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Mapping 19 Juni 2015 Pagi
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PETA PASIEN ORTHOPAEDI Jumat, 19 Juni 2015 MRT/VER/AYT/GIT/AIP/ASD/GAS/MID/PUR/WOS/MYH/VEL/DIQ/RID
BGSLBED
NAMA Umur CM Dx OrthoICD 10
Dx non ortoMRS STTS
Tgl Tindkn
TindakanICD
9PLAN Status
RABER
LAB yg tdk normal PJ STAF
Mwr 2AIP`
2ARia Rini
Ning Kusuma P
14 01304991Open amputatum digiti 3,4,5 pedis S
OF metatarsal 4,5 pedis S comminutive displaced gr.IIB skin loss dorsum pedis S 18/6 post op 18/6post cito debridement + amputasi trans
metatarsal 3,4,5 pedis S
rawat post optatalaksana raw surface dorsum
pedis S ~ TS Plastikumum kls 3
B. Plastik
18/6 Hb 14.2, Ht 44, L 7.5, T 266
VER/AYT/
PUR/AIPAP
2E Heru C 15 01302478Susp. Osteosarcoma R. proximal humerus (D) metastase
pulmo - 28/5 post OP 6/6 - alih leader interna pro kemoterapiBPJS NPBI
kls.3 interna
9/6 Hb 11.0, L 12.1, T 26219/5 Hb 9.1 L 15.3 T 511 LED1 88 LED2 111 Alkali
fosfatase 355 Alb 2.8FNAB tidak didapatkan
tanda ganas
VER/AYT/PUR/AIP
AP
2F Pujiyanto 40 01303130 abses femur-gluteus (S)sequelle coxitis hip (S) DM tipe 2 1/6 - 15/6 post cito evakuasi pus + debridement
post re debridement + debridement Hiprawat luka post OP BPJS PBI - 10/6 Hb 13,8 Al 18,5 At
334 Cr 0,5 Ur 50
VER/AYT/
PUR/AIPUH
8J Pawiro Sumarto
70 00921965 Destruksi illiac wing (D), massa pelvis (S)Paraparese inferior ec MBD Adeno Ca Parotis
- 26/5 - - konservatifFNAB ulang, alih rawat HOM, raber
B.onko BPJS NPBI internaB.onko
10/6 Hb 10.2, L 10.2, T 210
9/6 Alb 2.7,hasil FNAB gambaran
sarcoma dd/ chondrosarcoma usul
biopsi
VER/AYT/
PUR/AIPAP
Mlt3GAS
4A Marinem 52 01300287 Destruksi Femur (S) 1/3 tengah displaced + destruksi VTh XII ec MBD Squamous cell Ca paru
Pulmonologi : Squamous cell Ca paru 25/5 - - Paru: kemoterapiKonservatif
MRI Femur (S) BPJS Pulmo 9/6 Hb 10.1 AL 14.6 AT 259
MID/GAS BJ
5CHendra
Noor 52 01290883Fr linier tibia (S)
raw surface regio cruris – pedis (S) Interna : DM Type II post op 24/2post OREF
post debridement + nekrotomiperawatan + mobilisasi post OP
medikasi / 3 hari BPJS NPBI -11/6 Hb 8.6 AL 10.4 AT 125 Hba1c 6.4 GDP 126
GDS 158 Alb 2.4MID/GAS BJ
8A Deasy 25 01264848Chondrosarcoma R. Distal Femur (S)
Infected megaprostesis Femur Distal (S) pulmonologi : Nodul kalsifikasi TB Lama 3/12 post op8/12
27/12Post wide excisi + Megaprostesa
Post debridement + Irigasi
‘ perawatan post OPmedikasi / 5 hari
BPJS(titipan dir) Pulmo
6/6 Hb 10.9 AL 9.6 AT 559 GDS 99 Alb 3.6 Na 137 K
3.7 Cl 109MID/GAS BJ
20C Sumino 58 01302175
Paraplegi inferior level VTh.VII dg tandem lession (LMN type) ec MM
Fraktur kompresi patologis VTh XII ec MMUlcus decubitus R.sacrum gr.IV, ulcus decubitus R.pedis D et
S
Interna: anemia gravis, inkontinensia uri et alvi, splenomegali ringan, efusi
pleura bilateralNeuro: paraparese inferior, hipoestesi
setinggi VTh.III
pre Op - Work up diagnostik Medikasi ulkus dekubitus, cek SPE BPJS Kls.I Interna, Neuro
9/6 Hb 10.1 AL 14.6 AT 259
29/5 SGOT 43 SGPT 46 Alb 1.6 Glo 4.8, LED1 71, LED2
95
MID/GAS RYN
MWR3GAS
3B Rati 83 CF Collum femur (D) transcervical Garden type II AO 31.B2 Cardio : Decomp cordis NYHA II, OMI anteroseptal
14/6 pre Op - Skin traksi Pro Hemiarthroplasty (menolak operasi)
BPJS PBI Cardio 14/6 Hb 11.5, Al 13.7 AT 251 GDS 157 Cr 0.7 Ur 32
VER/AYT/
PUR//GAS
RYN
6BIna
Nurliana33 01304605 CF clavicula D 1/3 tengah alman grup 1 cominutif displaced
edema cerebrifr. maxilla D dengan hematosinus
15/6 pre op 20/6 pro ORIF BPJS kls 2B.SarafB.Plasti
k
VER/AYT/
PUR//GAS
AP
RGBGIT
D Sukirno 56 01304445 OF tibia fibula S severe comminutive gr IIIC stenosis total a.tibialis anterior post bypass + heparin
13/6 pre op 16/6 post bypas a.tibialis anteriorPerbaikan KU
jika vaskular membaik pro OREF perawatan luka tiap hari
VIP B BTKV
16/6 Hb 6,4 Al 12,6 At 110
13/6 GDS 145, Ur 41, Cr 1.0, PT 16.9, PTT 48.8
GIT/MYH/VEL
RYN
K Rahmanto 27 01304155 CF subtrochanter femur S displaced Plastik : combutio elektrik 12% 10/6 pre op 18/6 post ORIF elektif rawat luka post OP umum kls 3B.plasti
k10/6 Hb 11.2, L 11.4, T
156GIT/
MYH/VEL RYN
ICUGIT 11 warsono 26 01304611
CF metacarpal I manus S comminutive displaced, CF base phalanx proximal digiti I mamus (S) displaced,CF base metacarpal V manus (S) comminutive displaced
b. saraf : EDH reg temporal post craniotomi evakuasi EDH
plastik; fr zmc, fr rima orbita (D)15/6 pre op pro ORIF elektif (tgg acc b.saraf) umum kls 3
b. saraf B.plasti
k
15/6 hb 13,9 ht 42 al 15,1 at 430
GIT/MYH/VEL AP
TulipASD
6 Abu Sholeh
65 01304607CF distal radius D frykman VII colles typeCF distal radius S frykman VII colles type
CF patell D kominutif min displacedSAH regio parietal (S) 15/6 pre op 19/6 pro ORIF umum kls 2 B.Saraf 15/6 Hb 13.5, L 11.9, T
161MRT/
ASD/WOSAP
9 Riyanto 26 01304616
CF radius ulna 1/3 tengah displaced,posterior dislocation hip S Eipstein Thompson type 1 post
close redACL, PCL rupture dgn V. lacerasi R. Genu (S)
FBC anterioredema cerebri
fr le fort 115/6 pre op 15/6
22/6
post closed red hippost cito debridement knee + evaluasi
ligamen injury pro orif elektif BPJS PBIB.SarafB.plasti
k
MRT/ASD/WOS AP
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