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REKAPITULASI PASIEN BEDAH PLASTIK RSUP HAM MEDAN

TANGGAL 15 FEBRUARI 2018

RB2A
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
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
Post Rotational Flap + 07/02/2018 IVFD Asering 20 gtt/i 12/02/2018
dr. Emil,
Sri Susilawati PM Flap d/t Post (L) Hemimandibulectomi Inj Ceftriaxone 1 gr/12 jam, Hb: 7,4
4 Sp.BP-RE 05/02/2018
/P/49thn/70.80.78 Hemimandibulectomy (Join Bedah Inj Ranitidin 50 mg/12 jam Leu: 11.910
(2.1.2)
+ Wide Excision d/t Onkologi) Inj Ketorolac 30 mg/8jam Plt: 363.000

1
SCC Mandibula R/ Aff Hecting selang – seling Albumin: 2,4
pada daerah Flap yang
berubah warna

RB2B
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
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 Latisissmus Flap + STSG Inj ceftriaxone 1 gram/12 jam Plt: 853.000
dr.
Dorsi + STSG a/i (Rawat bersama Inj ketorolac 30 mg/8 jam Albumin: 3.0
UtamaSp.BP-
Elfina Soraya/P/44 Wide Incision d/t 28/12/2017 Onko dan BTKV) Inj ranitidin 50 mg/12 jam KGDs: 83
6. RE
thn/72.48.68 PhyloidesTumor Paracetamol 3x500 mg tab BUN/Ur/Cr: 5/11/0,48
(3.7.1)
Removal Sugg. 22/01/2018 Ganti balutan/2 hari Na/K/Cl: 135/4,4/104
Malignansi Repair flap asetilsistein 3x200 mg

2
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
Parasymphisis Cefadroxil 2x50 mg
Albumin: 3,9
dr. Emil, Mara Sutan Sinaloan Mandible Fracture + PCT 3x500 mg
KGDs: 79
8 Sp.BP-RE Siregar/ L/ 20 thn/ (L) 25/01/2018 Ranitidin 2x150 mg
BUN/Ur/Cr: 14/30/0,85
(3.5.5) 73.22.48 zygomaticomaxillarix R/Foto Posisi Waters
Na/K/Cl: 139/4.0/104
fracture

RB3
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
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
Juanda Plt: 556.000
9. fibula fx type IIIb + 18/01/2018 inj ranitidin 50 mg/12 jam
Dr. Frank, Putra/L/15th/72.97.13 Albumin: 3,5
close shaft femur fx (konsul dari 24/01/2018 inj ketorolac 30 mg/8 jam
SP.BP-RE KGDs: 96
orthopaedi) ORIF femur R/ soleus flap Rabu
(3.3.1) BUN/Ur/Cr: 12/26/0,51
Na/K/Cl: 136/4,0/105

3
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)
(1.2.2) 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

10/02/2018
Hb: 10.2
Leu: 10.460
dr. Utama, Flame burn grade IIa-Iib Plt: 618.000
Rio 14/02/2018 Albumin: 2.8
11. Sp.BP-RE 18% o/t face and both 05/02/2018
Ardiansyah/L/4th/73.36.98 (Debridement) KGDs: 100
(1.11) leg
BUN/Ur/Cr: 5/11/0,42
Na/K/Cl: 138/3.8/103

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

4
07/02/2018
Hb: 13,6
Leu: 16.170
Post release contracture Plt: 476.000
dr. Emil, Sp. Release contracture R/ release contracture + skin
Suan Tua Rambunan/L/9 + STSG d/t Contracture 06/02/2018 Albumin: 3,7
13. BP-RE + STSG graft
thn/ 73.12.35 o/t digiti 3,4,5 (L) KGDs: 108
(1.6.1) (7/02/2018) (7/02/2018)
Manus ec Burn Injury Na/K/Cl: 141/4.4/103
29/01/2018
BUN/Ur/Cr: 9/19/0.63
09/02/2018
Hb: 9.8
Post debridement d/t Leu: 9.860
IVFD RL 30 gtt/i
electrical burn 14% o/t Plt: 153.000
Apriyanto Pasaribu/L/21 Post Debridement Inj Ceftriaxone 1 gr/12 jam
14. 1.9.1 both hands and legs + Albumin: 1.9
thn/73.34.84 Post Fasciotomy Inj Ranitidin 50 mg/12 jam
Post fasciotomy d/t KGDs: 108
Inj Ketorolac 30 mg/8 jam
compartement syndrome BUN/Ur/Cr: 7/15/0,44
Na/K/Cl: 122/3,7/92

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

HCU
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
10/02/2018
Hb: 17,2
leuko: 21.000
dr.Emil, Muhammad Flame burn grade II a-b
16 10/02/2018 11/02/1018 Plt: 258,000
Sp.BP-RE Bilal/L/63th/73.38.31 43% + post debridement
BUN/Ur/Cr: 9/19/0,71
Na/K/Cl: 136/4,0/108
KGD: 106

5
ICU
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
12/02/2018
Hb: 23,6
leuko: 29,970
Flame burn grade II-III Plt: 217,000
dr.Emil,
Jonny Nasib 86% o/t face, chest, 13/02/2018
17 Sp.BP-RE 10/02/2018 11/02/2018
Parulian/L/42th/73.38.29 abdomen, back, BUN/Ur/Cr: 34/73/0,86
extremities Na/K/Cl: 148/4,8/109
KGD: 137
albumin: 1,8

PICU
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
10/02/2018
Hb : 10,2
Leuko : 8.140
Plt : 156.000
Dr. Emil Chemical Burn Grade
Irene Sembiring/P/13 Rawat bersama
18 Akmal, IIA- II B 10% o/t Back 7 Februari 2018 R/ Rawat Luka
tahun/73.35.94 Bedah Anak 12/02/2018
Sp.BP - RE and Chest
Albumin : 2,7
KGD : 96
BUN/Ur/Cr : 13/28/0,47
Na/K/Cl : 140/ 3,6/106

6
RA4BS
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
11/02/2018
Hb: 12,0
leuko: 8,020
30/01/2018
RA4 BS Anak Zulfan/L/14 Segmental Mandibule R/Susul hasil CT-scan midface Plt: 211,000
19 (konsul ke
(Bed 1) thn/73.10.81 Fracture 3D KGD: 87
b.plastik)
BUN/Ur/Cr: 9/19/0,48
Na/K/Cl: 139/3,7/106
Albumin: 3,3

RA4
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
07/02/2018
Hb: 6,6
Leu: 12.540
Plt: 318.000
dr. Utama, 08/02/2108 R/rawat ulkus dengan madu per
M.Syafei/ L/73 Alb: 2,1
20 Sp.BP-RE Ulkus decubitus grade IV (konsul ke 3 hari
thn/ 34.91.17 Ca: 8,90
(2.3.3) b.plastik) Miring kanan kiri per 2 jam
05/02/2108
BUN/Ur/Cr: 8/17/0,5
09/02/2018
Na/K/Cl: 126/2,9/85

7
RA1
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
11/02/2018
Hb: 10,9
leuko: 8,310
dr. Emil, SpBP- Skin Avulsion (R) foot d/t 01/02/2018
Lina/P/28 30/01/2018 Plt: 323,000
21 RE open (R) talotarsal fracture (konsul ke R/Rawat Luka
th/73.26.67 (Debridement) BUN/Ur/Cr: 11/24/0,6
(3.2.1) type IIIA b.plastik)
Na/K/Cl: 135/3,8/105
Albumin: 3,2
KGD: 112

RA2
TGL MASUK
DPJP/ TGL OPERASI
NO IDENTITAS DIAGNOSIS (HARI TERAPI/RENCANA HASIL LAB
RUANGAN (KETERANGAN)
RAWATAN)
06/02/2018
Hb: 13,2
dr. Utama, Lacerated wound o/t face leuko: 10,090
Abdul 07/02/2018
22 Sp.BP-RE + post debridement + (R) 07/02/2018 Plt: 235.000
Hanif/L/17th/73.34.74 (Debridement)
(2.3.3) angle mandibula fracture BUN/Ur/Cr: 9/19/0,51
Na/K/Cl: 139/4,1/105
KGD: 92