RABU, 13 JULI 2022

ICU A

BED 5

NY. RUSMINI/P/73TH/11543051

KONSUL : 7/7/2022

DX : + DM FOOT PEDIS S + HEMIBALLISMUS D DT HYPERGLICEMIC STATE + GRADUAL DOC DT

SEPTIC ENCEPHALOPATHY DD HYPOXIC ENCEPHALOPATHY + HYPERGLICEMIA DT DM TYPE 2 DD HHD
DD KAD + MODERATE HYPERNATREMI + MILD HYPOKALEMIA + HYPERCHLOREMIA +
HIPOALBUMINEMIA(NY. RUSMINI/P/73TH/11543051)

TX : + RAWAT LUKA DENGAN DRESSING TULLE DAN BURNAZIN

DPJP : DR. DR. HRM, SPBP-RE(K)

ICU C

BED 2

NY. MISTIN/P/39TH/11487027

MRS : 6/7/2022

DX : + INFECTED WOUND REGIO SUPRAORBITA S POST EKSISI TUMOR + SKIN EXCESS +

REKONSTRUKSI EYEBROW DT SOP CEREBRI RESIDIF REGIO FRONTAL SINISTRA EC MENINGIOMA(NY.
MISTIN/P/39TH/11487027)

TX : + POST DEBRIDEMENT INFECTED WOUND POST EKSISI MENINGIOMA (13/7/2022)

DPJP : DR. ARV, SPBP-RE

BED 4

TN. TARIONO/L/44TH/11543399

MRS : 8/7/2022

DX : + CKR 356 TANPA PERDARAHAN INTRAKRANIAL + SUBDURAL HYGROME REGIO FRONTAL D ET S

+ FR. ZMC S + FR. NOE D ET S TIPE 1 + FR. MAXILLA LE FORT II + FR. OS PALATUM S TIPE 1(TN.
TARIONO/L/44TH/11543399)

TX : + POST DEBRIDEMENT + ADVANCEMENT FLAP (09/07/2022) + POST REKONSTRUKSI TULANG

WAJAH (12/7/2022) + RAWAT LUKA ABRASI DENGAN HYDROCOLLOID

DPJP : DR. DIO, M. SC., M. KED.KLIN., SPBP-RE

HCU CILIWUNG

BED 11

NY. WINARTI/P/49TH/11543322

KONSUL : 10/7/2022

DX : + DIABETIC FOOT REGIO PLANTAR PEDIS D & REGIO DORSUM PEDIS S + UPPER GI BLEEDING +
DM TIPE 2 + ANEMIA + HYPOALBUMINEMIA + THROMBOSITOPENIA(NY.
WINARTI/P/49TH/11543322)

TX : + RAWAT LUKA DENGAN AUTOLYTIC DEBRIDEMENT BURNAZIN PLUS + URGENT DEBRIDEMENT

+ PERBAIKAN KU (TRANFUSI PRC DAN ALBUMIN)

DPJP : DR. RUM, SPBP-RE

MAHAKAM

BED 10

NY. RASEMI/P/74TH/11543743

KONSUL : 12/07/2022

DX : + CVA TROMBOSIS DD EMBOLI + HT ST 2 + DM TYPE 2 ON INSULIN + MODERATE

HYPOALBUMINEMIA + DIABETIC FOOT PEDIS D WAGNER IV(NY. RASEMI/P/74TH/11543743)

TX : + RAWAT LUKA MOIST DENGAN AUTOLITIK DEBRIDEMENT + SURGICAL DEBRIDEMENT JIKA KU

OPTIMAL

DPJP : DR. DR. HRM, SPBP-RE(K)

NICU MANINJAU

BY. NY. WAHYUNI/P/39HR/1.900GR/11541280

MRS : 19/6/2022

DX : + OBS SEIZURE + POST ROSC + SUPERFICIAL-MID DERMAL BURN INJURY 5.5% DT THERMAL
CONTACT + FULL THICKNESS BURN INJURY 5% REGIO EXTREMITAS INFERIOR ET SUPERIOR S DT
THERMAL CONTACT + BBLR/PRETERM + HIPERBILIRUBINEMIA + POST DEBRIDEMENT (20/6/2022) +
POST RE-DEBRIDEMENT (24/6/2022) + POST RE-DEBRIDEMENT (29/6/2022) + POST RE-
DEBRIDEMENT (4/7/2022) + POST RE-DEBRIDEMENT (8/7/2022) + POST RE-DEBRIDEMENT
(11/7/2022)( BY. NY. WAHYUNI/P/39HR/1.900GR/11541280)
TX : + PRO DEBRIDEMENT

DPJP : DR. RUM, SPBP-RE

CISADANE

BED 5

TN. M. HASAN/L/53TH/11543058

MRS : 5/7/2022

DX : + CKS 345 + SAH + EDH FRONTAL D + EDH OCCIPITAL + FR LINIER FRONTAL D + FR MAXILLA D
NON LEFORT + FR RIMA ORBITA SUPERIOR D + FR RIMA ORBITA INFERIOR D + SUBGALEAL
HEMATOME FTP D + MULTIPLE VULNUS ABRASIO FACIAL REGION + CHRONIC WOUND DORSAL SIDE
R RING FINGER + CF SUBTROCHANTER L FEMUR + CF R ANKLE WEBER B(TN. M.
HASAN/L/53TH/11543058)

TX : + RAWAT LUKA ABRASIO DENGAN HYDROCOLLOID DRESSING + POST REKONSTRUKSI TULANG

WAJAH (13/7/2022)

DPJP : DR. RUM, SPBP-RE

BED 6

TN. KAMARI/L/53TH/11543728

MRS : 12/07/2022

DX : + CKR 456 + CH REGIO FRONTAL + EDEMA SEREBRI + FR MAXILLA LE FORT I + FR ANTERIOR DAN
POSTERIOR WALL SINUS FRONTAL D + FR LINEAR OS FRONTAL D + FR RIMA ORBITA INFERIOR D /S +
FR ARCUS ZYGOMA S + FR ANGULUS MANDIBULA S(TN. KAMARI/L/53TH/11543728)

TX : + RAWAT LUKA DENGAN HYDROCOLLOID DRESSING + URGENT REKONSTRUKSI TULANG WAJAH

DPJP : DR. DR. HRM, SPBP-RE(K)

BED 14

TN. HISYAM/L/40TH/11541889

MRS : 25/6/2022

DX : + COB 114 - 234 + SUSP DAI + FR. ZYGOMA S + FR. MAXILLA S NON LE FORT + ABRASION
WOUND REGIO FACIALIS (TN. HISYAM/L/40TH/11541889)

TX : + PRO URGENT REKONSTRUKSI TULANG WAJAH + RAWAT LUKA ABRASIO DENGAN

HYDROCOLLOID DRESSING

DPJP : DR. DIO, M. SC, M. KED. KLIN, SPBP-RE

BED 16

TN. DIMAS ADE/L/19TH/11543179

MRS : 6/7/2022

DX : + PNEUMOTHORAX D + PERITONITIS GENERALISATA DT PERFORASI JEJUNUM POST TRAUMA +

CKR 456 TANPA PERDARAHAN INTRAKRANIAL + OPEN DEGLOVING REGIO PELVIS D + OPEN WOUND
PELVIS S + OPEN WOUND ZYGOMA S + MULTIPLE VULNUS ABRASIO FASCIALIS + CF MIDDLE SHAFT R
CLAVICLE + OF MIDDLE SHAFT R HUMERUS GR IIIA + MULTIPLE VULNUS ABRASION ULNAR SIDE L
ELBOW + OF R ILIAC WING + CF L INFERIOR RAMUS PUBIS + VULNUS LACERATUM L BUTTOCK
REGION(TN. DIMAS ADE/L/19TH/11543179)

TX : + DEBRIDEMENT + STSE DEGLOVING PELVIS S + ADVANCEMENT FLAP OPEN WOUND ZYGOMA S

(6/7/2022)

DPJP : DR. ARV, SPBP-RE

BED 20

NY. MUTMAINAH/P/41TH/11543414

MRS : 9/7/2022

DX : + FR COSTAE 2 LATERAL S + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + OPEN WOUND

REGIO FRONTAL + OPEN WOUND INFERIOR NASAL + SUSP CLOSED DEGLOVING PEDIS D + CF MIDDLE
SHAFT L CLAVICLE + OF INTERCONDYLAR R FEMUR GR. IIIA(NY. MUTMAINAH/P/41TH/11543414)

TX : + POST DEBRIDEMENT + ADVANCEMENT FLAP GA (REGIO INFERIOR NASAL) + STSE REGIO PEDIS
D

DPJP : DR. WMA, SPBP-RE (K) MO

PICU

BED 5

AN. ERIKA/10TH/45KG/11533084

KONSUL : 12/7/2022

DX : + DERMATITIS KONTAK + PARALISIS DIAFRAGMA S POST TRACHEOSTOMY + ENCEPHALITIS DT

HSV + PNEUMONIA(AN. ERIKA/10TH/45KG/11533084)

TX : + RAWAT LUKA BERKALA DENGAN MOMETHASONE FUROATE + GENTAMICIN CREAM

DPJP : DR. DR. HRM, SPBP-RE(K)

KAWI (16)

NY. SULASTRI/P/78TH/11543175

MRS : 6/7/2022

DX : + SUSP. PEMFIGUS VULGARIS + SEVERE HYPOALBUMIN--> RAWAT LUKA DENGAN TULLE DAN
KASSA STERIL + POST DEBRIDEMENT (12/7/2022)( NY. SULASTRI/P/78TH/11543175)

TX : + RAWAT LUKA DENGAN TULLE DAN KASSA STERIL + POST DEBRIDEMENT (12/7/2022)

DPJP : DR. ARV, SPBP-RE

TN. SURATNO/L/51TH/11542773

MRS : 3/7/2022

DX : + SUPERFICIAL MID DERMAL BURN INJURY REGIO KEPALA, ABDOMEN, BACK, EXTREMITAS
SUPERIOR D, EXTREMITAS INFERIOR D/S 26% RS 15% DT API + DEBRIDEMENT GA (3/7/2022) + POST
RE-DEBRIDEMENT (8/7/2022)--> PRO DEBRIDEMENT (14/7/2022)( TN. SURATNO/L/51TH/11542773)

TX : + PRO DEBRIDEMENT (14/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

TN. SUPRAPTONO/L/52TH/11542774

MRS : 3/7/2022

DX : + SUPERFICIAL MID DERMAL BURN INJURY REGIO KEPALA, EXTREMITAS SUPERIOR D/S,
EXTREMITAS INFERIOR D 28% RS 20% DT API + DEBRIDEMENT GA (3/7/2022) + POST DEBRIDEMENT
(8/7/2022)--> PRO DEBRIDEMENT (14/7/2022)( TN. SUPRAPTONO/L/52TH/11542774)

TX : + PRO DEBRIDEMENT (14/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

GALUNGGUNG 18

BED 1

NN. WULAN/P/16TH/11543321

MRS : 7/7/2022

DX : + CKR 456 TANPA PERDARAHAN INTRACRANIAL + FR NASAL + FR DENTOALVEOLAR PARS

MAXILLA + ABRASIO LABIA SUPERIOR --> POST ARCHBARR + REPOSISI NASAL + NASAL SPLINT
(9/7/2022)( NN. WULAN/P/16TH/11543321)
TX : + POST ARCHBARR + REPOSISI NASAL + NASAL SPLINT (9/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

LAWU 19

BED 4

TN. EVAN/P/20TH/11543400

MRS : 9/7/2022

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + FR. MAXILLA D NON LEFORT + FR NASAL +
MULTIPLE FACIAL ABRASION + MULTIPLE VULNUS ABRASION LATERAL SIDE R SHOULDER,
ANTEROLATERAL SIDE R KNEE & LATERAL SIDE L LOWER LEG + VULNUS LACERATUM DORSAL SIDE R
FOOT--> PRO URGENT REPOSISI NASAL + REKONSTRUKSI TULANG WAJAH + RAWAT LUKA ABRASI
SECARA MOIST DENGAN HYDROCOLLOID DRESSING(TN. EVAN/P/20TH/11543400)

TX : + PRO URGENT REPOSISI NASAL + REKONSTRUKSI TULANG WAJAH + RAWAT LUKA ABRASI
SECARA MOIST DENGAN HYDROCOLLOID DRESSING

DPJP : DR. WMA, SPBP-RE (K) MO

BED 9

TN. M. SOLEKHUDIN/L/44TH/11537575

MRS : 13/6/2022

DX : + CHRONIC WOUND POST INCISI DRAINASE ABSCESS SUBMANDIBULA + ANEMIA +

HYPOALBUMINEMIA + POST DEBRIDEMENT + NPWT (15/6/2022) + POST RE-DEBRIDEMENT + NPWT
(21/6/2022) + POST RE-DEBRIDEMENT + NPWT + SWAB DASAR LUKA EVALUASI (28/6/2022) +
PSEDOMONAS ESBL + POST SUPRACLAVICULAR FLAP + STSG (7/7/2022)--> AFF JAHITAN GRAFT(TN.
M. SOLEKHUDIN/L/44TH/11537575)

PLAN : + AFF JAHITAN GRAFT

DPJP : DR.DR.HRM, SPBP-RE(K)

BED 37

TN. K. HARIANA/L/62TH/11542972

MRS : 5/7/2022

DX : + CKR 356 TANPA PERDARAHAN INTRAKRANIAL + SUBDURALHYGROMA FRONTAL S + OPEN

WOUND SUPRAORBITA S + HT STG II + ATROFI CEREBRI + FR MAXILLA LEFORT I + FR RIMA ORBITA
INFERIOR D/S + DENTAL AVULSION + JOINT EFFUSION L KNEE DT SUSP HEMARTHROSIS + CF L
PATELLA INCOMPLETE--> RAWAT LUKA DENGAN MOIST DRESSING + PRO URGENT REKONSTRUKSI
TULANG WAJAH(TN. K. HARIANA/L/62TH/11542972)

TX : + RAWAT LUKA DENGAN MOIST DRESSING + PRO URGENT REKONSTRUKSI TULANG WAJAH

DPJP : DR. RUM, SPBP-RE

JAYAWIJAYA (21/22)

BED 5

NY. LIE VONNY/P/69TH/11543464

MRS : 10/07/2022

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + OPEN WOUND FRONTAL REGION + OPEN
WOUND LABIA ORIS SUPERIOR--> POST DEBRIDEMENT + PRIMARY HECTING GA (11/7/2022)( NY. LIE
VONNY/P/69TH/11543464)

TX : + POST DEBRIDEMENT + PRIMARY HECTING GA (11/7/2022)

DPJP : DR. RUM, SPBP-RE

BED 9

AN. ZALINADIA/P/9BLN/8KG/11520994

MRS : 11/07/2022

DX : + SELULITIS REGIO WRIST S + POST DUHAMEL PROCEDURE 1 TAHAP (TANPA STOMA) H+5 DT
OBSTIPASI KRONIS EC HIRSCHPRUNG’S DISEASE--> KOMPRES DENGAN NS + RAWAT DENGAN SALEP
GENTAMYCIN(AN. ZALINADIA/P/9BLN/8KG/11520994)

TX : + KOMPRES DENGAN NS + RAWAT DENGAN SALEP GENTAMYCIN

DPJP : DR. ARV, SPBP-RE(K)

BUNAKEN(24C)

BED 2.2

NY. SOESIANA/P/75TH/11498002

MRS : 11/07/2022

DX : + SELULITIS PEDIS ET CRURIS D--> URGENT DEBRIDEMENT + NPWT(NY.

SOESIANA/P/75TH/11498002)
TX : + URGENT DEBRIDEMENT + NPWT

DPJP : DR. ARV, SPBP-RE(K)

BED 3.2

SDR. FLOURENTIUS VIGO DAMAYANTO/L/19TH/11541052

MRS : 11/7/2022

DX : + ABSESS MANDIBULA + FR. MANDIBULA SEGMENTAL--> PRO DEBRIDEMENT + EKSTERNAL

FIXASI(SDR. FLOURENTIUS VIGO DAMAYANTO/L/19TH/11541052)

TX: + PRO DEBRIDEMENT + EKSTERNAL FIXASI

DPJP : DR. DR. HRM, SPBP-RE(K)

PANGANDARAN (27)

BED 30

TN. FERIANTO/L/27TH/10902390

KONSUL : 10/07/2022

DX : + MORBUS HANSEN MULTI BACILLARY EERYTHEMA NODUSUM LEPROSUM DERAJAT BERAT

DENGAN DISABILITAS DERAJAT 2 + ANEMIA + AKI--> PERBAIKAN KU + RAWAT LUKA MOIST
DRESSING DENGAN GENTAMISIN SALEP + PRO URGENT DEBRIDEMENT JIKA KELUARGA SETUJU(TN.
FERIANTO/L/27TH/10902390)

TX : + PERBAIKAN KU + RAWAT LUKA MOIST DRESSING DENGAN GENTAMISIN SALEP + PRO

URGENT DEBRIDEMENT JIKA KELUARGA SETUJU

DPJP : DR. RUM, SPBP-RE

PARANGTRITIS 28

BED 15

NY. TUKINI/P/70TH/11157847

MRS : 7/7/2022

DX : + ULKUS DECUBITUS REGIO SACRUM GRADE IV + CA MAMMAE S T4BN3CM1 (VERTEBRAE) POST

MRM S KEMOTERAPI ZOMETA 6X + KEMOTERAPI TC 1X ON HORMONAL THERAPY--> POST NPWT
(8/7/2022)( NY. TUKINI/P/70TH/11157847)

TX : + POST NPWT (8/7/2022)

DPJP : DR. DIO, SPBP-RE

POLIKLINIS

TN. TARI/L/73TH/11543608

MRS : 11/07/2022

DX : + CKS 345 + SAH + SUBDURAL HYGROMA FRONTOBASAL D/S + SUBDURAL HYGROMA

FRONTOPARIETAL S + CEREBRAL EDEMA + FR. MAXILLA LE FORT I DAN II + FR. ZMC S + FR. RIMA
ORBITA D + OPEN WOUND REGIO FRONTAL D + OPEN LABIA ORIS SUPERIOR D + MULTIPLE DENTAL
LOOSE + MULTIPLE ABRASION WOUND FASCIAL REGION + CF L PATELLA INCOMPLETE + OF L TIBIAL
PLATEAU SCH. VI + OF PROXIMAL SHAFT L FIBULA GR. IIIA + VULNUS ABRATION ANTEROMEDIAL
SIDE L THIGH + VULNUS ABRATION ANTERIOR SIDE L KNEE + MULTIPLE VULNUS ABRATION
ANTERIOR SIDE L LOWER LEG

TX : + RAWAT LUKA DENGAN MOIST DRESSING + POST DEBRIDEMENT ADVANCEMENT FLAP + PRO
URGENT REKONSTRUKSI TULANG WAJAH

DPJP : DR. ARV, SPBP-RE(K)

TN. LEE NARDO/L/17TH/11543377

MRS : 8/7/2022

DX : + OBS. TTT + CKR 346 TANPA PERDARAHAN INTRAKRANIAL + CONTUSIONAL HEMORRHAGE +

FR. LINEAR OS TEMPORAL D + FR. ZMC D + FR. MAXILLA NON LEFORT D + FR. CORONOID
MANDIBULLA D + OPEN WOUND REGIO SUPRAORBITA S + OPEN WOUND REGIO SUPRAORBITA D +
OPEN WOUND LABIA ORIS SUPERIOR D + MULTIPLE ABRASION WOUND FASCIAL REGION + CF
MIDDLE SHAFT L FEMUR + ABRATION WOUND AT ANTERIOR SIDE L LOWER LEG + MULTIPLE
LACERATUM WOUND AT ANTEROMEDIAL & ANTEROLATERAL SIDE L LOWER LEG AND DORSAL SIDE L
3RD TOE + OF PROXIMAL SHAFT L TIBIA FIBULA FIBULA GR IIIA + CF BASE 1ST METATARSAL L FOOT +
OF PROXIMAL PHALANX L 2ND TOE + OF MIDDLE PHALANX L 2ND TOE

TX : + POST DEBRIDEMENT + ADVANCEMENT FLAP + PRO URGENT REKONSTRUKSI TULANG WAJAH

+ RAWAT LUKA ABRASIO DENGAN HYDROCOLLOID DRESSING

DPJP : DR. DIO, M. SC., M. KED.KLIN., SPBP-RE

KRS

TN. WAHIDIN/L/51TH/11537991

MRS : 11/7/2022

DX : + CHRONIC WOUND REGIO FEMUR S + DM TYPE II

PLAN: + POST RE DEBRIDEMENT + NPWT (12/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

TN. HIDAYATULLOH/L/30 TH/11525584

MRS : 11/6/2022

DX : + DOC DT SUSP. ME TB DD BAKTERIAL + POST STATUS FOCAL TO BILATERAL MOTOR ONSET

TONIC CLONIC SEIZURE DT EPILEPSY SYMPTOMATIC + PARAPARESE INFERIOR UMN TYPE DT. SUSP.
SPONDILITIS TB + PRESSURE ULCER REGIO SACRUM DAN FEMUR D GR III + MILD HYDROCEPHALUS +
PNEUMONIA HAP + TB PARU + ANEMIA (9,8) + LEUKOSITOSIS (11.250) + HYPOALBUMINEMIA (2,67)
+ HYPONATREMIA (130) + HYPOKALEMIA (2,95)

TX : + RAWAT LUKA MOIST DRESSING DENGAN BURNAZINE + PERBAIKAN KU SESUAI TS NEURO DAN
PARU

DPJP : DR. DR. HRM, SPBP-RE(K)

RINJANI

AN. YASIN KHOIRUDIN/L/3TH/11423220/RINJANI

MRS : 6/7/2022

DX: + HYPOSPADIA DISTAL PENILE

TX : + POST CHORDECTOMY + URETROPLASTY (7/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

TN. MULYONO/L/67TH/11542755

MRS : 2/7/2022

DX : + CKR 356 TANPA PERDARAHAN INTRAKRANIAL + FR. MAXILLA LE FORT II + FR. OS. NASAL + FR.
ANGULUS MANDIBULLA D + FR RIMA ORBITA INFERIOR D/S + FULL THICKNESSS DERMAL BURN
INJURY REGIO CRURIS D 1% + CF HUMERUS

TX :

BP : + POST REKONSTRUKSI TULANG WAJAH + DEBRIDEMENT BURN INJURY REGIO CRURIS D

(7/7/2022)

BR : + P-S HUMERUS (7/7/2022)

DPJP : DR. DR. HRM, SPBP-RE(K)

TN. AHMAD MIFTAHURROZIQ/L/21TH/11534565

MRS : 12/7/2022
DX : + ARCHBARR WIRING POST FRAKTUR SUBMANDIBULA

TX : + PRO AFF ARCHBAR

DPJP : DR. ARV, SPBP-RE

AN ARUMI NASHA/P/1TH/8KG/11306285

MRS : 12/7/2022

DX : + HEMANGIOMA REGIO MAXILLA S

TX : + INJEKSI BLEOMYCIN KE 3

DPJP : DR. ARV, SPBP-RE

AN. HASNA/P/8TH/11543506

MRS : 12/7/2022

DX : + HEMANGIOMA REGIO CUBITI S

TX: + PRO INJEKSI BLEOMYCIN KE 1 (13/7/2022)

DPJP : DR. ARV, SPBP-RE

PAPS

(-)

MENINGGAL

NY. SUISTINI/P/57TH/11543429

MRS : 9/7/2022

DX : + CHRONIC WOUND DT MID DERMAL BURN INJURY RS 18% REGIO FACIALIS, THORAX
POSTERIOR, EXTREMITAS SUPERIOR ET INFERIOR D/S DT FIRE + HIPERNATREMIA + SEPSIS

TX : + POST DEBRIDEMENT GA (10/7/2022)

DPJP : DR. WMA, SPBP-RE (K) MO

NY. SITI AMINAH/P/39TH/11541238

MRS : 19/6/2022

DX : + CONTUSIO PULMONUM S + SEPSIS + OPEN WOUND DT DEGLOVING INJURY REGIO BRACHII ,

FLANK ET GLUTEUS D POST DEBRIDEMENT (20/6/2022) + CKR 456 + CONTUSSIONAL
HAEMORRHAGE REGIO CAPSULA INTERNA D ET S + SUBDURAL HYGROMA REGIO FRONTOBASAL
BILATERAL + FACIAL ABRASION + POST RE-DEBRIDEMENT + NPWT (24/6/2022) + POST
DEBRIDEMENT + NPWT (29/06/2022) + DEBRIDEMENT + EXPLORE + NPWT (4/7/2022)

TX : + POST RE-DEBRIDEMENT EXPLORE + NPWT (9/7/2022)

DPJP : DR. DIO, M. SC, M. KED. KLIN, SPBP-RE

NY. BOINEM/P/71TH/11543070

KONSUL : 11/7/2022

DX : + ULCUS DECUBITUS GR II REGIO SACRUM + SEPSIS + CVA TROMBOSIS BRAINSTEM 3RD ATTACK
OH-12 + HT ST I + HF ST C FC II DT CAD, HHD + HYPONATREMIA HYPOOSMOLAR HYPOVOLEMIA + AKI
+ SEVERE HYPOALBUMINEMIA

TX : + PERAWATAN LUKA MOIST + MOBILISASI MIRING KIRI KANAN TIAP 3 JAM

DPJP : DR. ARV, SPBP-RE

TN. JOKO SUSANTO/L/42TH/11543589

MRS : 11/7/2022

DX : + CONTUSIO PULMONUM D + FR. COSTAE 4,5,6 POSTERIOR D + CKS 225 + SAH + CH REGIO
PARIETAL S + CH REGIO TEMPOROBASAL D + EDEMA CEREBRI + FR. LINIER OS TEMPORAL D + FR.
LINIER OS FRONTAL D + TEARDROP FRACTURE AT VERT. CERVICAL V UNDEFINED ASIA + FR. MAXILLA
NON LE FORT D + FR. RIMA ORBITAL SUPERIOR ET INFERIOR D + MULTIPLE ABRASION WOUND
FASCIAL REGION

TX : + RAWAT LUKA DENGAN MOIST DRESSING + PRO URGENT REKONSTRUKSI TULANG WAJAH

DPJP : DR. ARV, SPBP-RE(K)

TERIMA KASIH DOKTER.