LAPORAN IRD TANGGAL 16 - 22 OKT 2020

BEDAH SARAF
OPERASI NON-OPERASI
NO NO
TRAUMA REG OPERATOR RABER TRAUMA RABER

CKR 456 + FRAKTUR IMPRESI REGIO FRONTAL + FRAKTUR RIMA ORBITAL

SUPERIOR D + FRAKTUR RIMA ORBITAL INFERIOR D + FRAKTUR LATERAL BUTRES CKR 456 + OPEN WOUND REGIO FRONTAL --> DEBRIDEMENT + PRIMARY HECTING LA
1 MAXILLA D + OPEN WOUND REGIO FRONTAL BONE BASED + CLOSE FRACTURE TAL BP, BR 1 (MENOLAK GA) (ARJUNA MAULANA/L/2,5TAHUN/11494575)
DIGITI 1 METAKARPAL D --> DEBRIDEMENT PRIMARY HECTING LA
(AFAN/L/19TH/11494609)

OPEN WOUND SUPRAORBITA D + CF MIDDLE SHAFT R CLAVICLE --> CKR 456 + SDH TEMPOROPARIETAL D + CONTUSIONAL HEMORRHAGE FRONTAL S -->
2 2
DEBRIDEMENT + PRIMARY HECTING LA (SUBAGIO/L/60TH/11494601) NON OPERATIVE MANAGEMENT (VIKO FIRDAUSI NUZULA LUBIS/L/17TH/11494590)

CKS 335 + CONTUSIO PULMONUM S + MODERATE ARDS + SUBDURAL HYGROME

REGIO FRONTAL D/S + OPEN WOUND REGIO FRONTAL + FR ANGULUS
MANDIBULA D + FR PARASIMFISIS MANDIBULA S + FR DENTOALVEOLAR PARS HEMATOPNEUMOTHORAX D + CONTUSIO PULMONUM D + FR. COSTAE VII-X D
3 MANDIBULA + MULTIPLE VULNUS ABRATION REGIO L FOREARM, R&L HAND, L BP, BT, BR 3 POSTERIOR + CKR 456 TANPA LESI INTRACRANIAL --> NON OPERATIVE MANAGEMENT BT
KNEE, R ANKLE, L FOOT + MULTIPLE VULNUS LACERATUM DORSAL SIDE L HAND (GITRI/P/55TH/11494614)
+ VULNUS LACERATUM MEDIAL SIDE L KNEE + CF R ACETABULUM -->
DEBRIDEMENT + PRIMARY HECTING LA (MOH. ERSAD/L/34TH/11494838)

CKR 456 TANPA LESI INTRACRANIAL + FR. MAXILLA DEXTRA NON LEFORT + FR. ZMC D +
FR. ANGULUS MANDIBULA D + FR. CORPUS MANDIBULA S + FR. CONDYLE MANDIBULA
S + VULNUS LACERATUM PALMAR SIDE R HAND + FINGER TIP INJURY R RING FINGER
4 ALLEN TYPE IV + VULNUS LACERATUM ANTERIOR SIDE R LOWER LEG + BP, BR
HYPERGLYCAEMIA DT UNCONTROLLED DM TYPE 2 --> NON OPERATIVE MANAGEMENT
(LILIS CAHYONO/L/44TH/11494643)

CKS 345 + CONTUSIONAL HEMORRHAGE REGIO TEMPORAL S + SAH + EDEMA CEREBRI

+ FR LINIER TEMPORAL D + MULTIPLE VULNUS ABRASIO REGIO FACIALIS + CF
5 BP, BR
METAPHYSEAL R DISTAL RADIUS INTRAARTICULAR --> NON OPERATIVE MANAGEMENT
(JUNED/L/57THN/11494741)

INTERNAL BLEEDING HD STABIL + CKR 456 + FR NASAL + OPEN WOUND REGIO

6 FRONTALIS + MULTIPLE VULNUS ABRASIO REGIO FACIALIS --> DEBRIDEMENT PRIMARY BD, BP
HECTING LA (SUPRIYADI/L/43TH/11494769)
CKR 456 + VULNUS ABRASIO REGIO FRONTAL --> NON OPERATIVE MANAGEMENT
7 (SUKARI/L/43TH/10481502)
JUMLAH 3 2 JUMLAH 7 4 1
NO NON-TRAUMA REG OPERATOR RABER NO NON- TRAUMA RABER
SOP CEREBRI REGIO TPO S EC GLIOBLASTOMA POST EKSISI TUMOR + RADIOTERAPI +
CVA INFARK + HIDROSEFALUS OBSTRUKTIF + DM TIPE II + AZOTERMIA + ANEMIA KEMOTERAPI --> NON OPERATIVE MANAGEMENT (BENNY
1 -- > PRO EVD (TIWUK/P/48TH/11494606) TAL NEURO 1 16 22 1 1 0 6 0 32 55
KURNIADI/L/46TH/11472595)

ICH SUB KORTEKS VOL. 22CC + HT EMERGENCY STAGE II --> OBSERVASI KETAT DAN
2 HEAD CT KONTROL JIKA GCS TURUN 2 POIN (SALIM/L/55TH/11494628) IKA

ITP + STATUS EPILEPSY + CH REGIO PARIETAL S + SDH SUBAKUT PARIETOOCCIPITAL D

(1,2 CM 7 SLICE) + ANEMIA + GUM BLEEDING --> PERBAIKAN KU UNTUK TOLERANSI
3 IKA
OPERASI + BEDAH SARAF RABER (EVALUASI ULANG JIKA TOLERANSI OP TERCAPAI)
(ALESSANDRO/L/8TH/24,5KG/11382770)

CKR 456 + SUBDURAL HYGROMA FTP D/S + VULNUS ABRASIO REGIO PARIETAL S -->
4 PRO CT SCAN EVALUASI H-5 ATAU BILA KLINIS MEMBERAT (EDY
SUBIANTO/L/59TH/11494815)
CKR 456 + SUBDURAL HYGROME REGIO TEMPORAL S --> NON OPERATIVE
5 MANAGEMENT, CT SCAN EVALUASI H+5 (MUJIONO IHSAN/L/41TH/11494909)

AGENESIS CORPUS COLLOSUM + MODERATE COMMUNICATING HYDROCEPHALUS ON

VP SHUNT KOCHER D + MENINGOENCEPHALOCELE POST EKSISI CELE + WOUND
6 DESHICENCE REGIO OCIPITAL POST EKSISI CELE SUSP LEAKAGE LCS --> PRO CT KEPALA BP
DENGAN KONTRAS + SWAB LUKA + KULTUR DAN ANALISIS LCS DARI CHAMBER VP
SHUNT (KENZIO/L/8BLN/8KG/11486098)

JUMLAH 1 1 JUMLAH 6 3

LAPORAN OK SENTRAL
BEDAH SARAF
DIA GNOS TINDA KA OPERATO BIMBING
No TGL NAMA BILLING RUANG ANESTESI
IS N R AN

CHRONIC
HEADACH
E + SUSP
MENINGI
TIS TB
(A17.0) + VP SHUNT
EDEM A DOUBLE
1 24/08/20 QUEEN 11490586/2019622 13HCU CEREBRI SET UP GA FAR
( G93.6) + EVD
MILD (02.21)
COM MUN
ICA TING
HYDROCE
PHA LUS
(G91.9)

CVA SAH
(I60.9) +
IV H
(I61.5) +
M ODERA
TE
HYDROCE
PHA LUS
( G91.9) + VP SHUNT
2 24/08/20 MUNIKAH 11489680/2018738 ICU KOCHER GA TAL
HT GRADE D (02.4)
II (I10) +
PNEUMO
NIA
(J18.9) +
POST
REEVD
KOCHER
D

INFECTED
W OUND
POST
EXCICI
CELE
POST RE
DEBRIDE
VP
MET SHUNT
3 25/08/20 BY NY. DIAN EKA 11488290/2017391 15 PEDIKEL KOCHER S GA DON
FLAP
(H13)+ (02.4)
POST AFF
VP S HUNT
+ POST RE
EVD
KOCHER S
(H12)

CHRONIC
HEADACH
E + SUSP
MENINGI
TIS TB
(A17.0) + VP SHUNT
DOUBLE
4 25/08/20 MUHAMMAD ASIR 11490593/2019631 13HCU TB PARU SET UP GA FAR
ON OAT
( A15.0)+ EVD
M ODERA (02.21)
TE
HYDROCE
PHA LUS
(G91.9)

SEVERE
COMUNN
ICANS
HYDROCE VP SHUNT
5 27/08/20 BY. NY. ROHMANI 11490659 15 PHA LUS KEEN S GA FAR
ON V P (02.4)
SHUNT
KEEN D
(G91.9)

JUMLAH 5 5

16 17 11 13 12 13 8 9 12 14 6 8 8 10 73 84 43% 50%

17 20 12 14 10 12 9 10 11 13 8 10 8 10 75 89 45% 53%

14 16 11 13 13 14 12 14 10 12 6 8 9 11 75 88 45% 52%

44% 52%

6
8 6 12 0 0 0 0
24 7 9 0 0 0 0
50 9 20 3 5 0 0
60 13 15 3 3 0 0
15 14 18 2 2 0 0
12 10 12 1 1 0 0
39 8 14 1 1 0 0
214 12 14 2 4 0 0
79 114 12 16 0 0
 LAPORAN KONDISI RUANGAN TANGGAL 16 - 22 OKTOBER 2020
SEKSI: BEDAH SARAF

RUANG NO DIAGNOSIS TGL MRS PRE OP SIAP OP POST OP KONSERVATIF RABER LAMA
RAWAT

11
14

SURGICAL SITE INFECTION POST EKSISI CELLE POST INCISI DRAINAGE

(13/10/2020 H-6) POST RE DEBRIDEMENT + KULTUR SWAB
1 (19/10/2020) -> RAWAT LUKA BERKALA, BEBAT TEKAN LUKA, OBS 12/10/2020 1
PRODUKSI DRAIN + MANDI DENGAN CHLORHEXIDINE + USUL DARI (H+9)
PPRA (DR. IRENE, SP.A) UNTUK DILAKUKAN DEBRIDEMENT DAN SWAB
ULANG (M.AZAM WABIL/L/10BL/8.7KG/11488172)

15
AGENESIS CORPUS COLLOSUM + MODERATE COMMUNICATING
HYDROCEPHALUS ON VP SHUNT KOCHER D +
MENINGOENCEPHALOCELE POST EKSISI CELE + WOUND DESHICENCE
REGIO OCIPITAL POST EKSISI CELE SUSP LEAKAGE LCS -> CT KEPALA 19/10/2020
2 DENGAN KONTRAS + SWAB LUKA + KULTUR DAN ANALISIS LCS DARI (H+2) 1
CHAMBER VP SHUNT + RAWAT LUKA DENGAN STERILE DRESSING +
URGENT DEBRIDEMENT, EVALUASI , KP REPAIR (BERRYPLAST) JOIN OP
BEDAH PLASTIK KAMIS 22/10/2020 (KENZIO/L/8BLN/8KG/11486098)

16

PARAVERTEBRAL ABSES POST STABILISASI POSTERIOR + DEKOMPRESI

EC RADICULAR PAIN DT CANAL AND FORAMEN STENOSIS VL II-V EC
HNP + FR. KOMPRESI VL III + DM TYPE II + HYPOALBUMINEMIA + POST
DEBRIDEMENT + INSISI DRAINAGE ABSCESS (12/11/2020) -> CEK 11/10/2020
17 1 DL,GDA,SE,ALBUMIN + P/O : VIPALBUMIN 3X1 + DIET TKTP EXTRA (H+10) 1
PUTIH TELUR + MELANJUTKAN PEMBERIAN ANTIBIOTIK + OBSERVASI
KU, VS, ST NEUROLOGIS, PRODUKSI DRAIN (KUALITAS DAN
KUANTITAS) + VACUM DRAIN SETIAP PAGI - SORE SELAMA 14 HARI
(KADIM/L/50 TH/11187834)

18
SKULL DEFECT POST TDE ICH (8/7/2020) + FR MAXILLA LE FORT 2 +
OPEN WOUND PERIORBITA SUPERIOR S + POST DEBRIDEMENT +
19 1 PRIMARY CLOSURE + ARCHBARR + POST REKONSTRUKSI TULANG 17/10/2020 1
(H+4)
WAJAH) -> PRO CRANIOPLASTY (21/10/2020) HENDRA KUSUMA
(21/10/2020)
20
21
JUMLAH 0 0 4 0
 LAPORAN AKUT BEDAH SARAF TANG
BEDAH SAR
NO

JML

LAPORAN ICU BEDA

NO

JML
 9
6
4
1
0
6
0
11
 LAPORAN AKUT BEDAH SARAF TANGGAL 1
BEDAH SARAF

CKR 456 + SUBDURAL HYGROMA FTP D/S + VULLNUS ABRASIO REGIO PA

MANAGEMENT (EDY SUBIYANTO)

CKR 456 + Subdural hygrome regio Tempo

CKS 345 + CONTUSIONAL HEMORRHAGE REGIO TEMPORAL S + SAH + E

TEMPORAL D + MULTIPLE VULNUS ABRASIO REGIO FACIALIS + CF META
INTRAARTICULAR -> NOM (JUNED)
3

LAPORAN ICU BEDAH SA

DIAGNOSA / NAMA
SDH SUBAKUT FTP D ET S + AF RVR POST MITRAL VALVE REPLACEMENT +
FH (PERBAIKAN) -> CT SCAN KEPALA EVALUASI (KUSW

CKS 335 + CONTUSIO PULMONUM S + MODERATE ARDS + SUBDURAL HYG

OPEN WOUND REGIO FRONTAL + FR ANGULUS MANDIBULA D + FR PARA
DENTOALVEOLAR PARS MANDIBULA + MULTIPLE VULNUS ABRATION REG
KNEE, R ANKLE, L FOOT + MULTIPLE VULNUS LACERATUM DORSAL SIDE L H
MEDIAL SIDE L KNEE + CF R ACETABULUM -> DEBRIDEMENT + PRIMARY

2
6
16
11
8
1
19
14
2
13
20

UMUR/JK TGL MRS

P/59TH 10/20/2020

L/41TH 10/21/2020

L/54 TH 10/20/2020

UMUR/JK TGL MRS

P/55 TH 10/11/2020

L/34 TH 10/21/2020
COB 224-2X5-
113 + EDH
FRONTAL D +
DAI+
PNEUMONIA -
> NON L/24TH 8/4/2020
OPERATIVE
MANAGEMENT
(MUH.
MUSTAIN)
15 31
0 11
3 11
0 1
8 27
5 19
4 6
10 23
 KONSULAN TANGGAL 16 - 22 OCTOBER 2020

SEKSI TGL NAMA DIAGNOSA JAWABAN JUMLAH

 LAPORAN OK BEDAH SARAF TANGGAL 16 - 22 OKTOBER 2020
LAPORAN OK PAVILIUN
BEDAH SARAF
No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN

JUMLAH 0 0 6 6
5 5
LAPORAN OK EKSTIRPASI 12 20
16 20
No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN 13 19
10 10
BEDAH SARAF 13 14
JUMLAH 93 114

LAPORAN OK SENTRAL

BEDAH SARAF
No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN

SEVERE OBSTRUKTIF HYDROCEPHALUS (G91.9) + MULTIPLE CYSTIC

1 21/10/20 BY NY AYU NANDA 11494163 RANUPANI LESSION IN PERIVENTRICLE SUSP NEUROGLIAL CYST (G93.0) + PREMATURE VP SHUNT (02.3) GA 2 JAM M
+ BBLR

2 21/10/20 HENDRA KUSUMA 11487554 LAWU SKULL DEFECT POST TDE ICH (8/7/2020) (Z98.89) CRANIOPLASTY (020) GA 2 JAM M

Agenesis Corpus Collosum + Moderate communicating hydrocephalus On VP

3 10/22/2020 ETV + debridement + repair (join op bedah plastik
KENZIO 11486098 15 shunt kocher D + Meningoencephalocele post Eksisi cele + Wound deshicence GA 2 JAM M
22/10/2020)
regio ocipital post eksisi cele susp leakage LCS

JUMLAH 2

OPERASI
SEKSI
BEDAH SARAF
P
BEDAH SARAF
E
BEDAH SARAF
S
TOTAL

JUMLAH
BIMBINGAN 0
SEKSI 0
0
BEDAH SARAF 0

OPERASI

RESIDEN PEMBIMBIN JUMLA

G H