Room/
No. Identity
Admission
1. Post OREF (15/09/19) ec OF right
tibia proximal third grade 3B
Post ORIF PS (15/09/19) ec CF
right fibula distal third
Malunion right shaft metacarpal
V 6,38/Hct 19,55
Suspect Right BPI
2. Post debridement repair dura
(16/9/2019) et causa Dura Tear
Post Decompression –
stabilization – fusion
(30/08/2019) et causa Fracture
dislocation Th 12-L1 Frankel A
- Burst Fracture Th 1, L1
- Fracture bilateral lamina L1
- Fracture bilateral pedicle L1
- Fracture processus spinosus
Th 12, L1, L2, L3
3. -Neglected Left Elbow
Dislocation (4 years)
-Malunion Left Neck Radius
Pre/
Diagnosis Problem Treatment/ Planning
Post Op
Anemia (6,38) Cefoperazone 1gr/12 hours
Analgetic  TS Anasthesia
Laboratorium Elevation extremity
(15/09/2019) Maintain Backslab
Wbc 19,65/Plt 146,10/Hb Tranfussion PRC Hb > 10
SF 2 times/day
P/ EMG evaluation
Post op Pain (+) controlled Ceftriaxone 1 gr every 12 hr
with analgetic Vitamin B complex 1tab every
8 hour
Drain Prod : 65cc/ 10hr Laxadine syrup 5ml every 8
hour
Lab 16/9/2019 (19:00) Analgetic ~ APS
Hb 9,54/Ht 30,96/WBC Log roll every 2 hour
6,71/PLT 229,4 Chest fisiotherapy
Amlodipine 5mg every 24 hour
Left Elbow Stiffness P/ Elbow Arthroplasty
Active ROM Left Elbow (17/09/2019)
0/30
TS Anesthesiolgist ASA I
4. CF Right Isolated Radius Proximal Pain on controlled ORIF PS (17/09/2019)
Third Stable Hemodynamic

TS Anesthesiolgist ASA II
with Hypertension grade I

5. -Post Debridement ORIF P/S Pain on controlled Ceftriaxone 2x1gr IV

(14/9/19) ec OF Left Humerus Dressing (+), discharge (-) SF 2x1 tab
Middle Third Grade 2 Drain 20cc/24 hours Analgesic ~ Anaesthesia
-Post Debridement ORIF TBW hemoragik Limb elevation
(14/9/19) ec OF Right Medial Active ROM distal (+) NWB with wheelchair
Maleolus Thumb extention (+) Drain humerus production
observation
ROM distal exercise
6. CF Right Intertrochanter Femur Anemia ( 9,89 ) P/ Conservative
BG type 1 Pending Operation
Internist :
Internist : Hemodialisa elective
CKD stg V ec DKD
CAD Cardio :
DM tipe II Valsartan 80mg tiap 24 jam
Obs leukositosis Laboratorium (4/09/2019)
Obs tombositosis Wbc 14,43/Hb 9,83/PLT
718,9/HCT 30,94
Cardio : GDS 191/Bun 41,4/Sc 7,82
CAD Hipertensi grd 1
7. Post closed reduction +
immobilisasi backslab
(9/09/2019) ec CF Left Tibia Pilon
Ruedi and Allgower Type II
CF Left Lateral Maleolus non
displaced
CF Left Talar Neck Fracture
Hawkins Type I
CF Left Calcaneus Essex Lopresti I
8. -Post debridement and
immobilization volar slab
11/9/2019 ec crush injury left
hand
-Post debridement and
immobilization backslab
11/9/2019 ec crush injury left
foot
9. Malunion Left Tibia Middle Third
Malunion Left Fibula Distal Third
(6 years)
10. Post Hemiarthroplasty bipolar ec
Negleted CF Left Intertrochanter
grd 3
Laboratorium 9/09/2019 Analgetic  anaesthesia
Wbc 17,90/Hb 13,77/Hct Muscle pumping
38,65/Plt 136,8 Elevation of extremity
Observation compartment
syndrome
Pain on controlled P/ Skin Graft
Stable Hemodynamic (18/09/19)
Ceftriaxone 2X1gr iv
Paracetamol 4x500mg po
Muscle pumping and ankle
exercise
Left hand and left foot
elevation
Patient have no complain P/ Osteoclasis + ORIF PS
Lab ( 2/9/19) :
WBC 7.31 / HGB 13.5 /
HCT 41.5 / PLT 253
Laboratorium 3/09/2019 Ceftriaxone 1gr/12 hours
HB 10,37/HCT 34.36/ PLT Analgetic  anathesia
123.30/ WBC 5.05 Muscle pumping
Ppt 15,3/INR 1,09/Aptt 29 Dressing change every 3 days
Obs. Drain production
11. CF Right Supracondylar Femur Laboratorium 13/09/2019 Paracetamol 500mg/6 hours
Malunion right intertrochanter HB 11,96/HCT 37.46/ PLT Immobilisation with skin
femur 258,6/ WBC 12.17 / traction 5 kg
OA Hip Elevation extremity
OA knee Muscle pumping
Planning
ORIF P/S (supracondylar)
12. Post Debridement + Pain at the operation site. Ceftriaxone 2x1gr
Microfracture (16/9/19) ec Paracetamol 3x500mg
Osteoarthritis Right Ankle + Lab ( 10/9/19) : Ice compress 20 minutes every
Cartilage defect WBC 7.5 / HGB 12.1 / HCT 2 hours
38.5 / PLT 215 Partial weight bearing with 2
cruches

13. CF right tibia plateau schatzker 6 Laboratorium 13/09/2019 Paracetamol 500mg/6 hours
HB 14,28/HCT 45.72/ PLT Maintain back slab 5kg
262.10/ WBC 17.32 P/ORIF PS ( Waiting schedule)

14. Post Right Hemiarthroplasty Bedridden P/Passive Rom Exercise Under

Bipolar ( - /02/2019)ec GA (join op)
Neglected Fracture Right
Intertrochanter Femur Plastic:
Post PFNA ( /11/2018) ec Debridement + Close Defect
Fracture Right Intertrochanter with Local Flap
Femur
Laboratorium 4/09/2019
Plastic Wbc 10,6/Hb 10,97/hct
Ulcus Decubitus gr III-IV Region 35,97/Plt 279
Bilateral Trochanter
 Ulcus Decubitus gr II Region
Sacrum

Internist
DOC
Hipoalbumin e.c Chronic
Inflammation
15. Post Redebridement (12/09/19) - Laboratorium 13/09/2019 Cefoferazone 1gr/12 hours
Antibiotic Beads ec Infected HB 9,06/HCT 27.91/ PLT Active ROM distal exercise
Wound Right Knee Post 481,1/ WBC 9.79 / Dressing Change every 3 days
Debridement (22/08/2019) -
ORIF PS (30/08/2019) ec Open
Right Floating Knee Fraser 2C
Grade 3B