusti 08/02/2018 Leu: 7.170
Ulkus diabetikum o/t R/ GV 3 hari dengan intrasid
20 Sp.BP-RE Sitorus/P/72 (konsul ke Plt: 327.000
buttock gel+ Bactigram tulle/ 3 hari
(2.2.4) thn/ 73.32.38 b.plastik) KGDs: 132
BUN/Ur/Cr: 6/13/0,34
Na/K/Cl: 139/2,8/103
07/02/2018
Hb: 6,6
Leu: 12.540
dr. Utama, 08/02/2108 R/rawat ulkus dengan madu per Plt: 318.000
M.Syafei/ L/73
21 Sp.BP-RE Ulkus decubitus grade IV (konsul ke 3 hari Alb: 2,1
thn/ 34.91.17
(2.3.3) b.plastik) Miring kanan kiri per 2 jam Ca: 8,90
05/02/2108
BUN/Ur/Cr: 8/17/0,5
Na/K/Cl: 120/2,6/77

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 04/02/2018
Hb: 15,2
Electrical burn 2% o/t (R)
04/02/2018 leuko: 17,490
dr.Arya, Sp.BP- Bayoangin/L/5 hand and (R) foot +
22 04/02/2018 (Debridement + Plt: 190,000
RE (BED 7) 2 thn/73.32.08 Traumatic ICH+ (L)
(Raber BS) Craniotomy) BUN/Ur/Cr: 7/15/2.0,45
Contusio frontal+ luka
Na/K/Cl: 132/3,5/100
bakar grade III
KGD: 134
albumin: 2.1

RA1
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
31/01/2018
Hb: 7.3
dr. Emil, SpBP- Skin Avulsion (R) foot d/t 01/02/2018 leuko: 8,350
Lina/P/28 30/01/2018
23 RE open (R) torsotarsal (konsul ke R/Rawat Luka Plt: 156.000
th/73.26.67 (Debridement)
(3.2.1) fracture type IIIA b.plastik) BUN/Ur/Cr: 9/19/0,74
Na/K/Cl: 129/3,4/104
KGD: 115

RB4 ANAK
TGL MASUK
N DPJP/ TGL OPERASI
IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
O RUANGAN (KETERANGAN)
RAWATAN)
18/01/2018
Hb: 7.3
dr. Emil, (R) Unilateral 28/01/2018
Nicholas/L/7 leuko: 7,400
24 SpBP- Labiognatopalatoschisis + (konsul ke R/ labioplasty
bln/71.24.22 Plt: 241.000
RE(3.3..4) Epilepsi + VSD b.plastik)
Na/K/Cl: 133/5/88
albumin: 3.7