Laporan MRS IGD selasa 22 Oktober 2019

Ruang Nama Tanggal MRS Jenis Kelamin Usia No Register Status Diagnosis Tindakan / Rencana Tindakan RPJ/DPJP
IGD Riswan 10/23/2019 L 25TH 11459705 UM CKR 456 + open wound regio Frontal Debridement + Primary suture (LA) CAN - Dr.Med.dr. TAL,SpBS
CKR 356 + Open wound regio Occipital +
18 Sitin 10/22/2019 P 46TH 11459681 UM CVA Sequele + Hipertensi stage II Debridement + Primary suture (LA) CAN - Dr.Med.dr. TAL,SpBS

SU Solikin 10/22/2019 L 51TH 11459549 JKN CVA ICH thalamus D + IVH + CKD st V on urgent VP shunt kocher S CAN - Dr.Med.dr. TAL,SpBS
routine HD + HT stage II

mild cholangitis + acute cholecystitis ec

19 Wahyu isrodin 10/22/2019 L 27TH 11459578 JKN Polyps Gallbladder Urgent Cholecystectomy CAN - dr.MSN,M.Kes, SpBKBD

IGD By.Ny. Aisyah 10/22/2019 P 6BLN 11459657 JKN Atresi ani dengan fistel rectovestibular Businasi + Urgent Sigmoidostomy (elective CAN - dr.LIK,SpB-KBA
unpatent + VSD OK central hari ini)

Peritonitis generalisata dt appendecitis

IGD Poerwito 10/22/2019 L 61TH 11459633 JKN acute perforata + AF RVR + HF St C FC III pro eksplorasi laparotomy + appendectomy CAN - dr.MSN,M.Kes, SpBKBD

IGD Putri 10/22/2019 P 9TH 11459684 JKN Abscess Submandibula Pro Incisi drainage abscess CAN - dr.SUS,SpBTKV

Adeno Ca recti 1/3 tengah T4bN1M1(liver)

18 Karsiyem 10/22/2019 P 65TH 11425976 JKN on chemotherphy + impending Obstruksi Pro urgent Transversostomy CAN - dr.MSN,M.Kes, SpBKBD

Bedah Saraf : Non Operative Management

CKR 356 +Obs TTT + Obs TTA + Fracture ZMC Bedah Plastik :Debridement and primary
D + Fracture Maksilla D non Lefort + Open suture (GA) + Urgent rekontruksi tulang
wound Regio labium oris inferior wajah CAN - Dr.Med.dr. TAL,SpBS - dr.
IGD Dana 10/22/2019 L 24TH 11459697 UM + Open wound regio supraorbita D + CF BTKV: Non Operative Management DIO,Msc.,M.Ked.Klin.,SpBP-RE - dr.SUS,SpBTK -
distal + third R Ulna isolated + V. abratio B.Digestif: Non Operative Management dr.MSN,M.Kes, SpBKBD - Prof.Dr.dr.MH,
ulnar side R forearm + V. abratio Ortopaedi : SpB.,Sp.OT(K)
anterolateral side L lower leg R forearm : Wound toilet + Moist dressing +
Short arm cast
L lower leg : Wound toilet + Moist dressing

CKR 356 + Burst lobe FTP D + EDH Frontal D

+ SDH TP D 5 mm 7 slice + Edema Cerebri + TDE Burst lobe + Debridement primary
IGD Alif 10/22/2019 L 20TH 11459699 UM Open wound Regio Frontal + Open wound closure. CAN - Dr.Med.dr. TAL,SpBS
regio supraorbita D + Fr Nasal +Fr Maxilla S
Non lefort

Low level bowel obstruction dt Susp

IGD Felysya 10/22/2019 P 7BLN 11459701 JKN Eksplorasi laparatomy k/p reseksi k/p stoma CAN - dr.LIK,SpB-KBA
Invaginasi + anemia

B.Saraf :Non Operative Management

CKR 356 tanpa perdarahan intrakranial + Ortopaedi : debridement + external CAN - Dr.Med.dr. TAL,SpBS - Prof.Dr.dr.MH,
IGD Nurochman 10/22/2019 L 51TH 11459706 UM Open fracture middle third R fibula tibia SpB.,Sp.OT(K)
fiksation
Peritonitis generalisata ec appendecitis akut
IGD Medyna 10/22/2019 P 11TH 11459693 JKN eksplorasi laparotomy kp reseksi kp stoma CAN - dr.LIK,SpB-KBA
perforata
IGD Ifan 10/23/2019 L 14TH 11459709 JKN peritonitis Generalisata dt perforasi hollow CAN - dr.LIK,SpB-KBA
organ (peritonitis trauma) Eksplorasi laparotomy kp reseksi kp stoma
IGD Nasrifa 10/22/2019 P 53TH 11459704 JKN CVA ICH Capsula externa+ HT st II+ DM tipe II CAN - Dr.Med.dr. TAL,SpBS
Pro TDE ICH + EVD kocher S
CVA ICH occipital D 3cc + HT stage II + DM
SU Rianto 10/22/2019 L 62TH 11459663 JKN type II Non Operative Management CAN - Dr.Med.dr. TAL,SpBS

General weakness + Ca Mamma S T4bN1M1

18 Kartini 10/22/2019 P 54TH 11235239 JKN (hepar, paru)+ anemia + hypoalbumin Perbaikan KU + KIE Terminal CAN - dr.HRY,SpB(K)Onk

Keterangan
Post Operasi
Pre Operasi
Konservatif