LOG BOOK TRAUMA IGD JULI 2018

RANAP
/
NO TANGGAL MEDREC NAMA UMUR DIAGNOSA MANAJEMEN STATUS DPJP
BLPL/P
P
Analgetic, antibiotic, tetanus prophylaxis
Oral surgery department:
Performed : closed reduction and
Closed fracture at left inferior orbita
fixation with interdental wiring
Open fracture of right parasymphisis mandible
Orthopaedic and traumatology department:
Open fracture of right radius distal third
Performed :
comminutive displaced Gustilo Anderson
Debridement, suturing,
grade IIIA
immobilization with
Open fracture of right ulna distal third
Tn. Rustandi anterior slab for right
1. 1 Juli 2018 4108 23 comminutive displaced Gustilo anderson UMUM PP WA
forearm
grade IIIA
Immobilization with skin
Closed fracture of right patella comminutive
traction for right thigh
displaced AO classification 3.4.C.3
ORIF P/S electively for right
Closed fracture at right femur middle third
radius & ulna
comminutive displaced Winquist Hansen type
CRIF interlocking nail
I Tscherne grade 0
electively for right femur
ORIF cerclage wire for
patella fracture
Analgetic, antibiotic
Performed:
Open tuft fracture at right little finger Swanson Debridement
An.Ananad
2. 1 Juli 2018 4117 5 Szabo type I Primary suture UMUM PP WA
a
Nail bed injury Repair nail bed
Trephanation
Protection alone
Analgetic
Performed :
Closed fracture at left intertrochanteric femur
3. 1 Julii 2018 4118 Tn. Tasman 52 Immobilization with skin traction BPJS OK WA
Evans unstable
Plan to :
CRIF with cephalomedullary nail
Analgetic
Foreign body at dorsoulna side of the left Plan to:
4. 1 Juli 2018 3519 An.Denys 11 th UMUM PP WA
forearm Exploration
Extirpation
 Analgetic, antibiotic dan Tetanus
prophylaxis
Plan to :
Debridement
Exploration
Joint sanning external fixation at
Open fracture dislocation at left knee operating theatre
Kennedy Type IV Further investigation with CT Scan
Open fracture at left proximal tibia AO Open reduction and internal fixation
2 Juli 2018
5. 4517 Tn.komar 24 41C3 Gustilo Anderson Grade IIIA with plate and screw electively for BPJS OK GU
Open fracture at left patella femur and tibia fracture
comminutive displaced AO 34C3 Conservative treatment for malunion
Malunion fracture at right clavicle fracture clavicle
But the patient refused due to
financial problem
Performed :
Debridement
Primary suture
Immobilization with wood splint
Closed fracture at left tibia middle
Analgesic
third spiral displaced Tscherne grade 0
2 Juli 2018 Performed
6. 4512 An. yuliani 14 Closed fracture at left fibula proximal BPJS OK GU
Closed reduction and immobilization
third oblique displaced Tscherne grade
with long leg cast
0
Analgetic, antibiotic and tetanus
Open fracture at left tibia proximal prophylaxis
third comminutive displaced Gustilo Plan to
2 Juli 2018 Anderson Grade IIIB Debridement
7. 4518 Tn.Budi 28 UMUM PP GU
Open farcture at left fibula proximal Open reduction and external fixation
third comminutive displaced Gustilo at operating theathre for tibial
Anderson grade IIIB fracture
Open wound care
Analgetic
Closed fragility fracture at right
Vitamin D supplementation
8. 2 Juli 2018 3878 Ny.Nirwati 85 proximal humerus comminutive BPJS BLPL GU
displaced NEER 4 parts
Performed
Immobilization with abduction splint
 Plan to :
Further investigation with CT-Scan and
DEXA examination
Hemiarthroplasty electively for
proximal humerus fracture
Closed fracture at right superior pubic
rami segmental displaced
Closed farcture at right inferior pubic
Analgetic
2 Juli 2018 rami segmental displaced
9. 4534 Tn.Suwito 64 Performed : UMUM PP
Closed farcture at left superior pubic
Consevative Treatment GU
rami transverse displaced
Closed fracture at left superior pubic
rami segmental displaced
Analgetic
Plan to :
2 Juli 2018
Reccurent anterior dislocation at right Closed reduction under general
10. 4541 Tn. Ishtar 26 UMUM BLPL
shoulder anestesia GU
Immobilization with sling swathe
Further investigation with MRI
Analgetic
Plan to :
Immobilization with above elbow cast
Closed fracture at left distal end radius
for distal end radius fracture
Frykman type II incomplete
11. 3 Juli 2018 4540 tn.Dadan 43
Closed fracture at base metacarpal I of left
Immobilization with thumb spica cast BPJS KMG 2 MN
for metacarpal fracture
hand incomplete
But patient refused
Performed :
Immobilization with wood splint
Analgetic, Bisphosphonate, Vitamin D, and
Calcium
Performed :
Closed fracture at left neck femur Garden Immobilization with skin traction
12. 3 Juli 2018 4724 Ny.Aah 70 type IV Plan to : - - MN
Suspect Osteoporosis Further investigation with DEXA
examination for osteoporosis
Bipolar hemiarthoplasty for neck
femur fracture electively
 Analgetic, antibiotic, tetanus prophylactic
Internal medicine department
Performed:
Blood transfusion
Iron supplementation
Orthopaedic and Traumatology department
Plan to:
Open reduction internal
Posterior dislocation of the right hip joint with
fixation with screwing and
closed fracture of right head femur Pipkin
immobilization with skeletal
classification type IV
traction for posterior hip
Open fracture at right tibia middle third spiral
dislocation and head femur
displaced Gustillo Anderson grade IIIA
13. 3 Juli 2018 4851 Ny. Besthy 21
Closed fracture at right fibula middle third
fracture BPJS BLPL MN
Open reduction internal
comminutive displaced Tscherne grade I
fixation with plate and screw
Closed fracture at left tibia middle third
for acetabular fracture
comminutive displaced Tscherne grade I
Debridement, primary
Iron deficiency anemia
suture, immobilization with
posterior slab and CRIF with
interlocking nail electively
for right tibia fracture
Immobilization with
posterior slab and CRIF with
interlocking nail electively
for left tibia fracture
• Open fracture at base proximal
nd
phalang oblique displaced of 2
toe oblique displaced GA grade II. Analgetic, antibiotic, tetanus prophylaxis
• Open fracture at head proximal Plan to :
rd Debridement, ORIF K-wire, repair
phalang of 3 toe chipping. tendon and muscle, immobilization
• Lacerated wound at left foot dorsal with boot slab at operating theatre
aspect with total rupture: But the patient refused due to financial
14. 5033 Mr.Engkus 60 Extensor hallucis longus tendon BPJS RANAP HH
4 Juli 2018 problem
Extensor hallucis brevis tendon Performed :
Extensor digitorum longus tendon of Debridement, repair tendon, repair
nd rd
2 and 3 toes muscle,
• Lacerated wound at right leg Immobilization with boot slab in
anteromedial aspect with partial emergency ward
rupture of extensor digitorum
longus muscle
 Analgetic, antibiotic
• Closed fracture at right distal end Plan to :
radius Fryckman type III Tscherne Debridementand and suturing for
grade I lacerated wound at right hand
• Lacerated wound at right hand ORIF with screwing for distal end
palmar aspect radius fracture
15. 4 Juli 2018 5270 Mr.Usman 36 • Lacerated wound at right middle But the patient refused due to financial UMUM BLPL HH
finger volar and dorsal aspect problem
• Excoriated wound at right index and Performed :
ring finger dorsal aspect Debridement and and suturing for
• Hook nail deformity at right index lacerated wound at right hand
finger Immobilization with long arm cast
for distal end radius fracture.
Analgetic, antibiotic, tetanus prophylaxis
Plan to :
Debridement and FTSG at operating
theatre
Fingertip injury at left ring finger Allen
16. 4 Juli 2018 5279 Mr.Nanang 33 But the patient refused due to financial UMUM OK HH
classification type II
problem
Performed :
Debridement and FTSG at
emergency ward
Analgetic, antibiotik and tetanus prophylactic
Plan to :
Sharp wound at right ring finger Flexor zone I Debridement
with total rupture of FDP tendon with Exploration Repair Tendon
5 Juli 2018 laceration at A4 Pulley Repair Pulley
17. 5566 Tn.Ujang 17 UMUM RANAP AP
Sharp wound at right little finger flexor zone I Immobilization with dorsal block splint
with total rupture of FDP tendon with But patient ask to transfer to other hospital
laceration at A4 Pulley Performed :
Wound cleansing
Moist gauze dressing
Gangrene at left thumb
Open fracture at left lunate with bone loss
Open fracture at left schapoid with bone loss
Open fracture at left hamate
5 Juli 2018 Open fracture at left capitate with bone loss Management
Open fracture at left trapezoid with bone loss Analgetic, antibiotic, tetanus prophylactic
18. 95630 tn.sar,an 52 BPJS OK AP
Open fracture at left trapezium with bone loss Plan to :
st Transtibial Amputation
Open fracture at left base 1 metacarpal
oblique displaced with bone loss
nd
Open fracture at left 2 metacarpal
comminutive displaced
 Total rupture palmaris longus tendon
Total rupture FDS tendon
Total rupture FCR tendon
Total rupture FPL tendon
Total rupture FDP tendon
Total rupture APL tendon
Total rupture EPL tendon
Total rupture EPB tendon
Total rupture superficial branch radial nerve
Total rupture ulnar nerve
Total rupture median nerve
Total rupture at radial and ulnar artery
Analgetic, antibiotic, tetanus prophylaxis
Internal medicine department
Plan to :
Right Diabetic foot Wagner classification type Blood glucose regulation
3 Hemodialysis
Left diabetic foot Wagner classification type 1 Septic culture
19 95582 Tn.Dayat 56
Orthopaedic and Traumatology Department
UMUM OK AP
CHF functional class 4
5 Juli 2018 Plan to :
Nefropathy diabetic
Metabolic Acidosis Debridement
But patient rfused for surgical treatment
Performed :
Open wound care
Analgetic, antibiotic and tetanus prophylaxis
Plan to :
Debridement
Open tuft fracture at distal phalang of right Repair nail bed
5 Juli 2018 thumb transverse displaced Swanson Szabo Artificial Nail insertion in operating theatre
20. 95631 Tn.Fajar 21 BPJS BLPL AP
type 2 with nail bed injury, nail plate injury and But patient refused due to financial problem
partial nail plate loss Performed :
Debridement
Repair nail bed
Artificial nail insertion in operating theatre
Analgetic, antibiotic
Performed :
5 Juli 2018 Open fracture at right ulna middle third Debridement
oblique displaced Gustilo Anderson grade II Immobilization with posterior slab
21. 5646 Boy arif 10 UMUM RANAP AP
Closed fracture at right radius middle third Plan to :
transverse displaced Tscherne grade I CRIF with elastic nail
Immobilization with above elbow cast
electively
 Analgetic
Radiculopathy at level C6 due to traumatic Performed :
Ny.Aestining
22. 5 Juli 2018 5638 39 cervical spondilolistesis due to unilateral Immobilization with hard collar brace Umum RANAP AP
rum
fracture facet joint dislocation at level C6-C7 Plan to :
Further investigation with MRI
Analgetic
Vitamin D and calcium administration
Bisphophonate administration
Closed fragility fracture at left Performed:
6 Juli 2018
23. 6934 Ny.Ratmah 82 intertrochanter femur Evans unstable Immmobilization with skin Umum RANAP NN
Suspect osteoporosis traction
Plan to:
CRIF with cephalomedullary
nailing electively
Analgetic
Vitamin D and calcium administration
Bisphophonate administration
Closed fragility fracture at right neck Performed:
6 Juli 2018
24. 96000 Ny.Nastiani 67 femur Garden classification type IV Immmobilization with skin Umum PP NN
Suspect osteoporosis traction
Plan to:
Bipolar hemohip arthroplasty
electively

Fingertip injury at left ring finger Allen Debridement

25. 6 Juli 2018 20487 Tn.Rachmat 33 UMUM BLPL NN
type II Open wound care

Analgetic

Performed:
Closed fracture at right femur middle 3rd
7 Juli 2018 Transverse Displaced Winquist Hansen type Immobilization with skin traction
IV grade 0
26. 20609 Boy Difai 13 UMUM BLPL GT
Plan to :

CRIF with Plate and Screw

 Analgetic
Performed :
8 Juli 2018 Closed recurrent anterior dislocation of Closed reduction and immobilization
27. 4510 Luthfi 22 UMUM RANAP AK
right glenohumeral joint with sling and swathe
Plant to :
Further investigation with MRI
Oxygenation
Analgetic, antibiotic
Neurosurgery Department :
Performed : Conservative treatment
Mild Head Injury Plastic surgery Department :
Closed fracture at right acetabulum Judet- Plan to : Debridement and suturing
Letournel classification transverse and for lacerated wound
posterior wall type Orthopaedic and Traumatology Department :
8 Juli 2018 Tn.Ahmad
28. 3746 26 Closed fracture at right tibial spine Meyers- Plan to : UMUM PP AK
Fajar
McKeever classification type II Immobilization with skin traction
Lacerated wound at right superior palpabrae Further investigation with CT-scan
Multiple excoriated wound at right knee for acetabular and tibial spine
anterior aspect fracture
ORIF p/s for acetabular fracture
electively
CRIF screwing per arthroscopy for
tibial spine fracture electively
Analgetic, antibiotic, tetanus prophylaxis
rd Plan to :
Open fracture at right tibia distal 3
Debridement, suturing and
comminutived displaced Gustilo Anderson
immobilization with posterior splint
classification grade IIIA
8 Juli 2018 rd ORIF p/s for tibia and fibula fracture
29. 6141 M. As’Ad 22 Closed fracture at right fibula distal 3 electively UMUM PP AK
comminutived displaced Tscherne grade I No treatment for osteochondroma
Suspect syndesmotic injury *but patient refused due to financial problem
Osteochondroma at right proximal tibia Performed :
medial aspect Debridement, suturing and
immobilization with wood splint
Analgetic, antibiotic, tetanus prophylaxis
24 Performed :
30. 9 Juli 2018 6540 Tn.M Rizal Traumatic amputation at right forearm UMUM RANAP DM
Debridement
Transhumeral amputation
 Analgetic
Plan to :
Immobilization with posterior splint
Further investigation with CT-Scan
Tn.Waller Closed fracture of the right distal end radius ORIF P/S electively for radius and
31. 9 Juli 2018 6609 55 UMUM OK DM
Frykman type VII with DRUJ disruption ulnar fracture
CRIF with transfixing wire
But the patient refused all medical advise
Performed :
Immobilization with wood splint

Analgetic
rd
Closed fracture at left humerus middle 3 Performed:
32. 10 Juli 2018 16 transverse displaced Tscherne grade 0 without Immobilization with U slab UMUM PP HNR
96957 Tn.Rizky
neurological deficit Plan to:
CRIF intramedullary nail

• Closed fracture at right fibula middle

3rd oblique displaced Tscherne
10 Juli 2018 grade I Analgetic
33. 20852 Tn.Ujang 28 UMUM PP HNR
• Closed fracture at left fibula middle PRICE
3rd comminutive displaced
Tscherne grade I
Analgetic
Blood transfusion
Performed:
Neglected closed pathological fracture at left
Immobilization with skin traction
subtrochanter femur Russer taylor IIB suspect
34. 10 Juli 2018 6955 tn.Ahan 37 Plan to: UMUM RANAP HNR
primary bone tumor
Anemia Core biopsy
Further investigation with bone
scan
CRIF cephalomedullary nail
 11 Juli Analgetic
2018 20933 Neurosurgery Department
35. An. Reyhan 9 Mild Head Injury Performed : Conservative treatment BPJS PP GU
Right Skull Base Fracture Orthopaedic and Traumatology Departement
• Closed right ankle injury Dias Plant to : Immobilization with long
Tachdjian classification leg cast
supination inversion grade II But the patient refused due to financial
problem
Performed : Immobilization with
wood splint
• Closed fracture at right patella
transverse displaced
11 Juli • Malunion fracture at right tibial Analgetic
37. 2018 7317 Tn.Eman 65 plateau Performed: immobilization with kocher slab BPJS ANAP GU
• Malunion fracture at right proximal Plan to: ORIF with TBW electively
fibula
• Hemarthrosis at right knee joint
Analgetic, antibiotic and tetanus prophylactic
Plan to: debridement and VY flap at operating
11 Juli theatre
• Fingertip injury at leftindex finger
38. 2018 1052 An.Jaeni 11
Allen classification type III
But the patient refused due to financial UMUM PP GU
problem
Performed: debridement and VY flap
at emergency ward

Analgetic
Closed fracture at right distal 3rd tibia Immobilization with posterior splint
39. 97655 Ny Euis 52 BPJS RANAP
comminuted displaced Tscherne grade I ORIF P/S electively for tibial plateu and distal YY
12 Juli
tibial fracture
2018

Analgetic
Closed fracture at right calcaneus essex Immobilization with boot splint
40. 2717 Tn.Asep, 36 UMUM PP
12 Juli lopsresti tounge type Further investigation with ct scan YY
ORIF p/s electively
2018

12 Juli Open fracture of head proximal phalang of

Analgetic, antibiotic, tetanus prohylactic
2018 the right index finger Swanson Szabo type 2
41. 7658 TnMelandi 18 Plan to : BPJS BLPL YY
Traumatic amputation at level proximal
Debridement
phalang of the right middle finger
 Traumatic amputation at level middle phalang Repair stump for middle and ring
of the right ring finger finger
Orif K-Wire for index finger and
middle finger fractures
Analgetic, antibiotic, tetanus prohylactic
Skin Avulsion at right little finger
Plan to :
Open fracture of head proximal phalang of
Debridement + abdominal flap for
the right index finger Swanson Szabo type 2
12 Juli right little finger
42 7657 Tn. Morgan 40 Traumatic amputation at level proximal UMUM RANAP YY
2018 Debridement + primary suture for
phalang of the right middle finger
right ring finger
Traumatic amputation at level middle phalang
Conservative treatment for chipping
of the right ring finger
fractures
Analgetic, antibiotic, tetanus
prophylaxis
13 Julii Ny.Dea Lacerated wound at distal phalang
43. 7864 27 Performed : UMUM PP AR
2018 right index finger volar aspect
Debridement
Primary suture
Analgetic, antibiotic, tetanus
prophylaxis
Performed :
Debridement, exploration
Repair tendon
Lacerated wound at right hand flexor Repair artery
zone II extend to flexor zone IV with Repair muscle
avulsion tendon rupture of 1st FDS Primary suture
13 Julii muscle Immobilization with posterior splint
44 7944 Boy Ardi 11 UMUM PP AR
2018 Total rupture of superficial palmar Intraoperative Finding :
arch artery Avulsion total rupture 1st FDS muscle
Partial rupture of 1st Lumbrical Total rupture of :
muscle Superficial palmar arch artery
1st lumbrical uscle
Loss of recurrent (motor)branch of
median nerve
Partial rupture of adductor pollicis
muscle
 • Analgetic, antibiotic, tetanus
• Lacerated wound at right middle
prophylactic
finger extensor zone 2 with partial
• Performed:
rupture of central slip
• Debridement
• Open fracture at shaft middle
• Central slip
phalang of the right ring finger
repair and
comminutive displaced Swanson
suturing for
14 Julii Szabo type 2 with vascular
45. 21240 Tn.Yudi 23
compromised with total rupture
middle finger UMUM RANAP WA
2018 • ORIF cross wire,
dorsal digital artery and nerve
exploration,
ulnar aspect, total rupture central
artery and
slip, lateral band, proper palmar
tendon repair
digital artery ulnar side and nerve
for ring finger
• Fingertip injury at right little finger
• V-Y flap for
Allen classification type IV
little finger

• Analgetic, antibiotic and tetanus

14 Juli Finger tip injury at left little finger Allen
46. 7791 Tn. Ikin’ 22 prophylactic. Performed: UMUJM PP WA
2018 classfication type IV
• Debridement and primary closure

Analgetic, antibiotic, tetanus

Open Lisfranc injury at right foot prophylaxis
Myerson classification type B II
Plan to
Open fracture dislocation of the level
of right great toe with total rupture of Debridement
proper dorsal digital artery
ORIF K-Wire
Open fracture of the right medial
cuneiform oblique undisplaced Gustilo
15 Juli Immobilization with boot splint
47. 11273 Tn Rizal 58 Anderson grade IIIA UMUM PP RP
2018
20thn But the patient refused due to
Open fracture of the shaft 2nd
metatarsal of the right foot Gustilo financial problem
Anderson grade IIIA
Performed
Open fracture of the shaft proximal
phalang of the 2nd toe transverse Debridement
displaced Gustilo Anderson grade IIIA
Suturing
 Open fracture of the shaft proximal Immobilization with boot splint
phalang of the 3rd toe comminutive
displaced Gustilo Anderson grade IIIA

Open fracture of the shaft distal

phalang of the 4th toe transverse
displaced Gustilo Anderson grade IIIA

Open fracture head middle phalang

right 4th toe chipping Gustilo
Anderson grade IIIA

Total rupture of 2nd – 3rd EDL tendon

with tendon loss

Loss of dorsalis pedis artery

Analgetic, antibiotic
Plastic surgery department
Performed :
Closed fracture at right distal end radius
Debridement
Fryckman type VII Tscherne grade I
15 Juli Primary suture
48. 21835 Tn. Una 58 Lacerated wound at right superior BPJS OK RP
2018 Orthopaedic and traumatology
palpebrae
department
Lacerated wound at upper lips
Performed :
Immobilization with
above elbow cast
nd
Open fracture at head 2 left metacarpal Analgetic, antibiotic, tetanus prophylactic
comminutive displaced Swanson Szabo Plan to :
type II Debridement and exploration
rd
Open fracture at head 3 left metacarpal Repair tendon, muscle and
15 Juli
49. 211339 Tn. Radi 16 chipping Swanson Szabo type II capsule BPJS RANAP RP
2018
Open fracture at shaft proximal phalang Orif K-Wire for middle and ring
of left index finger transverse displaced finger
Swanson Szabo type II with vascular Ray amputation for left index
compromise finger
 Open fracture at shaft proximal phalang
of left middle finger transverse displaced
Swanson Szabo type II with vascular
compromise
Open fracture at shaft proximal phalang
of left ring finger transverse displaced
Swanson Szabo type II with vascular
compromise
Open dislocation at level DIP of left index
finger with total rupture of FDP tendon
and capsule
Lacerated wound at left hand flexor zone
3 with partial rupture palmar interoseus
muscle
Lacerated wound at left thumb volar
aspect
Lacerated wound at left little finger volar
aspect
Analgetic, antibiotic, and tetanus prophylactic
16 Juli Skin avulsion at left knee joint posterolateral Performed:
50 21415 Tn.Erwin 37
aspect Debridement
BPJS PP MN
2018
Primary suture
Hemopneumothorax at left hemithorax
Lacerated wound at left hemithorax lateral Analgetic, antibiotic and tetanus prophylactic
aspect
Intraabdominal haemorrhage due to Spleen Thorax Surgery Department
laceration AAST grade III and left kidney
laceration AAST grade III due to abdominal Performed:
blunt trauma
Lacerated wound at right arm anterior aspect CTT insertion for hemopneumothorax
Tn. with skin loss
16 Juli 21446
51. Kurniawan 30 Lacerated wound at right forearm anterior Serial chest X-ray and blood gas analysis UMUM PP MN
2018 aspect with partial rupture of brachioradialis
muscle and skin loss Debridement and primary suture for lacerated
Closed DRUJ disruption at right wrist joint wound
Closed fracture at left humerus middle third
transverse displaced Tscherne grade I Digestive Surgery Department
Closed fracture at left Radius middle third
transverse displaced Tscherne grade I Performed:
Lacerated wound at right knee joint anterior
aspect
 Conservative treatment

Orthopaedic and Traumatology Department

Performed

Debridement and open wound care for

lacerated wound at right arm

Debridement, repair muscle and open wound

care for lacerated wound at right forearm

Immobilization with posterior slab for DRUJ

disruption

Immobilization with U-slab for humeral

fracture

Immobilization with posterior slab for radius

fracture

Debridement and primary suture for lacerated

wound at knee joint

Plan to: ORIF with plate and screw electively

for humerus and radius fracture

ONail plate avulsion at right 2nd toe Analgetic, antibiotic and tetanus
prophylactic
Open fracture at head middle phalanx
of right 3rd toe with total oblique Plan to:
displaced
16 Juli 169132
53. Tn.Regi 24 Debridement and artificial nail BPJS RANAP MN
2018 3
Open dislocation at PIP joint of right insertion for nail avulsion at 2nd toe
3rd toe with total rupture of EDC
tendon 3rd toe, dorsal digital arteries Debridement and PIP joint
and proper palmar digital arteries disarticulation for 3rd toe
 Closed fracture at base proximal Debridement and ORIF with k-wire
phalanx of right 3rd toe incomplete and primary suture for 4th toe

Open fracture at head proximal phalanx CRIF with k-wire for 5th toe
of right 4th toe oblique displaced
But patient refused due to unavailable
Closed fracture of shaft proximal ward.
phalanx of right 5th toe oblique
displaced

Analgetic, antibiotic
17 Juli 169871 Lacerated wound at left ankle joint Plan to :
54.
2018 1 Boy Beri 5 UMUM PP HH
posterior aspect Debridement and primary
suture
Analgetic
Oxygenation
Neurosurgery department
Plan to : skull xray and head ct
scan
Orthopaedi and Traumatology
17 Juli 169873 Mild Head Injury
55. Mr.Miftahul 18 department UMUM RANAP HH
2018 5 Closed fracture right forearm
Plan to :
Closed fracture right femur
Cervical, thoraks,
pelvic, Forearm and
femur xray
Immobilization with
wood splint
Analgetic, antibiotic, tetanus
prophylactic
Moderate Head Injury Oxygenation
Closed fracture around right shoulder Neurosurgery department
17 Juli 169873 th
56. Mr. Apip 20 Open dislocation at 4 MCP of right Plan to : skull xray and head ct- UMUM PP HH
2018 6
hand scan
Open fracture right tibia distal third Orthopaedi and Traumatology
department
Plan to :
 Cervical, thoraks,
pelvic, shoulder, hand
and ankle xray
Immobilization with
splint
Analgetic
Performed :
Ny.Dwi Closed Fracture of the Right Clavicle Distal Immobilization with Arm sling
18 Juli RANA
57. 21588 Astuti 47 Third Tranverse Displaced Allman Plan to : UMUM GT
2018 Classification group II Typ. e II B Open Reduction and Internal
P
Fixation with Plate and Screw
Electively

Sharp wound at right hand dorsal aspect Analgetic, antibiotic, tetanus prophylaxis
18 Juli Tn.Andi ekstensor zone II with partial rupture of Performed :
58. 98982 25 UMUM PP GT
2018 extensor digitorum communis and extensor Debridement
indicis proprius Suturing

Analgetic
Mild Head Injury suspect skull base Neurosurgery Departement
fracture at left anterior fossa Performed : Conservative
Closed fracture at left clavicle middle treatment
rd Orthopaedic and Traumatology
19 Juli Tn. Ujang 3 oblique displaced Allman RANA
59. 21712 50 Department UMUM AK
2018 classification group I P
Performed : Immobilization
Closed fracture at left body scapula with arm sling for clavicle and
Zdravkovic type I scapula fracture
Lacerated wound at left face region Plan to : ORIF P/S for clavicle
and scapula fracture electively
Analgetic, antibiotic, tetanus
rd prophylactic
Closed fracture at left femur distal 3 Performed :
19 Juli comminutive displaced Winquist Debridement and primary RANA
60. 21278 Ny, Riris 24 UMUM AK
2018 Hansen type I, Tscherne grade I suture P
Lacerated wound at right leg Immobilization with skin
anteromedial aspect traction
Plan to :
 CRIF Intramedullary nail
electively

Analgetic, antibiotic and tetanus prophylactic

Performed:
Debridement
Closed avulsion fracture at lateral condyle of
Primary suture
right femur Tscherne grade I
20 Juli 169945 Ny.Reniasi Immobilization with postrior slab
61. 35 Open fracture at right tibial plateau UMUM PP DM
2018 2 h comminutive displaced Schatzker type VI
Plan to:
ORIF with plate and screw for tibia
Gustilo Anderson grade IIIA
fracture electively
ORIF with screwing for tibial plateau
fracture
Open fracture at medial condyle of base Analgetic, Antibiotic and Tetanus Prophylaxis
proximal phalang of right 5th toe Performed:
comminutive displaced Gustilo Anderson Debridement
grade III with partial rupture of extensor Primary suture
20 Juli 169074 Tn.Sukan
62. 35 digitorum brevis and extensor digitorum Immobilization with postrior slab UMUM PP DM
2018 2 a longus tendon Plan to:
Open fracture at head of right 5th ORIF with plate and screw electively
metatarsal comminutive displaced for Tibial plateau and Tibia fracture
electively
Gustilo Anderson grade III
Analgetic
Performed:
Closed pelvic ring injury Young and Immobilization with pelvic
Burgess classification combined type wrap, and skin traction for left
21 Juli 169956 RANA
63 Tn.Eka P 70 Closed fracture of left acetabulum lower extremity umum MN
2018 7 P
Judet-Letournel classification anterior Plan to:
, column type Further investigation with CT-
Scan
ORIF P/S electively
Oxygenation
Moderate head injury Analgetic
Skull base fracture at anterior fossa Neurosurgery department:
21 Juli Tn.Tris rd th th th RANA
64 169957 38 Closed fracture of right 3 , 4 , 5 , 6 , Conservative treatment umum MN
2018 th th th
P
7 , 8 and 9 ribs posterior aspect Thorax surgery department:
Right lung contusion Serial chest xray & blood gas
analysis
 Closed fracture at right clavicle middle Orthopaedic and Traumatology
third transverse undisplaced Allman department:
classification group I Immobilization with arm sling

Sharp wound at left hand extensor

zone TIV-TV with total rupture of : Antibiotic, analgetic, tetanus
APL tendon prophylactic
EPB tendon Performed:
ECRB tendon Debridement
21 Juli Tn.Tatang EPL tendon Repair tendon RANA
65 9234 42 th umum MN
2018 Superficial branch of radial Repair artery P
artery Repair nerve
Medial branch of superficial Primary suture
branch radial nerve Immobilization with thumb
Lateral branch of superficial spica cast
branch radial nerve

Analgetic, antibiotic
22 Juli Ny.Viona Lacerated wound at left foot posterior Performed : RANA
66 99610 30 th umum RP
2018 aspect Debridement and Primary P
sutured

Right diabetic foot wagner Analgetic, antibiotic, oxygenation with nasal

canule
classification Grade V with septic shock Internal medicine department:
Acute kidney injury due to diabetic Blood glucose regulation
23 Juli Tn.Hamba kidney disease Electrolytes correction
67 99651 82 BPJS PP YY
2018 li Electrolytes imbalance due to Anesthesiology department
hyponatremia and hypocalsemia Early goal direct theraphy
Orthopaedic and Traumatology department:
Respiratory alkalosis with metabolic Performed open transtibial
compensation amputation
Analgetic, antibiotic, tetanus prophylactic
Sharp wound at right wrist joint flexor Performed
tendon zone V with total rupture of Debridement
23 Juli Tn.Learby Artery radial Exploration RANA
68 99977 28 Repair tendon
BPJS YY
2018 Flexor carpi radialis tendon P
Abductor policis longus tendon Repair artery
Immobilization with thumb spica
Extensor policis brevis tendon cast
 Left ankle sprain
Tn.I Gusti Left ankle joint stiffness due to contracture left
Analgetic
24 Juli achilles tendon
Budiana RICE
69
2018 700172 80 Left knee joint stiffness due to osteoarthritis
No treatment for malunion fracture,
UMUM PP AP
left knee joint Kellgren Lawrence grade IV
osteoarthritis and ankle stiffness
Malunion fracture of the left intertrochanter
femur
Ganggrene at right great toe and third Ganggrene at right great toe and third
toe with : toe with :
Closed farcture at medial Closed farcture at medial
condyle of base distal phalang condyle of base distal phalang
Tn.Kamal of right great toe transverse of right great toe transverse RANA
70 91372 26 umum HNR
25 Juli udin displaced displaced P
2018 Closed fracture at medial Closed fracture at medial
condyle of head proximal condyle of head proximal
phalang of right great toe phalang of right great toe
chipping chipping
Ganggrene at right great toe and third Ganggrene at right great toe and third
toe with : toe with :
25 Juli Closed fracture at medial Closed fracture at medial
2018 condyle of base distal phalang condyle of base distal phalang
170056 Tn.Muhta of right great toe transverse of right great toe transverse
71 r 44 BPJS PP HNR
8 displaced displaced
Closed fracture at medial Closed fracture at medial
condyle of head proximal condyle of head proximal
phalang of right great toe phalang of right great toe
chipping chipping
Intubation
Traumatic diaphragm herniation at left
hemithorax
Analgetic
Closed fracture at left 9th, 12th ribs posterior
26 Juli aspect
Thorax surgery department:
2018 170085 Tn.Kadmi RANA
72 34 BPJS YY
2 na th th th th
Closed fracture at right 4 , 5 , 7 , 8 ribs
Performed: P
posterior aspect
Hernioraphy emergency
Respiratory alkalosis
CTT insertion
 Spinal cord injury complete lesion at level Conservative for costae fracture
T11 due to fracture dislocation at level V. T12
Frankel type A Orthopaedic and Traumatology department

Closed fracture at left tibia middle 3rd Plan to:

comminutive displaced Tscherne grade I
Immobilization with posterior splint
Closed fracture at left fibula middle 3rd
comminutive displaced Tscherne grade I
ORIF P/S electively for tibial fracture
electively
Closed left ankle injury Weber classification
type B
ORIF screwing for malleolar fracture
electively
.
Immobilization with TLSO for fracture
dislocation T12

Further investigation with MRI

Decompression and posterior stabilization for

fracture dislocation T12 electively

Analgetic
27 Juli An..Aditia Ring Strangulated at Right Ring Finger RANA
73 667834 5 Performed : Ring Removal at BPJS WA
2018 Urbaniak Classification Class I P
Emergency Ward

Analgetic, Antibiotic
An.Wibiksa Lacerated Wound at First Interweb
74 22532
na
9 Performed : Debridement + Primary UMUM PP WA
27 Juli Space of Right Hand
Suture
2018