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ICD X ICD IX
K 35.80 Acute appendicitis 99.2 Injection or infusion of other
288.60 Elevated white blood cells
G68.9 Acute pain therapeutic
47.0 Appendicectomy
Z79.891 The use of analgetic oral
No Identitas Diagnosis Manajemen
2. By. Ny. Reni Indriyani • Bayi cukup bulan, Sesuai masa IVFD D10% 10 ml / jam
/L/0 hari/19030857 kehamilan,dengan malformasi anorectal Puasa
tanpa fistula
Pasang OGT
• Hipoglikemia terkoreksi
Konsul TS Pediatri
Foto cross table
ICD X Pto laparatomy colostomy
Q 42.3 Anorectal malformation
E16.2 Hypoglicemia
ICD IX
99.2 Injection or infusion of other
therapeutic
87.64 X-ray of lateral cross table
54.1 Laparotomy
46.10 Colostomy
Triage Bedah
No Identitas Diagnosis Manajemen
3. Ni Nyoman Martini Cedera Kepala Berat (E2VxM4) Konservatif
/P/55 thn/19030869 ICH regio basal ganglia (kapsula interna) dextra IVFD RL 20 tpm
Cephalhematoma frontal et temporoparietal S Head up 30 °
ISS : 14 Hematosinus D/S O2 on bagging 10 LPM
RTS : 5.6764 Fr. Dinding lateral sinus maksillaris D/S Inj. Ceftriaxone 2x1 gr IV
Fr. Rima orbita inferolateral S Phenitoin 3x100 mg
TRISS : 77.34% Vulnus excoriasi r. Colli dextra
ICD X ICD IX
S06 Severe brain injury 93.96 Supplemental oxygen therapy
S06.36 Intra cranial hemorrhage
S02 Fracture of skull and facial bones 99.2 Injection or infusion of other
therapeutic
99.21 Injection of antibiotic
Triage Bedah
No Identity Diagnosis Management
Cedera Kepala Ringan (E4V5M6) IVFD RL 20 tpm
4. Basrawi/L/37 thn/
FBC Fossa Media Head up 30 °
19020878 CF clavicula 1/3 tengah dextra Oksigenasi FM 8 LPM
Paracetamol 3x750 mg PO
ISS : 2 ICD X Antibiotik
RTS : 7.841 S06 Mild brain injury Terapi orthopedi
S02.1 Fracture of base skull
TRISS : 99.7%
S42.02 Fracture of shaft of clavicle ICD IX
93.96 Supplemental oxygen therapy
99.2 Injection or infusion of other
therapeutic
Konsultasi (2)
Triage Pediatri
No Identitas Diagnosis Manajemen
1. I Nengah Dwi Buda • HAEC post pull-through • Puasa
• Malnutrisi berat • Total parenteral nutrisi ()
Adnyana / L / 8 thn / • Anemia (8.80) • Ceftriaxone 2x500 mg IV
17044533 • Hiponatremia (125) • Metronidazole 3x200 mg IV
• Hipoalbuminemia (1.9) • Rectal washing 2x/hari
ICD X ICD IX
K95 Hirschsprung associated with enterocolitis 99.2 Injection or infusion of other
post pull-through
therapeutic or prophylactic
E 42 Severe malnutrition
D 64.9 Anemia, unspecified substance
E 87.1 Hyponatremia 99.21 Injection of antibiotics
E 88.09 Other disorders of plasma-protein
metabolism, not elsewhere classified
Triage Medik
No Identity Diagnosis Management
1. Ida Ayu Nyoman • CKD stage V e.c. suspect DKD butuh akses • Insersi catheter double lumen Jugular
vaskular pro HD dextra
Ariani/P/68 • Edema paru
thn/01585764 • DM tipe II
• Hipertensi stage I
• Hiperkalemia (7.7)
• Anemia (7.5)
ICD X ICD IX
N18.5 Chronic kidney disease due to type II Z45.2 Encounter for adjustment and
diabetes mellitus
management of implanted device
J81.0 Acute lung edema
H35.0 Secondary hypertension
E87.5 Hyperkalemia
D 64.9 Anemia, unspecified
Operasi (3)
Ni Putu Novi Diantari/P/25 thn/19017299
Diagnosis : Appendicitis suppuratif
Prosedur : Appendicectomy
Operator : dr. I Komang Weka, Sp.B
Asisten : DPS/SYE
Instruktor : dr. I Gede Suwedagatha, Sp.B (K)Trauma
AA Bagus Whinu Perdana/L/20 thn/19030530
Diagnosis : Cedera Kepala Ringan (E4V5M6) + Fr. Maxilla S + Fr. Maxilla D + Fr.
Frontozygoma S + Fr. Arcus Zygoma S + Maloklusi
Prosedur : ORIF Miniplate dan Rekonstruksi
Operator : TAM
Assistan : CYD/SYE
Instruktor : dr. I Gede Suwedagatha, Sp.B (K)Trauma
I Dewa Putu Darmayasa/L/55 thn/19030682
Diagnosis : Kebutuhan akses vascular untuk HD + ACKD e.c. suspect renal on CKD +
Nefrolithiasis + Hipertensi stage I + Anemia + Asidosis metabolik + Dyspepsia
syndrome + HHD
Prosedur : Insersi catheter double lumen Jugular dextra
Operator : EDS
Assistan : SUN
Instruktor : Dr. dr. Ketut Putu Yasa, Sp.BTKV (K)
Mortality (0)
DETAIL KASUS
Ni Putu Novi Diantari/P/25 thn/19017299
Keluhan utama: nyeri perut kanan bawah
Riwayat penyakit sekarang:
Pasien datang dengan mengeluhkan adanya nyeri perut bagian kanan bawah sejak 4 hari lalu. Nyeri dirasakan hilang
timbul, disertai dengan adanya mual (+) dan muntah (+) sebanyak 2 kali. Demam disangkal, namun terdapat penurunan
nafsu makan (+).
Present Status
Keadaan umum: tampak sakit sedang
Kesadaran: Compos mentis
TD : 110/70 mmHg
N : 84x / menit
RR : 20x / menit, SpO2: 98% tanpa oksigen
Tax : 36,40C
VAS : 5/10
Ni Putu Novi Diantari/P/25 thn/19017299
ICD X ICD IX
Present Status
Keadaan umum: tampak rewel
Kesadaran : Compos mentis
HR : 120x / menit
RR : 44x / menit
Tax : 37 0C
By. Ny. Reni Indriyani/P/0 yo/19030857
Kepala : Normocephali
Mata : Rp +/+ isokor 3 cm/3 cm, Rc +/+
Colli : KGB tidak teraba membesar, kelenjar thyroid tidak teraba membesar
Thorax :
I : pergerakan dinding dada simetris kanan=kiri
Pal : vocal fremitus kanan=kiri
Per : sonor/sonor
Aus : Cor : S1S2 reg, murmur (-)
Po : ves +/+, rh -/-, wh -/-
Abd :
I : distensi (-)
Aus : bising usUS (+) normal
Pal : supel (+), NT (-)
Per : tympani (+)
Anorectal: ANAL DIMPLE (-), FISTEL (-)
Ext : hangat +, oedema -/-
Foto Klinis
Laboratorium 05/07/19
APTT 37.2
DIAGNOSIS TERAPI
Bayi cukup bulan, Sesuai masa kehamilan,dengan IVFD D10% 8 ml/jam
malformasi anorectal tanpa fistula Puasa
Hipoglikemia terkoreksi Pasang OGT
Foto cross table lateral tanggal 16/07/19 jam 07.00
Konsul TS Pediatri
Pro laparotomy colostomy
ICD IX
ICD X
99.2 Injection or infusion of other therapeutic or
• Q 42.3 Anorectal malformation prophylactic substance
87.64 X-ray of lateral cross table
54.1 Laparotomy
46.10 Colostomy
Ni Nyoman Martini/P/55 thn/19030869
ISS : 14 RTS : 5.676 TRISS : 77.34%
MOI : tidak diketahui, pasien ditemukan tergelatak di jalan, tidak ada saksi yang mngetahui mekanismenya.
PRIMARY SURVEY
Status generalis:
Keadaan umum: tampak sakit sedang, terintubasi dari RS Bangli
Kesadaran: E1VxM5
TD : 90/60 mmHg
N : 104x / menit
RR : 16x / menit
Tax : 36,7OC
Ni Nyoman Martini/P/55 thn/19030869
ISS : 2 RTS : 7.841 TRISS : 99.7%
Head : Cephalhematoma (+) regio frontal dengan ukuran ± 10x8 cm dan di regio temporo-parieto kanan dengan ukuran ± 5x4 cm, terdapat
vulnus excoriasi di regio frontotemporal ukuran ± 3x1 cm, terdapat vulnus axcoriasi ± 4x3 cm, perdarahan aktif (-)
Mata : Rp 2 mm / 3mm anisokor, Rc +/+
Maxillofacial:
Terintubasi (+), hematoma pada area pertengahan mandibula dextra (+)
Colli : KGB tidak teraba membesar, kelenjar thyroid tidak teraba membesar
Thorax :
I : pergerakan dinding dada simetris (+/+)
Pal : fremitus kanan = kiri
Per : sonor/sonor
Aus : Cor : S1S2 reg, murmur (-)
Pulmo : ves +/+, rh -/-, wh -/-
Abd :
I : distensi (-)
Aus : bising usus (+) 4x / menit normal
Pal : supel (+), defense (-)
Per : tympani(-)
Ext : hangat pada perabaan +, oedema -/-
Foto Klinis
CT Scan kepala
ICD X ICD IX
• S06 Severe brain injury 93.96 Supplemental oxygen therapy
• S06.36 Intra cranial hemorrhage 99.2 Injection or infusion of other therapeutic
• S02 Fracture of skull and facial bones 99.21 Injection of antibiotic
Basrawi/L/37 thn/19030878
ISS: 2 RTS: 7.684 TRISS:99.7%
MOI: pasien pengendara sepeda motor dan terjatuh sendiri, helm (+), jatuh ke kanan.
PRIMARY SURVEY
Present status
Keadaan umum: tampak sakit sedang
Kesadaran: Compos mentis
TD : 120/70 mmHg
N : 88x / menit
RR : 20x / menit
Tax : 36,20 C
Basrawi/L/37 thn/19030878
ISS: 2 RTS: 7.684 TRISS:99.7%
Present Status
Kepala : cephalhematoma (-)
Mata : Rp + / + Isokor 3mm / 3mm, Rc + / +
THT : terlihat bekas otorrhagia, perdarahan aktif (-)
Thorax : pergerakan dinding dada kanan=kiri
Pulmo : Vesicular pulmo + / +, ronchi - / -, wh - / -
Cor : S1 S2 regular
Abdomen: distensi (-) BU (+) N
Extremitas : terlihat adanya deformitas pada regio shoulder dextra, ROM
terbatas
Foto Klinis
Rontgen
DIAGNOSIS TERAPI
• Cedera Kepala Ringan (E4V5M6) IVFD RL 20 tpm
• FBC Fossa Media Head up 30 °
Oksigenasi FM 8 LPM
• CF clavicula 1/3 tengah dextra
Paracetamol 3x750 mg tab PO
• ICD X ICD IX
• S06 Mild brain injury 93.96 Supplemental oxygen therapy
• S02.1 Fracture of base skull 99.2 Injection or infusion of other therapeutic or
• S42.02 Fracture of shaft of clavicle prophylactic substance
I Nengah Dwi Buda Adnyana / L / 8 thn / 17044533
Present status
Keadaan umum: tampak sakit sedang
Kesadaran: Compos mentis
N : 96x / menit
RR : 18x / menit
Tax : 36,70 C
BB : 19 kg
I Nengah Dwi Buda Adnyana / L / 8 thn / 17044533
Present Status
Kepala : cephalhematoma (-)
Mata : Rp + / + Isokor 3mm / 3mm, Rc + / +
THT : dalam batas normal
Thorax : pergerakan dinding dada kanan=kiri
Pulmo : Vesicular pulmo + / +, ronchi - / -, wh - / -
Cor : S1 S2 regular
Abdomen:
I: distensi (+), scar post op pullthrough regio hipochondrica dextra (+)
Aus: BU (+)
Pal: supel (+), NT (+)
Per: hipertympani (+)
Extremitas : hangat
RT: TSA (+) menurun, mukosa licin, massa (-), pada hand scuun: feses (+) warna kuning seperti
lumpur, gas (+)
Foto Klinis
Rontgen
Ca 7.1
DIAGNOSIS TERAPI
• HAEC post pull-through • Puasa
• ICD X ICD IX
• Q 43.1 99.2 Injection or infusion of other therapeutic or
• E 42 Severe malnutrition prophylactic substance
• D 64.9 Anemia, unspecified 99.21 Injection of antibiotics
• E 87.1 Hyponatremia
• E 88.09 Other disorders of plasma-protein
metabolism, not elsewhere classified
• 288.60 Elevated white blood cells
I Dewa Putu Darmayasa/L/55 thn/19030682
Present status
Keadaan umum: tampak sakit sedang, lemah
Kesadaran: Compos mentis
TD : 180/90 mmHg
N : 90x / menit
RR : 22x / menit
Tax : 360 C
Laboratorium 05/07/19
Plt 176.00
• Edema paru
• DM tipe II
• Hipertensi stage I
• Hiperkalemia (7.7)
• Anemia (7.5)
• ICD X ICD IX
• N18.5 Chronic kidney disease due to type II Z45.2 Encounter for adjustment and
diabetes mellitus management of implanted device
• J81.0 Acute lung edema
• H35.0 Secondary hypertension
• E87.5 Hyperkalemia
• D 64.9 Anemia, unspecified
FOTO POST OPERASI