- Kontrol 1 minggu - Rendam air hangat - Ganti verband - Follow up hasil PA - Na Diclofenac 2x50mg PO - Cefixime 2x200mg PO - Omeprazole 1x20mg PO - Pregabali 1x75mg PO
Sudah 62 56 RAP
7 17.11.23 Firman
Andhyka 081221073030 26 th L 0000021393
Right Chronic ankle sprain - X-ray, Lab, EKG, TFP (persiapan op)
- R/ Arthroscopic assisted ligament reconstruction
Sudah 96 94 RAP
8 17.11.23 Dadan
Kurnia 085942018816 32 th L 0002228806 - Diabetic foot at right 1st toe - Konsul Bedah Vaskular Sudah 96 94 RAP
Rabu, 15.11.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 15.11.23 Indri Sulastri 085591154615 25 thn P 0002221595 - Neglected talipes equinovarus at bilateral foot
- X-Ray bilateral ankle AP, Lateral
- X-Ray bilateral foot Ap, Oblique
- X-ray, Lab, EKG, TFP (persiapan op)
- R/ Deformity Correction+
Triple arthrodesis for bilateral foot
Sudah 62 56 RAP
2 15.11.23 Elsa Dwi
Sulastri 081111123238 42 thn P 0000379112
- Secondary OA at left ankle joint due to Neglected closed fracture ankle joint
- X ray ankle AP/Lateral /mortis weight bearing
- Cek lab darah rutin
- Persiapan operasi
(EKG,TFP,Xray,Lab lengkapi
Sudah 76 65 RAP
3 15.11.23 Fikri Dzikrul 087714968004 58 thn L 0002057032
- Equinus deformity at right ankle Post Bone lengthening at tibia with eksternal fixation due to POD 10 mont
- Xray ankle weight bearing Ap/lateral
- ATL and immobilization with boot cast bersama TS advanced trauma convert external fixation to Internal fixation.
Sudah 69 64 RAP
4 15.11.23 Mock Taufik 085295404203 50 thn L 0000051771
- Post FDL Release + dedormity correction due to Hammer toe at 2nd,3rd,4th and 5th of right tor POD 7 weeks
- Flexion contracture and subluxation of the right halux interphalanges joint
- Persiapan operasi
(EKG,TFP,Xray,Lab lengkap) - R/ interphalang joint
reconstruction
Sudah 76 65 RAP
5 15.11.23 Hayati 089660332512 58 thn P 0002147711
- Post TTC fusion with plate and screw due charcoat arthropaty POD 3 months
- Rendam air hangat - Lanjutkan terapi obat :
Pregabalin 1x75 mg PO Osteonat 1x35 mg Po (tiap minggu 1x)
Kontrol poli 1 bulan
Sudah 96 69 RAP
6 15.11.23 Mahmud 087763541809 36 thn L 0002196253 - Post ORIF P/S +
immobilization with arm sling due to Closed fracture at right clavicle middle third communitive displaced allman
- 4-5 times / day active pendulum exercise
pregabalin 1x75 mg PO natrium diclofenac 2x50 mg PO
Sudah 96 94 RAP
classification type I POD 1 month
Omeprazole 2x20 mg PO - Active ROM exercise - Kontrol 2 bulan
7 15.11.23 Suhana 081912368774 53 thn L 0002123817 - Union fracture at right calcaneus
- Pertahankan silicon heel pad untuk berdiri dan berjalan - X ray evaluasi Calcaneus
Axial Ap/lateral - Kontrol bila ada keluhan
Sudah 96 69 RAP
8 15.11.23 Sri Suyanti 081324106336 36 thn P 0002181717
- Joint Reconstruction with Low tibial osteotomy + ORIF P/S and bone graft insertion due to OA Ankle + Varus deformity at right knee joint POD 5 weeks
- Active ROM exercise ankledorsoflexion-
plantarflexion - Aff hecting
- PWB dengan 2 tongkat - GV setiap hari + aff hecting - Pregabalin 1x75 mg PO - Antibiotik stop - Kontrol 2 minggu
Sudah 69 64 RAP
9 15.11.23 Kafka Diaz
Chandra 081617475535 17 thn L 0002221563 - Peroneal tendon dislocation - Persiapan operasi (EKG,TFP,Xray,Lab lengkap) - R/ Peroneal nerve repair
Sudah 96 76 RAP
10 15.11.23 Enoy 085294944414 71 thn P 0002213447
- Left charcot foot with Neglected fracture of left ankle
- Boot Slab
- R/Ankle Fusion Sudah 80 74 RAP
Jumat, 10.11.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 10.11.23 Kenn Kahlil 082126263535 19 thn P 0002080085
- Post medial displacement calcaneal osteotomy + Brostrom procedure + Immobilization with boot slab due to :
- Chronic instability at right ankle joint with flat foot POD X
- Kontrol 1 minggu - Rendam air hangat
- Penggunaan Decker ankle joint
- Na Diclofenac 2x50mg PO - Cefixime 2x200mg PO - Omeprazole 1x20mg PO - Pregabali 1x75mg PO
Sudah 62 56 RAP
2 10.11.23 Nugraha
Ramdhani 0895343746481 20 thn L 0000954619
- Post Immobilization with boot slab due to closed fracture of left 3rd base metatarsal comminutive displaced - Infected wound at left foot
dorsal aspect
- Wound Cleansing
- Konsul bedah plastik Sudah 76 65 RAP
3 10.11.23 Irfan
Setiawan
087820233313 45 thn L 0002173887 - Post biopsy + Debridement + TTC fusion + Bone graft insertion POD 2 month
- X-Ray left foot ulang - Rendam air hangat - Pregabalin 1x75mg PO
Sudah 67 51 RAP
- Na Diclofenac 2x50mg PO - Lansoprazole 1x30mg PO - Kontrol 1 minggu
4 10.11.23 Anton
Sartono 08122023567 73 thn L 0001603382 - Corn Hammertoe at left foot - X-ray, Lab, EKG, TFP (persiapan op)
- R/ Hammer toe release
Sudah 96 69 RAP
5 10.11.23 Nia
Kurniasih 081392337295 37 thn P b
- Post talonavicular fusion due to Suspect arthritis TB at left talonavicular joint POD 4 month
- Injeksi triamcinolone - Kontrol poli DOTS - Kontrol 1 bulan - Rendam Air Hangat - Analsik 1x1 PO - Pregabalin 1x75mg PO - Eperison 2x50mg PO - Lansoprazole 1x30mg PO
Sudah 69 64 RAP
6 10.11.23 Neng Ipah
Rezeky 087888715775 40 thn P 0002214416
- Jones fracture type I at left foot
- Sequele stroke non
haemorhagic
- X-ray, Lab, EKG, TFP (persiapan op)
- R/ ORIF Screwing
Sudah 96 82 RAP
7 10.11.23 Lani Siti 081213094384 25 thn P 0002172631
- Post ORIF plate and screw due to:
- Closed fracture at right femur middle third comminutive displaced AO classification 32C3 Tscherne classification grade I
- - Closed fracture at right supracondylar femur segmental displaced AO classification 32C3 Tscherne classification grade I POD 2 months
-
- Post debridement + sural flap + STSG + AB beads insertion due to post OREF due to:
- - Open fracture at right tibia distal third comminutive displaced AO Classification 43A3 Gustillo Anderson grade 3A
- - Open fracture at right fibula distal third comminutive displaced AO Classification 4F2C Gustillo Anderson grade 3A
- POD 1 months
- X-Ray Leg AP/Lateral (ulang) - Rencana op jika dari bedah
plastic luka sudah kering - Cefixime 2x100mg PO - Na Diclofenac 2 x50mg PO - Omeprazole 1x20mg PO - Pre gabalin 1x75mg PO
Sudah 46 41 RAP
Rabu, 08.11.23
Nama No Hp Umur L/ Medrec Diagnosis Manajemen Assess AOFAS FAAM DPJP
P DPJP
1 08.11.23 Enung
Nurjanah 081298138563 60 thn P 0002165983
- Post deformity correction + Ankle arthrodesis with intramedullary nail, plate, and screw due to Charcot arthropathy at left ankle joint Brodsky classification type 4 POD 2 months
- Post debridement + Open wound care due to Diabetic foot ulcers at right foot Wagner grade 2 POD 2 months
- PWB dengan 2 tongkat - GV dengan hydrogel dan
rawat luka setiap hari (edukasi cara ganti verband)
- Kontrol 6 bulan
Sudah 62 56 RAP
2 08.11.23 Edison 082738293829 33 thn L 0002200842
-
• Post ORIF TBW due to Closed fracture at right patela POD 5 years
-
• Flexion contracture at right knee joint
- • Chronic Venous ulcer of right leg
- Cilostazol 2x 1 PO - Compressive bandage - Jawaban konsul recon (Saran
konsul bedah vaskuler)
Sudah 76 65 RAP
3 08.11.23 Iin 082121513939 60 thn P 0002200438
Wound debridement and exploration + ORIF screw + Immobilization with boot slab due to open right ankle injury Lauge Hansen classification SAD stage 2
- POD XXVI
- Rawat luka
- PWB dengan 2 tongkat - GV setiap hari
Sudah 85 84 RAP
4 08.11.23 Rainor Azizi 087823863444 17 thn L 0002154186 Post Supramaleolar osteotomy due
to pes cavus at right foot - Konsul anestesi & IPD
- R/ Supramaleolar Osteotomy Sudah 96 69 RAP
5 08.11.23 Umas Sujana 083832185632 51 thn L 0002151219
- Gout Arthritis at bilateral foot - Thopus at Right first MTP
joint
Infected thopus at left first MTP joint
- Persiapan operasi
(EKG,TFP,Xray,Lab lengkap) - R/Debridement + Thopus
excision
Sudah 80 74 RAP
6 08.11.23 Philip
Timotius 081220090000 52 thn L 0002009333
- Post gradual correction II with above knee cast due to Flexion contracture at left knee joint - Post Correction deformity +
Ankle arthrodesis + Osteotomy for left foot due to Equinocavovarus deformity at
left foot POD 3 weeks
- Kontrol 2 minggu aff hecting - GV Setiap hari
- Cefixime 2x200mg PO - Paracetamol 3x500mg PO - Ibuprofen 2x400mg PO - Pregabalin 1x75mg PO - Omeprazole 1x20mg PO - Konsul fisioterapi
Sudah 67 61 RAP
7 08.11.23 Enoy 085294944414 71 thn P 0002213447 - Left charcot foot with
Neglected fracture of left - Persiapan operasi
(EKG,TFP,Xray,Lab lengkap) Sudah 80 74 RAP
ankle - R/Ankle Fusion
Jumat, 03.11.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 03.11.23 Lusciana
Marisca 085279892290 40 thn P 0002211532 - Chronic Plantar Fascitis - EKG,TFP,X-ray, dan Lab (persiapan operasi)
- R/ Strayer Procedure
Sudah 69 64 RAP
2 03.11.23 Gugun
Gumilar 082738293829 33 thn L 0002200842
- Post Debridement + ORIF K wire multiple metatarsal at left foot
*POD 3 weeks*
- Post wound closure with STSG *POD 10 days*
- Kontrol 2 minggu - Kontrol poli bedah plastic - Cefixime 2x200mg PO - Na Diclofenac 2 x50mg PO - Omeprazole 1x20mg PO
Pre gabalin 1x75mg PO
Sudah 76 65 RAP
3 03.11.23 Abdurrohim 081283245470 23 thn L 0002173888
- Post debridement + Joint reconstruction + Low tibial osteotomy + Bone graft insertion due to Non-specific chronic osteomyelitis at left ankle joint POD 3 weeks
- Remove Hecting - GV/ hari dengan betadine - Kontrol 2 minggu - Cefixime 2x200mg PO - Na Diclofenac 2 x50mg PO - Omeprazole 1x20mg PO - Pre gabalin 1x75mg PO
Sudah 67 61 RAP
4 03.11.23 Salma Ayu
Ludfiah 0881022017483 21 thn P 0002169239
- Post debridement + Reamputation due to Necrotizing fasciitis at left leg
*POD 5 weeks*
- Konsul IKFR untuk
penggunaan prosthtetic - Kontrol 1 bulan
Sudah 67 61 RAP
5 03.11.23 Rahayu 082214206074 32 thn P 0002106226 - CRPS forefoot post traumatic at right great toe
- Konsul dr. Asep Sp.N (neurologi) untuk tatalaksana lnyeri
- Terapi sesuai TS. Neurologi
Sudah 90 80 RAP
6. 03.11.23 Lani Siti 081213094384 25 thn P 0002172631 - Post ORIF plate and screw due to:
- Closed fracture at right femur middle third comminutive displaced AO classification 32C3 Tscherne classification grade I
- - Closed fracture at right supracondylar femur segmental displaced AO classification 32C3 Tscherne classification grade I POD 2 months
-
- X-Ray Leg AP/Lateral (ulang) - Rencana op jika dari bedah
plastic luka sudah kering - Cefixime 2x100mg PO - Na Diclofenac 2 x50mg PO - Omeprazole 1x20mg PO - Pre gabalin 1x75mg PO
Sudah 46 41 RAP
- Post debridement + sural flap + STSG + AB beads insertion due to post OREF due to:
- - Open fracture at right tibia distal third comminutive displaced AO Classification 43A3 Gustillo Anderson grade 3A
- - Open fracture at right fibula distal third comminutive displaced AO Classification 4F2C Gustillo Anderson grade 3A
- POD 3 weeks
7 03.11.23 Fajar Saputra 083816376015 25 thn L 0001932787 - Post Arthroscopy debridement due to right ankle arthritis POD 3 week
- Fisioterapi Latihan berdiri - Rendam air hangat
- Latihan stretching achilles tendon
- Kontrol 1 bulan
- Na Diclofenac 2x50 mg PO - Omeprazol 2x20 mg PO - Pregabalin 2x75 mg PO
Sudah 84 72 RAP
8 03.11.23 Rifki
Rahmadani 085320572025 22 thn L 0002211605 - Right Ankle medial instability
- Persiapan EKG,TFP, Lab, dan Xray
- R/ Deltoid ligament
reconstruction
Sudah 84 84 RAP
9 03.11.23 Rochayati 087723712366 52 th P 0002092027 - Pes cavus at right foot - Persiapan operasi
R/ Supramaleolar Osteotomy Sudah 96 69 RAP
10 03.11.23 Rainor Azizi 087823863444 17 thn L 0002154186 - Post Supramaleolar osteotomy due to pes cavus at right foot
- GV
- Persiapan EKG,TFP, Lab, dan Xray
- R/ Supramaleolar Osteotomy
Sudah 96 69 RAP
11 03.11.23 Syaifier
Saman 085720924595 50 thn L 0000127951 - Swelling at right ankle joint - X-Ray Ankle joint Sudah 93 78 RAP
Rabu, 01.11.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 01.11.23 Nurul Fajrina
Nadhilah 081464405330 23 thn P 0002191831 - Post ORIF screwing + malleolar osteotomy + + immobilization with boot slab due to to Closed fracture at right talus hawkins classification type II Tscherne
- PWB dengan 2 crutch beban 10 kg
- Stretching ROM ankle exercise
- Rendam air hangat - Kontrol 1 bulan
Sudah 69 64 RAP
classification grade I POD 1 month
2 01.11.23 Nugraha
Ramdhani 0895343746481 20 thn L 0000954619
- Post Immobilization with boot slab due to closed fracture of left 3rd base metatarsal comminutive displaced - Infected wound at left foot
dorsal aspect
- Wound Cleansing - PWB 2 tongkat - Kontrol 1 minggu
Sudah 76 65 RAP
3 01.11.23 Enung
Nurjanah 081298138563 60 thn P 0002165983
- Post deformity correction + Ankle arthrodesis with intramedullary nail, plate, and screw due to Charcot arthropathy at left ankle joint Brodsky classification type 4 POD 2 months
- Post debridement + Open wound care due to Diabetic foot ulcers at right foot Wagner grade 2 POD 2 months
- Remove Hecting - NWB 2 tongkat - GV dengan hidrogel - X-Ray ulang 1 bulan
Sudah 62 56 RAP
4. 01.11.23 Ny. Yetty
Laelawaty A. 08211513756 48 thn P 0002196588
- Post ORIF Plate and screw due to Closed fracture at left distal end radius intraarticular comminutive displaced Frykmann classification type VII Tscherne Classification Grade I *POD XXI*
- - Post ORIF screwing due to Isolated stable right medial maleolus fracture transverse displaced Herscovici Classification type A Tscherne classification grade I *POD XXI*
- Kontrol 1 bulan
- PWB dengan 2 tongkat Sudah 67 61 RAP
5. 01.11.23 Daspin 082128890863 45 thn L 0002143499
- Post gradual deformity correction with llizarov ring fixator due to Volkmann ischemic contracture at right foot + Equinus deformity POD 2 months
- Suspect chronic osteomyelitis at right distal femur and right foot
- Post sub talar arthrodesis due to Secondary osteoarthritis at right knee joint with flexion contracture with implant failure
- Ganti verband
- Rencana ankle arthrodesis dan ankle reconstruction Bersama Adv. Trauma (sesuai JOM adv. Trauma)
Sudah 52 46 RAP
6 01.11.23 Ida dastika 081223846081 53 thn P 0002210312 - Right ankle osteoarthris - Conservative treatment /operative treatment dengan ankle arthroplasty ( belum ada keputusan operasi dari pasien )
Sudah 83 81 RAP
- Glucosamine 3x500mg PO - Mecobalamine 3x500mg PO - Gabapentin 1x300mg PO
7 01.11.23 Hamdani 081617673921 37 thn L 0002188510
- Post debridement + ORIF Screwing due to Chronic osteomyelitis TB at left mid foot POD 2 weeks
- GV 1x Sehari - Konsul Poli Dots - PWB dengan 2 crutch
Sudah 58 51 RAP
Jumat, 27.10.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 27.10.23 Ajat Sudrajat 081294312943 60 thn L 0002178392
- Post Debridement and tophus Excision due to Infected tophus at bilateral ankle due to arthritis gout *POD XV*
- Co. Fisioterapi - GV + Aff Hecting - PWB dengan 2 tongkat - Mecobalamin 2x1 PO - Pregabalin 1x75mg PO - Ibuprofen 2x400mg PO
Sudah 76 65 RAP
2. 27.10.23 Dadang
Ismail 087742361734 57 thn L 0002197878
Post Debridement + Exploration + ORIF k wire due to:
•Open fracture of right calcaneus comminutive displaced Essex- Lopresti joint depression type Gustilo Anderson gr IIIA
Post Debridement + Exploration + ORIF K-wire due to
•Open avulsion fracture at left base metatarsal 5 Gustillo Anderson gr IIIA
*POD XVII*
- GV
- Rendam Air Hangat
- Konsul rujuk balik ke RSUD slamet Garut
Sudah 67 61 RAP
3. 27.20.23 Ajat Sudrajat 081294312943 60 thn L 0002138919
Post TTC fusion with plate and screws due to Ankle and subtalar arthritis + Equinovarus deformity at right ankle joint POD 2 month
- Kontrol adv trauma
- Kontrol poli foot and ankle 1 bulan
Sudah 76 65 RAP
4. 27.10.23 Neneng
Wangsih 087739905144 64 thn P 0002155144
Post calcaneoplasty + Tendon transfer + Immobilization with anterior slab due to Chronic achilles tendinitis at left foot POD 9 weeks
- Rendam air hangat - Kontrol bila ada keluhan - Pregabalin 2x75 mg PO - Na diclofenac 2x50 mg PO - Fisioterapi dilanjutkan
Sudah 67 61 RAP
5. 27.10.23 Isti Anggia 082120999633 30 thn P 0002132275
Post bilateral Ankle reconstruction with multiple tenotomy, osteotomy, Ankle fusion with plate and screws due to Equinovarus deformity at bilateral foot POD 5 months
- Latihan berjalan tanpa tongkat/walker dan Latihan berdiri dengan 1 kaki
- Mecobalamin 3x500 mcg PO - Na Diclofenac 2x50mg PO - Pregabalin 1x75mg PO - Kontrol 1 bulan
Sudah 71 56 RAP
6. 27.10.23 Tuti Susanti 089528447936 48 thn P 0002185069
Post ORIF with plate and screw due to Neglected Lisfranc injury at left foot POD XVI
- PWB dengan beban 20 kg - GV + Aff hecting - Kontrol 1 bulan
Sudah 64 61 RAP
7. 27.10.23 M. Prayoga 081212714661 10 thn L 0002097655
Post talar arthroeresis + immobilization with boot slab due to flexible pes plano valgus at left foot POD 1 month
- Remove Casting - X-ray Ankle
Ap/lateral/Mortise - Kontrol 1 bulan
Sudah 83 81 RAP
8. 27.10.23 Kokom
Komaria 08981648616 57 thn P 0002069642 Right Ankle Arthritis
- X-ray Ankle Ap/Lat/Mortise - X-ray Pedis ApOblique - Persiapan H-2 ( X-ray,
EKGT,TFP, dan Lab)
Sudah 64 61 RAP
Rabu, 25.10.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 25.10.23 Mamat 0895345172208 51 thn L 0002051989 - Post ankle arthroscopic debridement + Posterior and anterior ankle decompression with stieda process resection +
Implant removal +
- Ankle Stretching - Rendam air hangat - Glucosamin 2x500mg PO - Ibuprofen (jika nyeri )
Sudah 82 74 RAP
Immobilization with boot slab due to Anterior and posterior ankle impingement + Union fracture at right talar neck POD 3 months
2. 25.10.23 Bangkit
Sinulingga 081212468013 22 thn L 0002016839
- Post Debridement and open wound care due to Infected wound at posterolateral aspect of left foot POD 1 month with implant exposed Post TTC Fusion at left ankle POD 1 years 10 months
- X-Ray Ankle Ap/Lat/Mortise (weight bearing )
- R/ Remove implant
- Persiapan operasi (X-ray, lab, Ekg & TFP)
N/A 80 RAP RAP
3. 25.10.23 Iin 082121513939 60 thn P 0002200438
Wound debridement and exploration + ORIF screw + Immobilization with boot slab due to open right ankle injury Lauge Hansen classification SAD stage 2
POD XII
- Pertahankan slab
- GV setiap hari (Nacl, Sufratul, dan betadine)
- Menggunakan 2 tongkat
Sudah 85 84 RAP
4. 25.10.23 Sri Suyanti 081324106336 36 thn P 0002181717
Joint Reconstruction with Low tibial osteotomy + ORIF P/S and bone graft insertion due to OA Ankle + Varus deformity at right knee joint POD X
- Kontrol 2 minggu + Aff hecting - GV setiap hari
- X-ray left leg 2 minggu lagi - Aff hecting iliac region
Sudah 56 54 RAP
5. 25.10.23 Anugrah
Arsyah 081320177791 12 thn L 0002093846 Bilateral flat feet post fisioterapi + Medial arch support 11 months
- Medial arch support - Observasi
- Fisioterapi dan control di Al Ihsan
- Rendam air hangat
- Rencana operasi bila orang tua setuju
Sudah 87 78 RAP
6. 25.10.23 Aris
Syaefulloh 088706358416 24 thn L 0002190373 - Post debridement + Proximal phalanx amputation of great toe due to Open dislocation at
IP joint of right great toe 1 month
- Post CRIF intramedullary K- Wire + Immobilization with boot slab due to Closed fracture at right shaft of 2nd,
- GV
- AFF Wire di poli
- R/ Pregabalin 1x75 mg PO - Ibuprofen 2x 400 mg PO - Kontrol 1 bulan lagi - Lepas penggunaan slab
Sudah 56 54 RAP
3rd metatarsal comminutive
displaced Tscherne
classification grade 1 POD 1 month
Jumat, 20.10.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 20.10.23 Hotben
Simarmata 082121513939 44 thn L 0001639054 - Neglected closed fracture at left bimaleolar ankle
- Rencana Operasi H-2
- R/ Ankle arthrodesis Sudah 85 84 RAP
2. 20.10.23 Ny. Yetty
Laelawaty A. 08211513756 48 thn P 0002196588
- Post ORIF Plate and screw due to Closed fracture at left distal end radius intraarticular comminutive displaced Frykmann classification type VII Tscherne Classification Grade I *POD IX*
- Post ORIF screwing due to Isolated stable right medial maleolus fracture transverse displaced Herscovici Classification type A Tscherne classification grade I *POD IX*
- Kontrol 1 minggu cabut benang
- Latihan passive ROM exercise
Sudah 67 61 RAP
3. 20.10.23 Dadang
Ismail 087742361734 57 thn L 0002197878
Post Debridement + Exploration + ORIF k wire due to:
•Open fracture of right calcaneus comminutive displaced Essex- Lopresti joint depression type Gustilo Anderson gr IIIA
Post Debridement + Exploration + ORIF K-wire due to
•Open avulsion fracture at left base metatarsal 5 Gustillo Anderson gr IIIA
*POD X*
- Rawat luka
- Kontrol 1 minggu Sudah 67 61 RAP
4. 20.10.23 Wawan
Gunawan 081246033569 71 th L 0002072735
Post Remove Intramedullary Nailing, Convert to P/S due to Ankle arthritis due to Implant Exposed post Ankle Arthrodesis with Intramedullary Nailing POD 2 month
- Rawat luka
- PWB dengan tongkat menumpu di siku
- Kontrol 1 bulan
Sudah 69 65 RAP
5. 20.10.23 Abdurrohim 081283245470 23 thn L 0002173888
Post debridement + Joint reconstruction + Low tibial osteotomy + Bone graft insertion due to Non-specific chronic osteomyelitis at left ankle joint POD IX
- Rawat luka terbuka
- Kontrol 2 minggu Sudah 67 61 RAP
6. 20.10.23 Iman Faizal 08116818887 42 thn L 0002203294 Malunion fracture of right talus with secondary OA
- Rencana operasi H-2
- R/ Debridement + Achilles tendon lengthening + Arthrodesis
Sudah 67 61 RAP
7. 20.10.23
Salma Ludfiah
0881022017483 21 thn P 0002169239
Post debridement + Reamputation due to Necrotizing fasciitis at left leg POD XXI
- Kontrol 2 minggu - Cefixime 2 x 200mg - Paracetamol 3 x500mg - Ganti verband
Sudah 72 68 RAP
8. 20.10.23 Dede
Maelani 08816656649 22 thn P 0002037478 Post TTC fusion due to open left ankle injury POD 1 year
- X-ray Ankle weight bearing
- GV
- R/ Remove implant + Debridement
Sudah 72 68 RAP
9. 20.10.23 Ajat Sudrajat 081294312943 60 thn L 0002178392
Post Debridement and tophus Excision due to Infected tophus at bilateral ankle due to arthritis gout POD VIII
- Partial Weight Bearing
- Kontrol 1 minggu Sudah 76 65 RAP
10. 20.10.23 Nia
Kurniasih 081392337295 37 thn P 0002139120 Post talonavicular fusion due to Suspect arthritis TB at left talonavicular joint POD 3 month
- Rendam air hangat
- Passive ROM Ankle exercise - Partial Weight bearing - MP 2x8mg PO
- Pregabalin 2x 75 mg PO - Analsic 1x1 tab PO - Kontrol 2 minggu
Sudah 69 64 RAP
11. 20.10.23 Kesatria Rio
Gumilang 08158022629 36 thn L 000256946
Post Achilles tendon lengthening + Release tendon + Sequestrectomy + Debridement + Bone excision due to hammer toes at right 2nd , 3rd toes + Achilles tendon contracture + equinus deformity at right ankle Secondary osteoarthritis at right foot *POD 2 months*
- Kontrol Kembali jika ada keluhan
- Eperison 2x50mg PO - Ibuprofen 2x400mg PO
Sudah 59 53 RAP
12. 20.10.23 Tuti Susanti 089528447936 48 thn P 0002185069
Post ORIF with plate and screw due to Neglected Lisfranc injury at left foot POD IX
- Rendam air hangat
- Passive ROM ankle exercise - PWB 2 tongkat
- MP 2x8mg PO - Pregabalin 2x75mg PO - Analsic 2x1 tab PO
- Antibiotik lanjut clindamycin
- GV
Sudah 64 61 RAP
Rabu, 18.10.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 18.10.23 Cep Gupron
Gunawan 082121513939 38 thn L 0001848856
- Post Debridement + ORIF Screwing due to Open fracture of right calcaneus *POD 2 years*
- Post Remove Intramedullary nail at right femur due to Chronic osteomyelitis at right femur *POD 3 months*
- Rujuk balik ke RS Soreang rencana aff screw (Normed cannulated screw 4.5)
Sudah 85 84 RAP
2. 18.10.23 Solihat 081398573682 28thn P 0002202539 - Ankle Arthritis at right ankle joint due to AVN at right talar head
- Persiapan operasi
(EKG,TFP,Xray,Lab lengkap) - R/Ankle Fusion
Sudah 84 80 RAP
3. 18.10.23 Nurul Fajrina 081464405330 23 thn P 0002191831
- Post ORIF screwing + malleolar osteotomy + + immobilization with boot slab due to to Closed fracture at right talus hawkins classification type II Tscherne classification grade I POD XVII
- Kontrol 2 minggu dengan membawa hasil X-ray - NWB selama 2 minggu
Sudah 69 64 RAP
4 18.10.23 Salma
Syamrotul Fuadah
081222015454 23 thn P 0001874467 - Post Tibiotalar arthrodesis at right ankle due to Arthritis TB ar
right ankle joint *POD 2 years*
- X-ray Ankle AP/Lateral/mortise
- Kontrol 6 bulan untuk rencana aff implant
- Oscal 1 x 0,5 ug
Sudah 80 74 RAP
5 18.10.23 Muhammad
Mahmud 087763541809 36 thn L 0002196253
- Post ORIF Plate and screw at right clavicle middle third comminutive displaced allman
classification type I
- GV Setiap 2 hari
- Active rom exercise pendulum exercise
- Kontrol 1 minggu untuk rencana aff hecting dan evaluasi luka
Sudah 100 100 RAP
Jumat, 13.10.23
Nama No Hp Umur L/
P Medrec Diagnosis Manajemen
Assess
DPJP AOFAS FAAM DPJP
1 13.10.23 Ryan Ahmad 085860458706 21 thn L 0002168335
- Valgus deformity at right knee joint + Malunion fracture at right tibia proximal 3rd - - Post achilles tendon
lengthening + Immobilization with boot cast due to Plantar flexion contracture at right ankle joint POD 17
- *
- Partial weight bearing dengan 2 tongkat
- Passive ROM exercise - Aff gyps
Sudah 80 74 RAP