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Contoh Rekap Pasien (By DR Riswandi SpAn) Rangkap 3
Contoh Rekap Pasien (By DR Riswandi SpAn) Rangkap 3
NO Identitas Pasien OKA Diagnosis dan Tindakan DPJP Anestesi ASA Keterangan
Dx Coloid Goiter sinistra MJ II
1 Rukiah, Pr, 54 thn III Pro. Ismulobectomy sinstra
Suryani, Pr, 32 Dx Goiter Nodule Dextra MJ II
2 thn III Pro. Ismulobectomy Dextra
Dx Invasive Breast ca
Ratna Juita, Pr, 63 mammae sinistra T3N1M0 MJ III
3 thn III Pro. MRM Sinistra
Dx Ca Mammae sinistra
T4CN3MX post MRM
Wasinem, Pr, 55 Sinistra MJ III
4 thn III Pro. Open Biopsi
Dx : Cholelitiasis
Pro : Cholesistectomy MJ Batal (Pasien menolak tindakan
Ricky Taruna, lk , perlaparoscopy +
5 34 thn IV Persiapan open
Dx : Cholelitiasis
Pro : Cholesistectomy MJ II
Musyida Johan, perlaparoscopy +
6 pr, 50 thn IV Persiapan open
Dx : HNP L5-S1
Rita Purnama Pro : Decompress dan KA II
20 Sari, Pr, 37 thn VIII stabilisasi posterior
Sabarmi Lk Pr, 18 Dx : CTEV Sinistra KA I
21 th VIII Pro : PMR Sinistra
Dx Obstruksi parsial ec
stenosis duodenum pars II TY III-IV
dd anulare pancreas
M. Jamaluddin, Pro Laparotomi explorasi +
26 Lk, 6 hri X Duodenostomy
Albifardzan Dx Undesensus Testis TY II
27 Ghani, Lk, 4 thn X Pro Orchydopexy
By. Siti Nurhaliza, Dx : Mioma uteri multiple TY III-IV
28 Lk, 9 hri X Pro : Miomectomy
Dx.Tumor ovarium
Nuriah Juwita, Pr, Pro.Laparotomy TY II
29 25 thn XI kistectomy
Dx.Mioma Uteri Multiple +
kista ovarium bilateral +
infertil 12 th TY II
Pro.Laparotomy
Susi Damayanti, Miomectomy kistectomy
30 Pr, 36 thn XI sd salfingooferectomy
Dx : Ulkus diabetikum ar
pedis sinistra TY
Fitriani Idris Pro : Amputasi digiti 1
31 Umar, Pr, 41 thn XI pedis sinistra II
Dx : Tumor mediastinum +
Maryati, Pr, 49 Efusi pleura
49 thn Endos/Bronkos
Pro : Bronkoskopi KU III