Assalamualaikum Warahmatullahi Wabarakatuh.

Selamat Malam dokter.

Melaporkan kondisi ruangan Bedah Plastik :

Jumat, 02 September 2022

ICU A

Bed 8

Tn. Ario Rachmono/L/59th/11548474

MRS : 30/08/2022

Dx :

- Respiratory Failure on ventilator dt Contusio Pulmonum S dd Pneumonia aspirasi

- Moderate ARDS

- CKS 225 - 1x1 on ventilator - on sedasi

- Edema Cerebri

- Fr. ZMC S

- Fr. Segmental Mandibula

- Fr. Maxilla D Non Le Fort

- Fr. Nasal

- Fr. Nasofrontal

- Open wound regio eyebrow S

- Open wound regio frontal D et S

- Open wound regio nasal

- Open wound regio Mental S

Tx :

- post debridement + advancement flap GA (31/8/2022)

- Post archbarr wiring (31/8/2022)

- pro urgent rekonstruksi Tulang wajah

DPJP : dr. ARV, SpBP-RE(K) LBL

Ny Sudarmini/P/70th/11165858

MRS : 29/08/2022

Dx :

- Pressure ulcer Regio sacrum – trochanter D Gr IV

- CVA infark with sequele

- Susp pneumonia dd lung TB

- DOC dt sepsis dd severe hydrocephalus

- Hipoalbuminemia

- Hipokalemia

Tx :

- Post debridement necrotomy (31/8/2022)

- Miring kanan kiri setiap 2 jam

- Memakai kasur anti decubitus

DPJP : dr. RUM, SpBP-RE

ICU B

Bed 5

Tn Hasanudin/L/57th/11512069

MRS : 20/08/2022

Dx :

- Infected wound extremitas superior S + CKD st V

Tx :

- Post debridement + VAC dengan GA (22/8/2022)

DPJP : dr. ARV, SpBP-RE(K) LBL

ICU C

Bed 3

Sdr. M. Nashoicul/L/17th/45Kg/11548830
Dx:

- COB 213

- EDH Frontal D et S vol. 130cc

- Edema cerebri

- pneumoencephal regio frontal D

- SAH

- obs.TTA

- Fr. Nasal

- Fr. ZMC D

- Fr. Maxilla D Non Lefort

- Open wound regio periorbital D

- V. Abrasi Facialis

Tx:

BP:

Pro Debridement + advancement flap

rawat luka moist dressing dengan hydrocolloid

Urgent rekonstruksi tulang wajah

DPJP: dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE.

HCU Cisadane

Bed 1

Tn. M. Galih Saputro/L/18th/11547747

MRS : 22/08/2022

Dx :

- COB 124 - 1x4 - on sedasi

- EDH Frontal Bilateral 10cc

- Pneumoencephal Reg. Frontal D et S

- Edema cerebri

- SAH

- CH frontal frontobasal S
- Fr. Depressed os frontal

- Fr. Nasal

- Fr. Rima orbita superior D/S

- Fr. Rima orbita inferior D/S

- Fr. Maxilla D/S Non Lefort

- Open wound regio mastoid S

- Open wound regio temporal S

- Open wound regio frontal

- Open wound regio nasolabial

- Open wound regio mucoginggival inferior

Tx :

- Post Debridement + advancement flap + platting rima orbita superior + nasofrontal

- Urgent rekonstruksi tulang wajah

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE.

Bed 6

Tn. Bunadi/P/50Th/11547574

MRS : 20/08/2022

Dx :

- Cellulitis Pedis S

- DM Type 2

- Sepsis

Tx :

- Non Operative Management

DPJP : dr. ARV, SpBP-RE(K) LBL

Bed 13

Tn. Sunardi/L/52th/11548856

Dx :

- CKR 356

- CH regio Frontal S, Vol 2cc

- Subgaleal Hematoma temporoparietal S

- Fr.Lefort 2,3

- Fr Nasal

- Open wound regio Frontal D/S

- Open wound periorbital Inferior D

- V. Abrasi Facialis

- Vulnus Abrasion superior side L Shoulder

- CF neck L 5th metacarpal

Tx :

BP :

Pro Debridement + advancement flap GA

rawat luka moist dressing dengan hydrocolloid

Urgent rekonstruksi tulang wajah

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE

Bed 24

Tn. M. Suudi/L/23th/11548292

MRS : 29/08/2022

Dx :

- CKR 356

- EDH Frontal, Volume 1cc

- CH Frontal D

- Open Fraktur Depressed os frontal

- Fr Maxilla S

- V. Abrasio regio facial

Tx :

- Rawat luka dengan Hydrocolloid Dressing

- Post archbarr wiring GA (30/08/2022)

- Urgent Rekonstruksi Tulang wajah

DPJP : dr. WMA, SpBP-RE (K) MO

Tn. Supriadi/L/46 th/11546904

Konsul : 22/08/2022

Dx :

- Spinal Cord Injury at level vert Cervical 7 ASIA C

- Pressure ulcer regio sacral gr II

Tx :

- Rawat luka moist dengan burnazine

- Miring kanan-kiri per 2 jam

- Penggunaan kasur angin

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE

Bed 30

Tn. Dandung Prasetyo/L/58 th/11548588

MRS : 30/08/2022

Dx :

- CKR 456

- Subdural Hygroma Frontoparietal bilateral

- Fr. ZMC D

- Fr. Rima orbita inferior D

- Stitched wound regio surpaorbita D & frontonasal D

- Multiple vulnus abrasion facial region

- Spinal Cord Injury at Level Vertebra Cervical 5 ASIA C

Tx :

- Pro urgent rekonstruksi tulang wajah

- Rawat luka abrasio dengan hydrocolloid dressing

DPJP : dr. ARV, SpBP-RE(K) LBL

Bed 33

Tn. Iwan Agung/L/42th/11548291

Dx :

- CKR 356

- Open Fraktur Depressed os frontal S

- Susp Teardrop Fraktur C6

- Fr ZMC S

- Open wound regio frontal S

- Open wound Periorbital S

- Open wound nasal S

- V. Abrasio regio facial

Tx :

- Rawat luka dengan Hydrocolloid Dressing

- Post Debridement + advancement flap + archbarr wiring GA (30/08/2022)

- Urgent Rekonstruksi Tulang wajah

DPJP : dr. WMA, SpBP-RE (K) MO

Mahakam

Bed 2

Tn Syamsul Hadi/L/35th/11548610

MRS : 31/08/2022

Dx :

- CKS 225

- Susp. DAI

- Edema serebri

- Fr. ZMC

- Fr. Rima orbita inferior S

- Multiple abrasio regio fasialis

Tx :

- Urgent Rekonstruksi tulang wajah

- Wound care with hydrocolloid dressing

HCU Sarangan

Bed 4

An. Almeera Cetta Zevanna/P/8th/28kg/11536009

Konsul : 16/8/2022

Dx :

- Ventrikulitis dd severe hydrocephalus on patent vp Shunt kocher D et S

- Riw Trepanasi dt Abses Cerebri

- Glomerular Disorder in Systemic Connective Tissue Disorder (Lupus Nefritis)

- Hipertensi stage II on Treatment

- Observasi Seizure

- Pneumonia

- Post endoscopic exploration + Irigasi + Septostomy septum pelusidum + revisi shunt kocher dextra
(19/05/2022)

- Skin defect dt Abcess Parasternal S

- Generalized (Acute) Peritonitis

- Intra abdominal abscess

- Peritoneal adhesions

Tx :

- Post Incisi Drainage Abcess (3/8/2022)

- Post EVD Kocher S

- Post Exploratory laparotomy + Lysis of peritoneal adhesions + repair of omentum

- Post Debridement + NPWT (16/8/2022)

- Post Debridement + NPWT (23/8/2022)

- Post Debridement + NPWT (30/8/2022)

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE

Kawi
Bed 2

Tn. Muliyadi/L/66th/11544641

Dx :

- Superficial mid deep dermal burn injury 50% regio back, extremitas superior D, extremitas inferior
D/S dt api

- Post debridement (20/07/2022)

- Post debridement (25/7/2022)

- Post debridement (21/08/2022)

- Post Debridement (24/08/2022)

- Post Debridement (28/08/2022)

- Septic condition

- Congestive pulmonum (perbaikan)

- Hypokalemia (perbaikan)

- Hyponatremia (perbaikan)

- Hipoalbuminemia

- Pneumonia CAP

- COPD

Tx:

-Pro Debridement

DPJP: dr RUM Sp BP-RE

Bed 3

An. Afa Ataullah/L/5th/25kg/11544113

MRS : 30/08/2022

Dx :

- Superficial-mid dermal burn injury regio extremitas superior D/S, extremitas inferior D/S, genitalias
28% dt kuah panas

- post Debridement (17/6/2022)

- post Debridement (1/8/2022)

- post Debridement (10/8/2022)

- Post Debridement (23/08/2022)

Tx :
- Pro Debridement (31/08/2022)

DPJP : dr. ARV, SpBP-RE(K)LBL.

Kerinci

Bed 3.1

Ny. Rahmi Triana/P/53th/11539679

Konsul : 23/08/2022

Dx :

- Squamos cell cancinoma left cheek region rT4aN0M0 Post NAC TPF Regimen 6x CR

Tx :

- Post Maxillectomy + Supraomohyoid neck dissection + Post Tutup defek dengan ALT flap
(23/08/2022)

- Pro re-debridement kp tutup defek palatum dengan mucoperiosteal-palatum flap (01/09/2022)

- Post Lateral Forhead flap (01/09/2022)

DPJP : dr. WMA, SpBP-RE

Bed 4.1

Tn. Rijanto/L/71th/11519145

MRS : 24/8/2022

Dx :

- Chronic ulcer regio pedis S post open degloving

Tx:

- Post Debridement + STSG

DPJP : dr. DIO, SpBP-RE

Bed 2.4

Ny. Sugiarti/P/73th/10644666

Konsul : 10/8/2022

Dx :

- Post Serial Focal to bilateral motor onset tonic clonic seizure dt epilepsy symptomatic
- SOP Cerebri supratentorial susp tumor cerebri metastase dd tumor cerebri primer

- Gradual DOC dt Metabolic dd Septic encephalopathy Perbaikan

- CVA Sequel

- Burn injury regio extremitas superior D et S dt thermal contact post debridement (30/7/2022)

Tx :

- Post Debridement (16/8/2022)

DPJP : dr. ARV, SpBP-RE (K) LBL

Bed 4.3

Tn Supranoto/L/42th/11547751

MRS : 22/08/2022

Dx :

- CKR 456 tanpa perdarahan intracranial

- Arachnoid Cyst Regio Parietal S

- Fr. ZMC D

- Fr. Ramus Mandibula D

- Fr. Rima orbita inferior D

- Stitched wound at anteromedial side R Knee

- Subconjungtival Haemorrhage OD

Tx :

- Post rekonstruksi tulang wajah (30/8/2022)

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE

Lawu

Bed 16

Tn. Zulfikar/L/24th/11548295

MRS : 29/08/2022

Dx :

- CKR 456 tanpa perdarahan intrakranial

- Edema Cerebri
- Open wound regio frontal D

- Open wound regio Zygoma D

- V. Abrasio regio facial

Tx :

- Post Debridement + (pedicle) advancement Flap GA (29/08/2022)

- rawat Luka Moist dressing dengan hydrocolloid

DPJP : dr. WMA, SpBP-RE (K) MO

Bed 17

Tn. M. Agung Catur/L/30th/11548130

MRS : 25/08/2022

Dx :

- CKS 345 tanpa perdarahan intrakranial

- Fr. Condylus mandibulla S

- Open wound regio supraorbita D

- Multiple abrasion wound fascial region

- Multiple vulnus laceratum volar side R index finger, dorsal side R middle finger, and dorsal side R
foot

- CF R 3rd shaft metacarpal

- CF head proximal phalanx R little finger

- OF R ankle Weber B

- CF R 1st shaft metatarsal

- Closed avulsion fracture R 5th base metatarsal

Tx :

Supraorbita

- Debridement + Advancement flap GA (26/8/2022)

- Rawat luka abrasio dengan hydrocolloid

Mandibulla

- Post TPF Flap (31/8/2022)

DPJP : dr. ARV, SpBP-RE(K) LBL

Sdr. Makhrus Ali/L/18th/11458460

MRS : 29/09/2022

Dx :

- CKR 456 tanpa perdarahan intrakranial

- Open Wound Regio Orbicularis Oris Superior

- Open wound regio orbicularis oris inferior

- Open wound regio maxilla S

- Multiple open wound regio periorbita S

Tx :

- Post Debridement + Advancement Flap GA (31/8/2022)

DPJP : dr. RUM, SpBP-RE

Bed 25

Sdr. Alfan Setiawan/L/18th/11548461

MRS : 29/08/2022

Dx :

- CKR 356

- contusional hemorhage frontal region

- SAH

- Edema Cerebri

- Hematosinus Maxilla D

- Open Wound Regio Periorbita S

- Open wound regio labia oris superior D

- Multiple facial abrasion

Tx :

- Post Debridement + Advancement Flap GA

- Rawat Luka dengan Hydrocollid Dressing

DPJP : dr. RUM, SpBP-RE

Bed 37
Tn. Adit/L/18th/11548309

MRS : 29/08/2022

Dx :

- CKR 456 tanpa perdarahan intrakranial

- Open wound periorbital superior S

- Open wound periorbital Inferior S

- Vulnus abrasi regio facialis

Tx :

Post debridement + advancement flap GA (29/08/2022)

Rawat luka abrasi dengan hydrocolloid dressing

DPJP : dr. WMA, SpBP-RE (K) MO

Bed 38

Tn. Achmad Da'ut/L/21th/11548297

MRS : 29/08/2022

Dx :

- CKR 456

- Open wound regio frontal

- Open wound regio occipital

- Open wound regio philtrum tunneling intraoral

- Multiple vulnus abrasi regio facialis

Tx :

Post debridement + (Pedicle) advancement flap GA (30/08/2022)

Rawat luka abrasi dengan hydrocolloid dressing

DPJP : dr. WMA, SpBP-RE (K) MO

Rinjani

Bed 13

An. Ahmad Kamil/L/4th/16kg

Konsul : 24/8/2022
Dx :

- Malignant hipertermi

- AKI stadium injury (pre renal)

- ODS papil atrofi

- XT sensory

- Symptomatic seizure ok Metabolic (Hipoglikemia dd Hipertermia) dd Kejang Demam Kompleks

- Gagal nafas

- Penurunan kesadaran ok suspek Ensefalopati Metabolik

- Upper GI Bleeding ok sistemic site dd Local Site

- Acute Liver Injury

- Selulitis manus Dextra

- Susp. ISK

- Keratitis okular

Tx :

- Rawat luka berkala

- Urgent debridement bila optimal (menolak)

DPJP : dr. WMA, SpBP-RE

Bed 14

An. Narendra/L/4th/11425694

Dx : Hipospadia penoscrotal

Tx : Pro urethroplasty

DPJP : dr. DIO, SpBP-RE

Bed 21

An. Yusriyah/P/8th/25Kg/11548285

MRS : 28/08/2022

Dx :

- CKR 356

- EDH regio temporoparietal D

- Edema cerebri
- Fr linier frontal D/S

- fr maxilla D Non lefort

- Obs TTT

- Multiple vulnus abrasi regio facialis

- CF R Distal Clavicle Neer type II

Tx :

- Pro urgent rekonstruksi tulang wajah

- Rawat luka abrasi dengan hydrocolloid dressing

DPJP : dr. WMA, SpBP-RE (K) MO

Jayawijaya

Bed 14

Dr. dr. Pudji Rahayu, SpTHTKL(K)/P/70th/11257502

MRS : 8/8/2022

Dx :

- Ulcer pressure regio sacrum gr IV

- CKD St V on HD

- AF RVR

- Post debridement + NPWT (10/08/2022)

Tx :

- Post Debridement (27/8/2022)

DPJP : Dr. dr. HRM, SpBP-RE(K)

Jimbaran

Bed 10

Tn Suyono/L/60th/11539446

MRS : 16/8/2022

Dx :

- BCC labia oris superior

- Failed Radial Forearm Free Flap

- Post Eksisi tumor + tutup defek dengan radial forearm free flap (18/8/2022)

- Post debridement (24/08/2022)

- Pro re-debridement kp tutup defek palatum dengan mucoperiosteal-palatum flap (31/08/2022)

DPJP : dr. ARV, SpBP-RE(K) LBL

Bed 61

Nn. Bunga lona/P/27th/11543588

Dx:

- Post Archbarr wiring

- Fr.Segmental mandibula

- Fr dentoalveolar maxilla

Tx :

AFF archbarr

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE.

Pangandaran

Bed 3

Sdr. Sutrisno/L/68th/11548732

MRS : 31/08/2022

Dx :

- CKR 456 tanpa perdarahan intracranial

- Fr. ZMC S

- fr rima orbita inferior S

- Open wound regio frontal

- Multiple facial abrasion

- Shoulder Dislocation

Tx :

- Debridement + advancement flap kp FTG GA

- urgent rekonstruksi tulang wajah

Bed 10

Tn. Dimas Trisna/L/30th/11546401

Dx:

Keloid regio colli, thorax, punggung dan ext sup DS

Tx :

Release contracture

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE.

Bed 22

Tn. Ponijianto/L/56th/11522281

MRS : 30/08/2022

Dx :

- Squamous Cell Carcinoma T3N1M0 at right Posterior Middle femur to proximal cruris

- Post Wide Eksisi + Diseksi KGB Inguinal + Debridement advancement flap (28/7/2022)

- Post debridement + NPWT (03/08/2022)

- Post Re-debridement + NPWT (11/08/2022)

- Post redebridement + NPWT (19/8/2022)

- Post redebridement + NPWT (25/8/2022)

Tx :

- Post debridement + STSG (31/8/2022)

DPJP : dr. ARV, SpBP-RE(K)LBL

Poliklinis

Nn Rahmadia/P/21th/11548678

MRS : 31/08/2022

Dx :

- CKR 456 tanpa perdarahan intrakranial

- Hematom mandibula
Tx :

Non operative management

DPJP : Dr. dr. HRM, SpBP-RE(K)

Tn. Aril/L/17 th/11548603

MRS : 30/08/2022

Dx :

- CKR 356 tanpa perdarahan intracranial

- Open wound regio mental

- Open wound regio submental

- Open wound labia oris inferior

- Alcohol Ingestion

Tx :

- Debridement advancement flap

DPJP : dr. ARV, SpBP-RE(K) LBL

Nn Silvia/P/18th/11548592

MRS : 30/08/2022

Dx :

- CKR 456 tanpa perdarahan intracranial

- Open Wound Periorbita D

- Fr. Arcus Zygoma D

- Fr. Frontozygoma D

- Fr. Maxilla D

- Vulnus Abrasio regio fasialis

- Vulnus Abrasion superior side L shoulder & posterior side R forearm

- CF middle shaft L clavicle

Tx :

Regio periorbita D

- Pro urgent debridement + advancement flap + rekonstruksi tulang wajah dengan GA (menolak)

- Pro debridement + advancement flap LA

DPJP : dr. ARV, SpBP-RE(K) LBL

PAPS

(-)

KRS

Sdr. Ahmat Sholikin/L/24th/11548720

MRS : 31/08/2022

Dx :

- CKR 456 tanpa perdarahan intracranial

- Open wound regio mandibula

- Open wound regio labia oris inferior

- Dental fracture incisivus I D/S

Tx :

- Pro Debridement + advancement flap GA

DPJP : Dr. dr. HRM, SpBP-RE(K)

Tn. Gufron/L/36th/11547725

MRS : 22/08/2022

Dx :

- Emfisema subcutis regio colli S

- Contusio Pulmonum S

- Mild ARDS

- CKR 456 tanpa perdarahan intrakranial

- Fr. maxilla D/S non le fort

- Fr. Segmental Mandibula D et S

- Fr. Dentoalveolar pars maxilla

- Open wound regio submental

- Dental avulsi Incisivus I superior sinistra, Incisivus - Caninus superior dextra

Tx :

- Post Debridement + advancement flap + archbar wiring (22/08/2022)

- Post rekonstruksi tulang wajah (30/08/2022)

DPJP : dr. DIO, M. Sc., M. Ked.Klin., SpBP-RE

Sdr. Achmad Bina/L/16th/11548832

DX:

- CKR 356-456

- Subgaleal Hematome temporal D

- V. Abrasi Facialis

Tx :

BS : Non operative management

BP : Rawat luka moist dressing dengan hydrocolloid

Tn. Salman/L/21th/11546381

MRS : 31/8/2022

Dx :

- Archbar wiring maxilla dan mandibula dt Fr condyle mandibula D

Tx :

- aff archbar

DPJP : dr. WMA, SpBP-RE(K) MO

Meninggal

(-)

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