Screening Bedah Plastik

Selasa,26 November 2019

No Tanggal Tanggal GV
Identitas Ruangan Diagnosis DPJP Rencana Lab
Masuk Operasi Terakhir
1. Ridwan 21/11/2019 HCU Luka Electrical burn mid dr. Emil 21/11/2019 22/11/2019 21/11/2019
Surbakti/L/32 Bakar to deep 19% o/t (R Akmal, Hb/Ht/Leu/Plt :
thn/79.68.58 hand, back and both Sp.BP-RE 16.3/46/21,040/195.000
leg)
Albumin 3.3
BUN/Ur/Cr : 14/30/1.07

20/11/2019
Hb/Ht/Leu/Plt :
16.4/48/20.900/220.000
Na/K/Cl : 136/4.2/104
KGDs : 130
BUN/Ur/Cr : 14/30/1.17

Urinalisis :
Warna : kecokelatan
Glu/bil/keton/BJ/pH :
-/+/+/1.020/6.5
Pro/urobil/nitrit/leu/dar :
+3/-/+/+/+
Eritrosit : 2-4
Leukosit : 0-4
Epitel : 0-1
Casts : +
Kristal : -
2. Sahruddin 20/11/2019 HCU Luka Selulitis o/t (L) leg dr. Emil 22/11/2019 24/11/2019
L/44th Bakar post debridement Akmal, Hb/ht/leu/plt:
796773 Sp.BP-RE 7,8/22/17.940/299.000
Albumin: 1.3
Kgds: 93
Na/K/Cl: 127/5/95

21/11/2019
Hb/Ht/Leu/Plt
11.9/32/39,900/384,000
Albumin 1.6
BUN/Ur/Cr 77/165/2.56
Na/K/Cl 131/5/100

20/11/2019
PT/APTR/INR :
13.9/43.2/1.28
Fibrinogen/D-Dimer :
471/3969
BUN/Ur/Cr : 50/107/1.24
3. Rohima 08/11/2019 HCU Luka Chronic Infected dr. Emil 12/11/2019 24/11/2019
Alayka Bakar Bed Wound d/t Flame Akmal, Hb/ht/leu/plt:
P / 5 th 4 burn injury grade Sp.BP-RE 8,6/24/7.080/83.000
79.53.74 mid dermal to deep Albumin: 2.2
dermal burns 32% Kgds: 103
post debridement Ca/na/K/Cl:
6,8/128/2,3/95

22/11/2019
Hb/Ht/Leu/Plt :
9.9/28/6.700/40.000
PT/APTT/INR/TT :
21/32.9/1.56/12.4
Fibrinogen / D-dimer :
334/3019
Albumin : 2.6
BUN/Ur/Cr : 7/15/0.41
Na/K/Cl/Ca :
129/2/95/7.2
CRP : 0.7
Procalcitonin : 89.99
4. Khairani 24/11/2019 HCU luka Flame burn mid dr.Emil 24/11/2019 24/11/2019
Sihotang bakar dermal 17% Sp.BP-RE Hb/ht/leu/plt:
P/39th 15,3/46/21.400/439.000
797296 Albumin: 3,2
Kgds: 112
BUN/ur/cr: 12/26/0.98
Na/K/Cl: 133/4,6/100

5. Rosida 19/11/2019 RB2A SCC Bucal DR.dr.Ka 27/11/2019 Hemimandib 01/11/2019

Harahap/P/56 3.2.4 mal Sp.B ulectomy+m Ph/pco2/po2/HCO3/Tco
thn/76.11.66 (K) Onk axilledomy 2/BE:
sinistra 7.5/23.3/161.1/20.6/21.3/
0.5
6. Khoirul ibnu 25/11/2019 RB2A Kontraktur o/t (L) dr.Frank 26/11/2019 Release
alfatih/L/2 2.4.3 digiti V manus Bierta kontraktur
thn/79.36.76 Buchari,Sp tanggal
.BP 26/11/2019
7. Septian 19/11/2019 RB2B Skin avulsi o/t (L) dr.Utama 19/11/2019 23/11/2019 24/11/2019
Gultom 3.8.3 foot + post Abdi Hb/ht/leu/plt:
L/20 thn debridement + Tarigan,Sp 12,2/36/9.170/200.000
79.66.13 STSG .BP-RE
21/11/2019
Hb/Ht/Leu/Plt :
7.5/22/10,300/109,000

19/11/2019
Hb/Ht/Leu/Plt :
12.7/38/22.090/204.00
GDS : 94
PT/APTT/INR :
15.8/28.6/1.15
BUN/Ur/Cr : 11/24/0.78
8. Kartini 25/11/2019 RB2B Post primary suture dr.Emil 25/11/2019 Perawatan 25/11/2019
lubis/P/33 thn / 3.6.3 Akmal,Sp. luka Hb/Ht/Leu/Plt:
79.73.28 BP-RE 11.5/35/12.280/297.000
Kgds : 114
9. Untung 22/11/2019 RB2B Fx basis cranii fossa dr.Mahyu Debris+oblit 25/11/2019
suryadi/L/27 3.7.1 anterior+fx maxila Daniel,Sp. erasi dam Ph/Pco2/PO2/Hco3/BE:
thn/79.71.14 BS kranialisasi 7.4/31/120/19.2/-5.2
sinus frontal
27/11
10. Ridwan 11/11/2019 RB2B Kronik osteomielitis dr.Utama 23/11/2019 Evaluasi 22/10/2019
purba/L/24 3.10.1 (R) tibia post STSG Sp.BP-RE STSG Hb/Ht/leu/plt:
thn/79.09.07 tanggal 13.8/38/12.720/216.000
29/11/2019
11. Sintong 23/11/2019 RB3 Post debridement + dr. Frank 23/11/2019 25/11/2019 24/11/2019
Mangiring 3.5.1 evakuasi marginal Buchari, Hb/ht/leu/plt:
Parhusip d/t crush injury + Sp. BP-RE 7,7/22/11.250/132.000
L/33th open skin degloving Raber
79.72.53 Ortho 23/11/2019
Hb/ht/leu/plt :
11,5/34/190.000/16.200
PT p/k : 15,7/13,9
INR : 1,15
APTT p/k : 30/33,2
Na/K/Cl : 140/4,3/106
KGDS : 96
12. Ahmad 17/11/2019 RA4 BS Fracture dr. Arya 26/11/2019 Orif tanggal 17/11/2019
Ramadani 3.3.4 zygomaxillaris + Tjipta 26/11/2019 Hb/Ht/Leu/Plt :
L/26 thn frakture symphisis Prananda, 13.6/38/33.100/196.000
79.63.38 mandibula Sp.BP PT/APTT/INR :
15.2/23.7/1.07
GDS : 140
BUN/Ur/Cr : 10/21/1.78
Na/K/Cl : 137/3.6/104
13. Albert Monang 13/11/2019 RA5 Scald burn Dr. Utama, 14/11/2019 22/11/2019
L/36 thn BTA (+) superficial to mid Sp BP-RE 13/11_2019
79.60.24 Pria dermal 47% o/t both Hb/Ht/Leu/Plt :
leg, hand, chest, 12.3/38/18.080/604.000
back KGDs : 214
BUN/Ur/Cr : 6/13/0.8
Na/K/Cl : 130/3.3/97

14. Sunarto RIC 416.2 Selulitis dd diabetic 23/11/2019

L/55th foot KGD Puasa : 123
79.56.97 DM tipe 2 KGD 2jam PP : 128
HHD
21/11/2019
Hb/Ht/Leu/Plt :
9/24/8,760/190,000

19/11/2019
Urinalisis :
Warna : kuning jernih
Glu/bil/keton/BJ/pH :
-/-/-/1.005/6.0
Pro/urobil/nitrit/leu/dar :
+1/-/-/-/-

Eritrosit : 0-1
Leukosit : 0-1
Epitel : 0-1
Casts : -
Kristal : -
KGDs: 100
KGD 2jam PP : 215
Hb-A1c :7.9
Kol.total : 102
Trigleserida: 50
HDL/LDL : 38/58