Log Book Poli AnF Rabu 03.04.24-2

(1)

Rabu, 05.04.24

No. Tanggal Nama No Hp Umur L/

P Medrec Diagnosis Manajemen Assess

DPJP AOFAS FAAM DPJP

1. 05.04.24 Pevy Astrie

Pratista.dr 082117010013 32 thn P 0002145961 - Chronic Ankle instability - R/ Ligament Reconstruction

Per Arthroscopy Sudah RAP

2. 05.04.24 Ny. Atik

Marwati 0895372246428 46 thn P 0002237092

- Post Traumatic Charcot Arthropathy of Right Foot with AVN Talus

- Post ORIF K-Wire due to Open Fracture at Right 2nd, 3rd, 4th, 5th Metatarsal - Post Orif Screw due to Open

Fracture at Right Talus, Right Calcaneous, and Lisfranc Injury at right Foot POD 4 Months

- R/ Remove K-Wire Sudah RAP

3. 05.04.24 Tn. Hendar 085722397704 32 thn L 0002276007

Post Debridement, exploration, repair tendon and ORIF K-wire:

- Open fracture at right 2nd metatarsal spiral displaced Gustilo Anderson classification grade II

- Open fracture at right 3rd metatarsal comminutive displaced Gustilo Anderson classification grade IIIB

- Open Fracture at right 4th metatarsal comminutive displaced Gustilo Anderson classification grade IIIB

with total rupture of 3rd, 4th extensor digitorum longus tendons

POD VII

- GV 2x/hari

- Pertahankan boot slab - Cefadroxil 2x500mg - Ibuprofen 2x400mg

Sudah RAP

4. 05.04.24 Tn. Dani Parsaoran Sormin

081214781924 19thn L 0002272160

- Post open reduction and reconstruction at PIP joint of right third toe due to Old unreduced dislocation PIP joint of right 3rd toe POD XIV

- Aff hecting

- Aff wire Sudah RAP

5. 05.04.24 Tn. Alwi - 60 thn L 0002274260 - Post transtibial amputation

due to Crush Injury at right foot POD X

- GV 2x/hari (bila rembes) - Levofloxacin 1x750mg - Ibuprofen 2x400mg - Mobilisasi jalan dengan 2

cructhes

Sudah RAP

6. 05.04.24 Nurhamdan

saputra 0882001894951 20 thn L 0002277878 - - Sudah RAP

(2)

7. 05.04.24 Ade Rukmini 082215218400 47thn P 0002272763 - Post Neglected Closed right

ankle injury - Sudah RAP

8. 05.04.24 Mohammad

farrel Arkhan 081289114907 16 thn L 0002184403 - - Sudah RAP

9. 05.04.24 Dirta 085314129630 46 thn L 0002260271 - Charcot arthropathy at left ankle

joint - R/ TTC Fusion Sudah 69 74 RAP

10. 05.04.24 Nurdin

Syamsudin 087860731940 44 thn L 0002277958 - - Sudah RAP

11. 05.04.24 Rahayu 0822-1420-6074 33 thn P 0002106226

- Post open debridement and roser plasty due to CRPS forefoot post traumatic at right great toe dd/

suspect neuroma POD XV

-GV

-Kontrol 1 minggu -Menunggu hasil PA - -Ibuprofen 3x400mg

Sudah 86 88 RAP

12. 05.04.24 Ersanda

Azka 087722319836 15 thn P 0001794638

- Post debridement per arthroscopy due to Sinus tarsi syndrome at left foot POD 20

- FWB dengan 1 tongkat - Na diklofenak 2x50mg - Pregabalin 2x75mg - Cefixime 2x200mg - Bisolvon 2x1tab

Sudah 90 84 RAP

13. 05.04.24 Lavida Nur

Himnasia 087857482387 22 thn P 0002269648 - - Sudah RAP

14 05.04.24 Tria Apriana 081779960999 30 thn P 0002199022

- Post Arthroscopy microfracture due to Osteochondral lesion of talus at right ankle POD 5 weeks

- Rendam air hangat - PWB

- Pregabalin 2x75mg - Na diklofenak 2x50mg

Sudah 80 74 RAP

15 05.04.24 Muhamad

Haikal 085759143227 20thn L 0002264880

- Post ORIF plate and

screwclosed fracture at left tibia middle third transverse displaced AO Classification 42A2 Tscherne Classification grade 1 POD XIV

- GV aff hecting - Kontrol 2 minggu - Cefixime 2x200mg - Ibuprofen 3x400mg - Omeprazole 2x20mg

Sudah RAP

16 05.04.24 Heri Susanto - 55 thn L 0002276613 - Bursitis Paramalleolar lateral dextra

- GV

- Natrium Diclofenac 2x50 mg - Cefixime 2x200 mg PO

Sudah RAP

17 05.04.24 Sumarni

Umar - 70 thn P 0002277940 - Plantar Fascitis - Natrium Diclofenac 2x50 mg Sudah RAP

18 05.04.24 Muhammad

Rafi Sabar - 26 thn P 0002278012 - Plantar Fascitis - Natrium Diclofenac 2x50 mg Sudah RAP

(3)

Rabu, 27.03.24

P Medrec Diagnosis Manajemen Assess

DPJP AOFAS FAAM DPJP

1. 27.03.24 Ojon Junaedi 085722015053 64thn L 0002272769

- Gouty Tophus at Left great toe and 2nd toe

- CKD stage IV

- HHD

- Hipertensi stage II

- R/ Tophus excision (Acc H-2) Sudah 64 52 RAP

2. 27.03.24 Riyatun 085759150767 43 thn P 0002265156

- Post Ankle debridement &

sinus tarsi debridement due to Sinus tarsi syndrome and Arthrofibrosis at left ankle joint POD 2 weeks

- Aff hecting

- Kontrol bila ada keluhan Sudah 71 63 RAP

3. 27.03.24 Lukman 081224024267 51 thn L 0001994812

- Post Debridement, ankle arthrodesis, and iliac bone graft insertion due to Chronic osteomyelitis at left ankle joint POD VI

- GV

- Cefadroxyl 2x500mg - Ibuprofen 3x400mg - Omeprazole 2x20m

Sudah 59 48 RAP

4. 27.03.24 Kenn Kahlil

Kitwana 082126263535 20 thn P 0002080085

- Post ATFL reconstruction with Brostrom procedure due to Left Chronic Ankle instability with flat foot POD 1.5 month - Post calcaneal osteotomy +

Brostrom procedure due to right chronic lateral ankle instability with flat foot POD 3 months

- Fisioterapi Sudah 62 56 RAP

5. 27.03.24 Topan

Bangkit 089668683998 36 thn L 0002275862 - Multiple gout arthritis

-Fisioterapi

-Allopurinol 1x300mg po -Na diklofenak 2x50mg po -Methylprednisolone 2x8mg po

Sudah 61 54 RAP

6. 27.03.24 Mohammad

Farel Arkhan 081289114907 16 thn L 0002184403

- Post Flatfoot deformity correction with : MDCO / Subtalar arthrodesis / Triple Arthrodesis due to

Symptomatic flat foot at left foot with Generalized Laxity POD VII

- GV

- Cefadroxil 2x500mg po - Ibuprofen 3x200mg po - Pertahankan boot slab - Kontrol 1 minggu

Sudah 56 63 RAP

7. 27.03.24 Dian

Hadiana

083147925345 /

083827386124 41 thn L 0001704825 - Susp tb arthritis at midfoot region

- Acc H-2

- R/ Debridement & Biopsy Sudah 81 73 RAP

(4)

8. 27.03.24 Matheus

Mado 081222918870 54 thn L 0002044910

- Post screw removal due to Screw pull out Post TTC Fusion with plate and screw, bone graft insertion, fibula osteotomy, and culture POD 4 months

-Kontrol bila ada keluhan

-FWB

-Xray ulang

Sudah 66 48 RAP

9. 27.03.24 Iman Faizal 081261000827 42 thn L 0002203294

- Post achilles tendon lengthening due to Malunion fracture at right talus with secondary

osteoarthritis and equinus deformity POD 1 month - Malunion fracture Post ORIF k

wire at left distal radius POD 2 years

- Neglected malunion fracture at right pubic rami and right acetabulum with secondary hip osteoarthritis

- Open wound care - Burnazin salep - Cefixime 2x200mg po - Omeprazole 2x20mg po - Ibuprofen 3x400mg po - Kontrol Adult Reconstruction

division (R/ Hip arthroplasty)

Sudah 64 42 RAP

10. 27.03.24 Dani

Parsaoran 081214781924 19 thn L 0002272160

- Post Open reduction and reconstruction PIP joint due to Old unreduced dislocation PIP joint of right 3rd toe POD 1 week

- GV

- Kontrol 1 minggu (R/ Aff

hecting dan Aff wire) Sudah RAP

Jumat, 22.03.24

P Medrec Diagnosis Manajemen

Assess

DPJP AOFAS FAAM DPJP

1. 22.03.24 Sofiyani^Ashfia Husein

- 19 thn P 0002274082

- Post Debridement, exploration, ORIF K-wire due to Open fracture at proximal phalang of left 3rd toe oblique displaced POD VIII

- Hallux valgus at left foot

-GV

-Kontrol 2 minggu, rencana aff hecting dan aff wire

-Cefixime 2x200mg -Omeprazole 2x20mg -Ibuprofen 3x400mg

Sudah RAP

2. 22.03.24 _Susilawati^Rini 081378457865 45 thn P 0002260239

- Post Strayer procedure and Plantar fasciotomy due to Plantar fascitis at left foot POD X

-GV

-PWB dengan crutches -Analsik 2x1tab

-Metilprednisolon 2x8mg -Kontrol 1 minggu

Sudah 87 68 RAP

3. 22.03.24 Ita Juwita 083105339650 54 P 0001816380

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at right foot POD 1 month

- Latihan Jalan - Rendam air hangat - Kontrol 1 bulan - Rencana xray ulang

Sudah 65 57 RAP

4. 22.03.24 ^{Yudha Octa} 081394516684 27 thn L 0002268801 - Post ORIF Plate and screw due - GV Sudah 69 74 RAP

(5)

to Pilon fracture at right ankle Ruedi and Allgower type III POD XXV

- Kontrol 2 minggu - Aff hecting - Lepas Boot slab - ROM Exercise - Ibuprofen 3x400mg - Omeprazole 2x20mg

5. 22.03.24 _Sugianto^Devi 081386885781 53thn P 0002272887

- Post Orif Plate and Screw due to Avulsion fracture at left base of 5th metatarsal transverse displaced Zone I POD XIV

- Aff hecting

- Full weight bearing dengan rocker bottom shoes - Kontrol 2 minggu

Sudah 71 56 RAP

6. 22.03.24 Rainor Azizi 087823863444 17 thn L 0002154186

- Post Debridement, Keystone Flap, STSG and immobilization with boot slab due to wound dehiscence at right lower leg POD 2 month

- Post supramalleolar osteotomy, ORIF P/S and mid foot reconstruction due to Pes cavus at right foot POD 3 month

-Aspirasi Sendi -GV setiap hari

-Cotrimoxazole 2x960mg -Clindamicyn 2x300mg -Pregabalin 2x75mg -Ibuprofen 3x400mg

Sudah 69 74 RAP

7. 22.03.24 ^Theresia_Juniati 081910690269 77 thn P 0002265142

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at left foot POD 1 Month

- Rendam air hangat - Kontrol 1 bulan - Pregabalin 2x75mg - Ibuprofen 3x400mg

Sudah 78 68 RAP

8. 22.03.24 Euis Maryati 085738199082 75 thn P 0002257762 - post hallux valgus correction due to Halux valgus at right foot POD 1 month

-Metilprednisolon 2x8mg -Ramipril 1x5mg -Pregabalin 2x75mg -Ibuprofen 3x400mg

Sudah 78 72 RAP

9. 22.03.24 _Kameliya^Yowan ^- 36 thn L 0002275753 - Chronic right ankle instability - Rencana MRI

- Ibuprofen 3x400mg Sudah 81 72 RAP

10. 22.03.24 ^{Ayi Hikmat}_Krida 08987131930 52 thn L 0002176671

- Post ankle arthrodesis due to Diabetic charcot neuropathy at left foot POD 4 month - Diabetes Mellitus Type 2

- Aff casting - Rendam air hangat

- PWB

- Metilprednisolon 2x8mg - Eperison 2x1tab

Sudah 78 63 RAP

11. 22.03.24 Rahayu 0822-1420-6074 33 thn P 0002106226

- Post open debridement and roser plasty due to CRPS forefoot post traumatic at right great toe dd/ suspect neuroma POD VIII

-GV

-Kontrol 1 minggu -Menunggu hasil PA -Ibuprofen 3x400mg

Sudah 86 88 RAP

12. 22.03.24 Meriyanjaya^Angga Fauji

- 34 thn L 0002275246

- Nonunion fracture at left medial maleolus with susp.

deltoid ligament injury - Union fracture at left fibula

middle third

- R/ Fibular lengthening ( Distal fibula plate, cannulated screw 4.5 Normed)

- Konsul H-2

Sudah 69 61 RAP

13. 22.03.24 ^{Gouw Boen}_Kie ^- 80 thn L 0002271888 - Neglected closed fracture at left

calcaneus - Aff boot casting

- Kontrol 1 bulan Sudah 55 38 RAP

(6)

14. 22.03.24 _Setiawan^Fajar 0853-1430-4144 43 thn L 0002266437 - Post Ligament reconstruction due to Left Chronic Ankle instability POD II

-GV

-Cefiximel 2x200mg po -Omeprazole 2x20mg po -Ibuprofen 3x400mg po -Pregabalin 2x75mg po -Kontrol 1 minggu

Sudah 75 69 RAP

15. 22.03.24 Ladiva Nur 087857482387 22 thn P 0002269648 - PostHeterotopic ossificans removal due to Heterotopic ossificans at right ankle POD II

-Aff hecting

-Metilprednisolon 2x8mg -Ibuprofen 3x400mg -Kontrol 2 minggu

Sudah 87 68 RAP

16. 22.03.24 Dara Jelita - 22 thn P 0002272026 - Post intramedullary nailing due to closed fx at left tibia pod 1 month

-Kontrol 1 bulan

-Lanjut Kontrol di Dustitra Sudah 78 63 RAP

17. 22.03.24 Kasyfillah^Deva Az-Zahra

- 20 thn P 0002275360 - Brachymetatarsia at left foot

R/ Gradual lengthening Persiapan operasi ( EKG, TFP, Lab, Xray Thorax, Konsul IPD, Konsul Anestesi)

Sudah RAP

18. 22.03.24 _Anzasmara^Triani ^- ^{28 thn} ^P ^0002121377 - TB arthritis at right ankle

- ibuprofen 3x400 mg po - lanjutkan OAT - kontrol 1 bulan

Sudah 65 47 RAP

Rabu, 20.03.24

Assess

DPJP AOFAS FAAM DPJP

1. 20.03.24 ^{Elsa Dewi}_Sulastri 081111123238 42 thn P 0000379112

- Post TTC fusion with ETN due to secondary OA at left ankle joint due to neglected closed fracture ankle joint POD 3 month

- Pregabalin 2x75mg - Ibuprofen 3x400mg - Carmed krim

- PWB 30 kg dengan 1 tongkat - Kontrol 1 bulan

Sudah 76 65 RAP

2. 20.03.24 ^AngelinCheryl Widjaja

085222345676 16 thn P 0002247245

- Post Diagnostic arthroscopy + ATFL reconstruction with Brostrom-Gould procedure due to Left Chronic ankle instability with syndesmotic injury POD XIV

- Generalized joint laxity

- GV, Aff hecting - Kontrol 1 bulan - Pasang boot cast - Analsik 2x1 tab - Metilprednisolon 2x8mg

Sudah 87 79 RAP

3. 20.03.24 _Hadiana^Dian 41 thn L 0001704825 - Susp tb arthritis at midfoot region

- Persiapan operasi ( EKG, TFP, Lab, Xray Thorax, Konsul IPD, Konsul Anestesi)

- Cek Infection marker - R/ Debridement & Biopsy

Sudah 81 73 RAP

4. 20.03.24 ^Riyatun 085759150767 43 thn P 0002265156 - Post Ankle debridement &

sinus tarsi debridement due to Sinus tarsi syndrome and Arthrofibrosis at left ankle joint POD VII

- GV

- Kontrol 1 minggu - Cefixime 2x200mg - Ibuprofen 3x400mg

Sudah 71 63 RAP

(7)

- Omeprazole 2x20mg

5. 20.03.24 Asrip 085813722202 61 thn L 0002275238 - Neglected closed fracture dislocation at right ankle joint with tarsal tunnel syndrome

- R/Open reduction and ankle fusion with screw

Sudah 56 39 RAP

6. 20.03.24 _Simarmata^Hotben 081221974749 44 thn L 0001639054

- Post Remove implant + TTC fusion with intramedullary nail due to Implant failure post ankle arthrodesis with plate and screw due to neglected closed fracture at left bimaleolar ankle POD 1 months

- PWB

- Rendam air hangat - Pregabalin 2x75mg - Ibuprofen 3x4oomg - Carmed krim - Kontrol 1 bulan

Sudah 85 84 RAP

7. 20.03.24 Rita Urianti 081313199711 59 thn 0002255864

- Post Hallux valgus correction due to Halux valgus at left foot POD 1,5 month

- Post 2nd and 3rd toe amputation due to diabetic foot POD 4 years

- Diabetes Mellitus terkontrol

- Bandage dengan posisi abduction

- Oles carmed - Kontrol 1 bulan

- Pasien masih menunda Operasi selanjutnya.

Sudah 87 68 RAP

8. 20.03.24 Gunadiputra^Boby

085795924909

082121352947 19 thn L 0002156097

- Post joint and ligament reconstruction with medial capsulorraphy, lateral capsule release + augmentation with internal brace due to Neglected dislocation at 1st MTP joint of right foot POD 1 months - TB Abdomen on OAT (bulan

ke-8)

- Rendam air hangat - Kontrol kembali jika ada

keluhan

Sudah 81 61 RAP

9. 20.03.24 _Rohman^Oman 081809121517 52 thn L 0002275245 - Charcot arthropathy at left foot

- R/ TTC Fusion

Sudah 56 39 RAP

10. 20.03.24 Meriyanjaya^Angga Fauji

- 34 thn L 0002275246

- Nonunion fracture at left medial maleolus with susp.

deltoid ligament injury - Union fracture at left fibula

middle third

- R/ Fibularlengthening ( Distal fibula plate, cannulated screw 4.5 Normed)

Sudah 69 61 RAP

11. 20.03.24 Tria Apriana 081779960999 30 thn P 0002199022

- Post Arthroscopy microfracture due to Osteochondral lesion of talus at right ankle POD 3 weeks

- Injeksi Triamcinolone - Kontrol 2 minggu - Rendam air hangat - PWB

- Pregabalin 2x75mg - Na diklofenak 2x50mg

Sudah 80 74 RAP

12. 20.03.24 ^Raikan 0895330602371 19 thn L 0002259132 - Post Debridement, STSG, and remove external fixation post OREF due to Open right ankle

- Kontrol luka ke Bedah Plastik - R/ Equinus deformity

correction (Awal Mei 2024)

Sudah 55 17 RAP

(8)

injury Lauge Hansen

Classification SER type IV POD I Month

- Post CRIF with Intramedullary K-Wire due to Closed fracture at right base 2nd metatarsal comminutive displaced POD 2 month

- Post CRIF with screwing due to Closed avulsion Jones fracture at right base 5th metatarsal transverse displaced POD 2 month

- Post ORIF screwing due to Closed fracture at right medial malleolus POD 2 month - Post ORIF screwing due to

Syndesmotic injury at right ankle injury POD 2 month

13. 20.03.24 Arian Faftur

Iman - 27 thn L 0002268477

- Post ORIF with Plate and screw due to Closed fracture at right clavicle middle third Allman classification group 1 Tscherne classification grade 0 POD 1 month

- Hydropneumothorax kanan dengan collaps paru kanan (Perbaikan)

- Closed fracture at right head of 2nd metatarsal oblique displaced Tscherne classification grade I - Post Debridement, exploration, and ORIF K-wire due to:

- Closed fracture at right shaft of 3rd metatarsal comminutive displaced Tscherne classification grade I

- Open fracture at right head of 5th middle phalanx comminutive displaced Gustilo Andersen grade II

- Susp. Post ganglionic Brachial plexus injury upper lesion

- GV, Aff hecting

- Mecobalamin 3 x 500 mg - Ibuprofen 3 x 400 mg - Cefixime 2x200 mg

- Observasi 3 bulan untuk brachial plexus injury

Sudah 52 31 RAP

14. 20.03.24 Dedi Hidayat 08997128170 28 thn L 0002266448

- Post Achilles tendon repair + FHL tendon transfer due to Right Chronic achilles tendon rupture POD 1 Month

- Ibuprofen 3x400 mg -Eperison 2x50mg -Kontrol 2 minggu

Sudah 71 65 RAP

(9)

15. 20.03.24 ^Ersanda_Azka 087722319836 15 thn P 0001794638

- Post debridement per arthroscopy due to Sinus tarsi syndrome at left foot POD 7

- GV setiap 2 hari - FWB dengan 1 tongkat - Na diklofenak 2x50mg - Pregabalin 2x75mg - Cefixime 2x200mg - Bisolvon 2x1tab - Kontrol 1 minggu

Sudah 90 84 RAP

16. 20.03.24 ^Muhamad_Haikal 085759143227 20thn L 0002264880

-Post ORIF plate and

screwclosed fracture at left tibia middle third transverse displaced AO Classification 42A2 Tscherne Classification grade 1 POD VII

- GV

- Kontrol 1 minggu - Cefixime 2x200mg - Ibuprofen 3x400mg - Omeprazole 2x20mg

Sudah RAP

17. 20.03.24 Yuariyanti^Yuyun (Eksekutuf)

- 45 thn P 0001634341 -Plantar fascitis - Stretching exercise Sudah RAP

18. 20.03.24 Neng Solihat (eksekutif)

082118185563 /

085722330198 45 thn P 0002266796

-Post TTC fusion due to Charcot arthropathy at right ankle joint POD XIV

- GV, Aff hecting

- PWB

- Kontrol 1 bulan

Sudah 69 74 RAP

Jumat, 15.03.24

Assess

DPJP AOFAS FAAM DPJP

1. 15.03.24 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 9 months

- Mecobalamin 3x500 mg po - Pregabalin 2x75 mg PO prn - Rendam air hangat - Kontrol jika ada keluhan

Sudah 71 56 RAP

2. 15.03.24 Sugianto^Devi 081386885781 53thn P 0002272887

- Post Orif Plate and Screw due to Avulsion fracture at left base of 5th metatarsal transverse displaced Zone I POD

- GV

- Kontrol 1 minggu - Ibuprofen 3x400mg po - omeprazole 2x20mg po

Sudah 71 56 RAP

3. 15.03.24 Eni Rohaeni 089620064208 37 thn P 0001669482

- Post injeksi triamsinolon due to plantar fascitis at left foot - Post plantar fascia release and

gastrocnemius resection with strayer procedure due to plantar fascitis at right foot POD 5 weeks

- Stretching exercise - Rendam air hangat - Metilprednisolon 2x8mg po - Ibuprofen 3x400mg po - Kontrol jika ada keluhan

Sudah 82 74 RAP

4. 15.03.24 Rini Budiarti 081383188174 64 thn P 0002273440 - Charcot arthropathy at left foot R/ TTC fusion

Konsul H-2 Sudah 42 38 RAP

(10)

5. 15.03.24 ^Djohan 082117300081 74 thn L 0002265660

- Neglected closed fracture at right ankle joint

- Charcot arthropathy at right foot - CKD

- R/ Ankle arthrodesis

Konsul H-2 Sudah 58 49 RAP

6. 15.03.24

M. Faiz Maulana Rahman

085217845814 10 thn L 0002274441 - Sever disease at right foot

- Rujuk balik

- Konservatif treatment - Stretching exercise - Ibuprofen syr 3xcth1 po

Sudah 88 82 RAP

7. 15.03.24 ^{Ladiva Nur}Himnasia 087857482387 22 thn P 0002269648

- PostHeterotopic ossificans removal due to Heterotopic ossificans at right ankle POD VII

- GV

- Kontrol 1 minggu - Lepas boot slab - Cefadroxyl 2x500mg po - Ibuprofen 3x400mg po

Sudah - - RAP

Rabu, 13.03.24

Assess

DPJP AOFAS FAAM DPJP

1. 13.03.24 Ojon Junaedi 085722015053 64thn L 0002272769

- Gouty Tophus at Left great toe and 2nd toe

- CKD stage IV

- HHD

- Hipertensi stage II

- R/ Tophus excision

- Hari ini USG ginjal, kontrol ke IPD

Sudah 64 52 RAP

2. 13.03.24 Sujana 089654945755 58 thn L 0001551886 - Secondary arthritis at right

ankle joint -R/ Ankle Arthrodesis

-Acc h-2, masuk JOM Sudah 66 64 RAP

3 13.03.24 Wawan

Gunawan 081398960852 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 7 month

- PWB dengan 1 tongkat - Calsium tab 2x1 - Vit D tab 1x1

- Osteonat tab 1x1/minggu - Ibuprofen 2x400mg - Pregabalin 2x75mg - Kontrol 2 bulan

Sudah 69 65 RAP

4 13.03.24 Ersanda

Azka 087722319836 15 thn P 0001794638 - Post debridement per arthroscopy due to Sinus tarsi

- GV setiap 2 hari

- FWB dengan 1 tongkat Sudah 90 84 RAP

(11)

syndrome at left foot POD 7

- Na diklofenak 2x50mg - Pregabalin 2x75mg - Cefixime 2x200mg - Bisolvon 2x1tab - Kontrol 1 minggu 5 13.03.24 Firman

Andhyka 081221073030 26 th L 0000021393 - Right Chronic ankle instability - Ligament reconstruction

- Acc H-2, masuk JOM Sudah 96 94 RAP

6 13.03.24

Angelin Cheryl Widjaja

085222345676 16 thn P 0002247245

- Post Diagnostic arthroscopy + ATFL reconstruction with Brostrom-Gould procedure due to Left Chronic ankle instability with syndesmotic injury POD VII

- Generalized joint laxity

- Buat window

- GV

- Kontrol 1 minggu - rencana ganti soft cast - Ibuprofen 3x400mg - Cefixime 2x200mg

Sudah 87 79 RAP

7 13.03.24

Diandra Rizki Alfarizi

08129391711 35thn L 0002273977 - Plantar fascitis at bilateral foot

- Latihan stretching - Eperison hcl 2x50mg - Metilprednisolon 2x8mg - Meloxicam 2x15mg - Pasien masih belum setuju

untuk dilakukan tindakan

Sudah 92 89 RAP

8 13.03.24 Iyah Marliah

(Eksekutif) - 59 thn P 0002273914 - Polyarthralgia dd reactive arthritis ec TB

- PWB

- Celexocib 2x200mg - Metilprednisolon 1x8mg

Sudah RAP

9 13.03.24 Ina Marlina

(Eksekutif) - 58 thn P 0002273916 - Baker cyst - Metilprednisolon 2x8mg

- Norvask 0-0-10 Sudah RAP

Jumat, 08.03.24

Assess

DPJP AOFAS FAAM DPJP

1. 08.03.24 Said 083843950967 49 thn L 0002235248

- Post Necrotomy Debridement and STSG due to infected wound post OREF joint spaning due to Open fracture dislocation at left talus body comminutive displaced Hawkins classification type IV Gustillo anderson

classification grade IIIB POD X

- Kontrol ke bedah plastik Sudah 63 52 RAP

2. 08.03.24 Yudha Octa 081394516684 27 thn L 0002268801 - Post ORIF Plate and screw due to Pilon fracture at right

- GV

- Kontrol 2 minggu Sudah 69 74 RAP

(12)

ankle Ruedi and Allgower type III POD XI

3. 08.03.24 Rini

Susilawati 081378457865 45 thn P 0002260239 - Plantar fasctis at left foot - Acc H-2

- Masuk JOM (Release plantar fascia)

Sudah 87 68 RAP

4. 08.03.24 Dena M.

Rizky 082129572434 20 L 0002221352

- Post Remove k-wire due to Surgical site infection post ORIF K-wire, ORIF screwing and reverse sural flap due to open fracture at left foot POD III

- GV

- Ibuprofen 3x400mg - Omeprazole 2x20mg - Kontrol 1 minggu

Sudah 82 74 RAP

5. 08.03.24 Hendrik

Setia 081022184820 33 thn L 0002235239

- Post supramaleolar osteotomy and ORIF P/S due to Malunion fracture of right bimaleolar ankle joint POD 2 months

- FWB

- Active passive ROM exercise ankle joint

- Gastrocnemius stretching - Konsul IKFR

- Kontrol 1 bulan

Sudah 78 63 RAP

6. 08.03.24 Ita Juwita 083105339650 54 P 0001816380

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at right foot POD XXI

- GV, Aff hecting - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Kontrol 2 minggu

Sudah 65 57 RAP

7. 08.03.24 Theresia

Juniati 081910690269 77 thn P 0002265142

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at left foot POD XVI

- GV, aff hecting - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Kontrol 2 minggu

Sudah 78 68 RAP

8. 08.03.24 Djedjen

Djaenudin - 40 L 0002269317

- Post ORIF with circlage wire due to Closed fracture at right patella comminuted displaced - Debridement and artificial nail

plate insertion due to Avulsion nail plate of right great toe - POD XIX

- Aff hecting

- Ibuprofen 3x400 mg po - Lepas slab

- Kontrol 2 minggu

- PWB

Sudah 65 47 RAP

9. 08.03.24 Restu - 17 thn L 0002155230

- Peroneal nerve palsy post limb salvage at left proximal tibia due to osteosarcoma

- Konsul IKFR, AFO

- Pasang boot slab Sudah 52 31 RAP

10. 08.03.24 Ade Rukmini 082215218400 47thn P 0002272763 - Neglected closed right ankle injury

- R/ ORIF P/S and Screwing - Acc H-2

- Masuk JOM

Sudah 48 34 RAP

11. 08.03.24 Euis Maryati 085738199082 75 thn P 0002257762

- post hallux valgus correction due to Halux valgus at right foot POD XXV

- GV, Aff hecting - Omeprazole 2x20mg PO - Ibuprofen 3x400 mg PO - Kontrol 1 bulan

Sudah 78 72 RAP

12. 08.03.24 Sisca Novianti

087778999989 33 thn P 0002257766 - Post Tendinitis excision (Calcaneoplasty), re-

- Lepas casting - GV, aff hecting

Sudah 71 54 RAP

(13)

attachment of Achilles tendon + FHL tendon transfer due to Achilles tendinitis with Haglund Defomity at right foot POD I month

- PWB

- Kontrol 1 bulan

13. 08.03.24 Wahyu 087824138340 73 thn L 0002179168

- Post debridement and culture due to Surgical site infection with implant exposed Post TTC revision with

intramedullary nailing due to suspect TB arthritis dd/

Charcott arthropathy at left ankle joint POD III

- GV

- Aff hecting di puskesmas - kontrol 1 bulan

Sudah 71 46 RAP

14. 08.03.24 Nia

Kurniasih 081392337295 38 thn P 0002139120

- Post remove screw, augmentasi plate, and Bone grafting due to arthritis TB at left talonavicular joint Post talonavicular fusion POD 1 month

- Xray ulang

- PWB

- Ibuprofen 3x400 mg PO - Pregabalin 2x75mg PO - OAT dilanjutkan - Kontrol 3 minggu

-

Sudah 69 64 RAP

15. 08.03.24 Muhammad

Prayoga 081212714661 10 thn L 0002097655

-Post calcaneal osteotomy due to flexible flatfoot (PesPlano Valgus) at left foot POD 8 months

- Post arthroeresis due to flexible flatfoot (PesPlano Valgus) at right foot POD 5 months

-Latihan jalan cepat-lari

-Kontrol 2 bulan Sudah 83 81 RAP

16. 08.03.24 Iman Faizal 081261000827 42 thn L 0002203294

- Post achilles tendon lengthening due to Malunion fracture at right talus with secondary

osteoarthritis and equinus deformity POD XV

- Malunion fracture Post ORIF k wire at left distal radius POD 2 years

- Neglected malunion fracture at right pubic rami and right acetabulum with secondary hip osteoarthritis

- Lepas casting - Burnazin salep - Cefixime 2x200mg po - Omeprazole 2x20mg po - Ibuprofen 3x400mg po - Kontrol Adv. Trauma division

and Hand division

Sudah 64 42 RAP

17. 08.03.24 Dani Parsaoran

Sormin

081214781924 20 thn L 0002272160 - Old unreduced dislocation PIP joint

- R/ Open reduction + Reconstruction PIP joint - Persiapan operasi ( EKG, TFP,

Lab, Xray Thorax, Konsul IPD, Konsul Anestesi)

Sudah RAP

18. 08.03.24 Rini Budiarti

(Eksekutif) - 65 thn P 0002273380 - Charcot arthropathy - R/ TTC Fusion

- Persiapan operasi ( EKG, TFP, Sudah RAP

(14)

19. 08.03.24 Eutik Hayati

(Eksekutif) - 62 thn P 0000855611 - Midfoot arthritis

- Morton neuroma - Metilprednisolon 2x8mg

- Pregabalin 2x75mg Sudah RAP

20. 08.03.24 Malikha Haura (Eksekutif)

- 20 thn P 0002273440 - Wrist sprain - Xray

- Wrist support Sudah RAP

Rabu, 06.03.24

Assess

DPJP AOFAS FAAM DPJP

1. 06.03.24 Irena Dwita

Rosdiana 081313324264 28 thn P 0002235248

- Post refracturization and ORIF plate and screw fibula due to Neglected closed fracure at left distal tibia fibula POD 3 months

- Latihan Stretching

2 06.03.24 Indri Sulastri 085591154615 25 thn P 0002221595

- Post Pantalar arthrodesis due to Neglected talipes

equinovarus at right foot post ankle reconstruction, deformity correction and TTC fusion with plate and screw POD 1 month

- Remove wire di poli (hari ini) - Latihan jalan menggunakan

crutches -> Lapor mandiri video berjalan per 3 hari via WA - Kontrol 1 bulan

- Xray ulang saat kontrol

Sudah 69 74 RAP

3 06.03.24 Kenn Kahlil

Kitwana 082126263535 20 thn P 0002080085

- Post ATFL reconstruction with Brostrom procedure due to Left Chronic Ankle instability with flat foot POD 1 month - Post calcaneal osteotomy +

Brostrom procedure due to right chronic lateral ankle instability with flat foot POD 1 month 2 weeks

- Lepas cast

- Pakai elastic verban/ ankle support

- Mecobalamin 3x500mg - Ibuprofen 3x400mg - Kontrol 1 bulan

Sudah 62 56 RAP

4 06.03.24 Nurul Fajrina Nadhilah

081464405330 23 thn P 0002191831 - Post ORIF screwing + malleolar osteotomy + immobilization with boot slab

- Latihan Stretching - Latihan jinjit

- Rendam air hangat setiap hari

Sudah 72 68 RAP

(15)

due to Closed fracture at right talus hawkins classification type II Tscherne classification grade I POD 2 months

- Kontrol 1 bulan - Xray ulang saat kontrol

5. 06.03.24 Randy

Wibawa 082117463110 29 thn L 0001599591

- Post ATFL Reconstruction with brostrom procedure due to ATFL tear at right ankle POD 1 Month

-Lepas casting -Ankle brace -Meloxicam 2x15mg -Eperison 2x50mg -Kontrol 1 bulan

Sudah 68 56 RAP

6. 06.03.24 Dedi Hidayat 08997128170 28 thn L 0002266448

- Post Achilles tendon repair + FHL tendon transfer due to Right Chronic achilles tendon rupture POD XVI

- Lepas casting -Meloxicam 2x15mg -Eperison 2x50mg -Kontrol 2 minggu

Sudah 71 65 RAP

7. 06.03.24 Resti

Septianti 0882000277195 18thn P 0000623349 - Thalasemia Major with ankle joint arthritis

- R/ MRI ankle joint - Ankle brace

- Na diclofenac 2x50mg - Kontrol setelah ada hasil MRI

Sudah 82 74 RAP

8. 06.03.24 Deni Anwar 085893038270 19 thn L 0002270629 - Neglected CTEV at right foot

with infected wound - Acc H-2, Masuk ke JOM Sudah 52 31 RAP

9. 06.03.24 Rita Urianti 081313199711 59 thn 0002255864

- Post Hallux valgus correction due to Halux valgus at left foot POD 1 month

- GV setiap hari dengan betadine dan sufratulle (Stop duoderm) - Bandage dengan posisi

abduction - Oles carmed - Kontrol 2 minggu

Sudah 87 68 RAP

10. 06.03.24 Tria Apriana 081779960999 30 thn P 0002199022

- Post Arthroscopy microfracture due to Osteochondral lesion of talus at right ankle

- Aff hecting

- Rencana injeksi triamcinolone saat kontrol

- Kontrol 2 minggu

Sudah 80 74 RAP

11. 06.03.24 Muhamad

Haikal 085759143227 20thn L 0002264880

-Post immobilization with above knee cast due to closed fracture at left tibia middle third transverse displaced AO Classification 42A2 Tscherne Classification grade 1 -Closed fracture at left medial

malleolus transverse displaced

- Masuk Rawat Inap

- Persiapan Operasi Sudah RAP

12. 06.03.24 Devi

Sugianto 081386885781 53thn P 0002272887 - Avulsion fracture at left base of 5th metatarsal transverse displaced Zone I

- Masuk Rawat Inap

- Orif Screwing (07.03.24) Sudah 62 56 RAP

13. 06.03.24 Rahayu 082214206074 32 thn P 0002106226

- CRPS forefoot post traumatic at right great toe dd/ suspect neuroma

- R/ Open debridement, Roser plasty

Sudah 90 80 RAP

14. 06.03.24 Ojon Junaedi 085722015053 64thn L 0002272769 - Gouty Tophus at Left great toe and 2nd toe

- R/ Tophus excision

- Persiapan operasi ( EKG, TFP, Sudah 64 52 RAP

(16)

15. 06.03.24 Ade Rukmini 082215218400 47thn P 0002272763 - Neglected closed right ankle injury

- R/ ORIF P/S and Screwing - Persiapan operasi ( EKG, TFP,

Sudah 48 34 RAP

16. 06.03.24 Rochayati

(Eksekutif) 087723712366 53 thn P 0002092027

- Post Ankle reconstruction with supramaleolar osteotomy and fixation with plate and screw, fibular osteotomy, and Achiles tendon lengthening due to Pes Cavus at right foot POD 11 months

- FWB

082118185563 /

085722330198 45 thn P 0002266796

- Post TTC fusion due to Charcot arthropathy at right ankle joint POD XIV

- GV

- Kontrol 2 minggu Sudah 69 74 RAP

18. 06.03.24 Enoy Sari

(eksekutif) 085294944414 71 thn P 0002213447

- Implant failure post ankle fusion with plate and screw due to left charcot foot with neglected fracture of left ankle POD 3 weeks

- GV

- Konsul Fisioterapi Sudah 80 74 RAP

19. 06.03.24

Dani Parsaoran

Sormin (Eksekutif)

- 20 thn L 0002272160 - Neglected fracture dislocation

at 3rd toe Proximal phalang - Pro ORIF Sudah RAP

Jumat, 01.03.24

Assess

DPJP AOFAS FAAM DPJP

1 01.03.24 ^{Dena M.}_Rizky 082129572434 20 L 0002221352

- Surgical site infection post ORIF K-wire, ORIF screwing and reverse sural flap due to open fracture at left foot POD 3 months

- GV

- Ibuprofen 3x400 mg po - Persiapan Operasi (konsultasi

anestesi dan IPD )

- R/ remove implant (K-wire) dan debridement (ODS)

Sudah 82 74 RAP

2. 01.03.24 _Djaenudin^Djedjen ^- 40 L 0002269317

- Post ORIF with circlage wire due to Closed fracture at right patella comminuted displaced - Debridement and artificial nail

plate insertion due to Avulsion nail plate of right great toe POD XII

- Aff hecting

- Ibuprofen 3x400 mg po - Lepas slab

- Kontrol 2 minggu

- Isometric quadricep exercise

Sudah 65 47 RAP

(17)

3. 01.03.24 ^Theresia_Juniati 081910690269 77 thn P 0002265142

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at left foot POD IX

- GV setiap hari - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Kontrol 1 minggu

Sudah 78 68 RAP

4. 01.03.24 Arian Faftur

Iman - 27 thn L 0002268477

- Post ORIF with Plate and screw due to Closed fracture at right clavicle middle third Allman classification group 1 Tscherne classification grade 0 POD IX - Hydropneumothorax kanan dengan collaps paru kanan (Perbaikan)

- Closed fracture at right head of 2nd metatarsal oblique displaced Tscherne classification grade I - Post Debridement, exploration, and ORIF K-wire due to:

- Closed fracture at right shaft of 3rd metatarsal comminutive displaced Tscherne classification grade I

- Open fracture at right head of 5th middle phalanx comminutive displaced Gustilo Andersen grade II

POD XII

- Susp. Post ganglionic Brachial plexus injury upper lesion

- GV

- pertahankan arm sling - pertahankan boot slab - kontrol 1 minggu untuk aff hecting

- Mecobalamin 3 x 500 mg PO - ibuprofen 3 x 400 mg PO - konsul IKFR

- observasi 3 bulan untuk brachial plexus injury

Sudah 52 31 RAP

5. 01.03.24 ^Muhammad_Prayoga 081212714661 10 thn L 0002097655

-Post calcaneal osteotomy due to flexible flatfoot (PesPlano Valgus) at left foot POD 8 months

-Post arthroeresis due to flexible flatfoot (PesPlano Valgus) at right foot POD 5 months

- konsul IKFR untuk pembuatan insole dengan arch support

- Ice compression pada lutut kiri bila nyeri

- towel curls exercise - x ray bilateral ankle

AP/Lateral

Sudah 83 81 RAP

6. 01.03.24 ^{Gouw Boen}

Kie - 80 thn L 0002271888 - Neglected closed fracture at left

calcaneus - paracetamol 3 x 500 mg PO

- gabapentin 2 x 300 mg PO - Immobilization with boot

cast

- xray axial view, xray right ankle AP/lateral

Sudah 55 38 RAP

(18)

- kontrol 2 minggu

Rabu, 28.02.24

Assess

DPJP AOFAS FAAM DPJP

1. 28.02.24 Indri Sulastri 085591154615 25 thn P 0002221595

- Post Pantalar arthrodesis due to Neglected talipes

equinovarus at right foot post ankle reconstruction, deformity correction and TTC fusion with plate and screw POD XXIII

- Post ankle reconstruction, deformity correction + TTC fusion with P/S due to Neglected talipes equinovarus at right foot POD 1 month

- pertahankan boot slab - Ibuprofen 3x400 mg po - Pregabalin 2x75mg po - Carmed cream dioleskan pada

sisi lateral

- Latihan berjalan dengan 2 tongkat .

Sudah 69 74 RAP

2. 28.02.24 Ita Juwita 083105339650 54 P 0001816380

- Post Hallux valgus correction with lapidus procedure due to Hallux valgus at right foot POD XII

- GV

- Ibuprofen 3x400 mg po - Pregabalin 2x75 mg po - Omeprazole 2x20 mg po - Kontrol 1 minggu

Sudah 65 57 RAP

Kitwana 082126263535 20 thn P 0002080085

- Post ATFL reconstruction with Brostrom procedure due to Left Chronic Ankle instability with flat foot POD XXI - Post calcaneal osteotomy +

Brostrom procedure due to right chronic lateral ankle instability with flat foot POD 1 month

- GV

- Ganti Soft cast - Ibuprofen 3x400mg PO - Kontrol 1 minggu

Sudah 62 56 RAP

4. 28.02.24 Dedi Hidayat 0899-7128-170 28 thn L 0002266448

- Post Achilles tendon repair + FHL tendon transfer due to Right Chronic achilles tendon rupture POD VIII

- GV

- Convert to circular cast - Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Pregabalin 2x75 mg po - kontrol 1 minggu

Sudah 71 65 RAP

5. 28.02.24 ^{Lani Siti} 081213094384 25 thn P 0002172631 - Post remove external fixation, Achilles tendon lenghtening and immobilization with bootcast

- Remove cast - GV, aff hectring - PWB dengan 1 tongkat

Sudah 46 41 RAP

(19)

due to Union fracture at right distal third tibia fibula POD 1.5 month

- Ibuprofen 3x400 mg bila nyeri - Kontrol 1 minggu

6. 28.02.24 Wahyu 087824138340 73 thn L 0002179168

- Surgical site infection with implant exposed Post TTC revision with intramedullary nailing due to suspect TB arthritis dd/ Charcott arthropathy at left ankle joint POD 26

- GV, open wound care - R/ Debridement and culture - Persiapan Operasi ( Lab, xray

thorax, EKG, TFP )

Sudah 71 46 RAP

7. 28.02.24 Dhyan 08122467057 34 thn L 0002268276

- Post ORIF p/s due to Closed fracture at right humerus middle third oblique displaced with neurological deficit (radial nerve) POD 1 week

- pertahankan wrist brace - mecobalamin 3 x 500 mg PO - GV, aff hecting

- konsul IKFR, kontrol RS Bekasi

Sudah 90 84 RAP

8. 28.02.24 ^{Raden Roro}_Tarjuni 0859566720 66 thn P 0002271402

- Insertional left achilles tendinopathy with haglund deformity

- R/ Open Calcaneoplasty - X ray left ankle AP/Lateral - Persiapan Operasi ( Lab, xray

thorax, EKG, TFP )

Sudah 72 64 RAP

9. 28.02.24 Deni Anwar 085893038270 19 thn L 0002270629 - Neglected CTEV at right foot with infected wound

- R/ Ankle reconstruction and TTC fusion

- Persiapan Operasi ( Lab, xray thorax, EKG, TFP )

Sudah 52 31 RAP

10. 28.02.24 _Febrian^Rivaldi 0857-9467-7058 16 thn L 0000747876

- Delayed union of right lateral and medial malleolus - Autism disorder

- FWB

- Kontrol 2 bulan untuk evaluasi xray

Sudah 76 65 RAP

Jumat, 23.02.24

Assess

DPJP AOFAS FAAM DPJP

(20)

1 23.02.24 Rainor Azizi 087823863444 17 thn L 0002154186

- Post Debridement, Keystone Flap, STSG and immobilization with boot slab due to wound dehiscence at right lower leg POD 1.5 month

- Post supramalleolar osteotomy, ORIF P/S and mid foot reconstruction due to Pes cavus at right foot POD 2 month

-Latihan berjalan dengan 1 tongkat -Ibuprofen 3x400 mg po

- Kontrol 1bulan

Sudah 69 74 RAP

2. 23.02.24 Joko Suparno 081224602100 53 thn L 0002090847

- Post debridement and end cap removal due to wound

dehiscence post Implant revision and Intramedullary nailing due to Post ankle arthrodesis with TTC fusion Ankle arthritis at right ankle joint Takakura classification stage IV POD III

- GV

- Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Pregabalin 2x75 mg po - Omeprazole 2x20 mg po - Rujuk balik

Sudah 64 52 RAP

3. 23.02.24 ^{Dena M.}

Rizky

082129572434 20 L 0002221352 Post Debridement, STSG and remove ab beads due to reverse sural flap necrotic at right foot POD XVIII

Post Debridement, FTSG, STSG and NPWT due to reverse sural flap necrotic at right foot POD XXII

Post Debridement + Tenodesis + defect closure with reverse sural flap + bone cemenct spacer + immobilization with boot slab due to :

- Open fracture at right 2nd base of metatarsal comminutive displaced Gustillo Anderson grade 3B

- Open fracture at right 3rd base of metatarsal comminutive displaced Gustillo Anderson grade 3B

- Open fracture at right 4th base of metatarsal comminutive displaced Gustillo Anderson grade 3B + Total rupture of extensor digitorum longus tendon

- GV

- Cefixim 2x200 mg po - Ibuprofen 3x400 mg po

- Persiapan Operasi ( Lab, xray thorax, EKG, TFP )

- R/ remove implant (K-wire) - ODS

Sudah 82 74 RAP

(21)

- Open fracture at right 5th base extend to neck of metatarsal comminutive displaced Gustillo Anderson grade 3B + Total rupture of extensor digitorum longus tendon

- Open fracture at right cuboid comminutive displaced Gustillo Anderson grade 3B

- Open fracture at Right lateral and intermediate cuneiform comminutive displaced Gustillo Anderson grade 3B

- Open Lisfranc injury Hardcastle classification type B2

- Post debridement and exploration + ORIF intramedullary K-Wire + Tendon repair + NPWT + Immobilization with boot slab POD 1 month

4. 23.02.24 Holil 79 L 0002266558

- Post ORIF P/S and ORIF screwing due to Closed ankle injury lauge hansen

classification Pronation- Abduction type III POD XX

- GV

- Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Kontrol 1 minggu

Sudah 44 31 RAP

5. 23.02.24 Linda 089655768596 50 thn P 0002198997

- Post Gastrocnemius resection, osteotomy, ORIF screwing, hallux valgue correction, MTP joint correction with K-wire and immobilization with bootslab due to Congenital Pes Plano Hallux valgus deformity at left foot POD 2,5 months

- GV

- Xray left foot, and Ankle joint AP/Lat

- Latihan jalan

- Omperazole 2x20 mg PO - Ibuprofen 3x400 mg PO - Pregabalin 2x75 mg PO

Kontrol 1bulan

Sudah 53 57 RAP

6. 23.02.24 ^Hendrik_Setia 081022184820 33 thn L 0002235239

- Post supramaleolar osteotomy and ORIF P/S due to Malunion fracture of right bimaleolar ankle joint POD 1,5 months

- Xray cruris

- FWB

- Ibuprofen 3x400 mg PO prn - Active passive ROM exercise

ankle joint - Kontrol 2 minggu

Sudah 78 63 RAP

7. 23.02.24 Euis Maryati 085738199082 75 thn P 0002257762 - post hallux valgus correction due to Halux valgus at right foot POD XI

- GV

- Cefixim 2x200 mg po - Omeprazole 2x20mg PO - Ibuprofen 3x400 mg PO

Sudah 78 72 RAP

(22)

-Pregabalin 2x75mg PO -Kontrol 2 minggu lagi



aff

hecting

8. 23.02.24 Sisca 087778999989 _{33 thn} _P _0002257766

- Post Tendinitis excision (Calcaneoplasty), re-attachment of Achilles tendon + FHL tendon transfer due to Achilles tendinitis with Haglund Defomity at right foot POD XVI

- GV

- Slab convert to boot cast - Pregabalin 2x75 mg - Ibuprofen 3x400 mg - Kontrol 2 minggu

Sudah 76 65 RAP

9. 23.02.24 Raikan 0895330602371 19 thn L 0002259132

- Post Debridement, STSG, and remove external fixation post OREF due to Open right ankle injury Lauge Hansen

Classification SER type IV POD VIII

- Post CRIF with Intramedullary K-Wire due to Closed fracture at right base 2nd metatarsal comminutive displaced POD 1 month

- Post CRIF with screwing due to Closed avulsion Jones fracture at right base 5th metatarsal transverse displaced POD 1 month

- Post ORIF screwing due to Closed fracture at right medial malleolus POD 1 month - Post ORIF screwing due to

Syndesmotic injury at right ankle injury POD 1 month

- GV

- Cefixim 2x200 mg po - Cefixim 2x200 mg po - Omeprazole 2x20mg PO - Ibuprofen 3x400 mg PO - Pregabalin 2x75mg PO - Kontrol 2 minggu

Sudah 55 17 RAP

10. 23.02.24 Mirna 081809759908 36 thn P 0001156314 - Malunion fracture at left first Metatarsal

- Konservatif - Oscal 1x1 po - Ibuprofen 3x1 po - Kontrol bila ada keluhan

Sudah 78 64 RAP

11. 23.02.24 ^Dhyan 08122467057 34 thn L 0002268276

- Post ORIF p/s due to Closed fracture at right humeris middle third oblique displaced with neurological deficit (radial nerve) POD 1 week

- GV

- Cefixim 3x400 mg po - Ibuprofen 3x400 mg po - Omeprazole 2x20mg PO - Pregabalin 2x75mg PO - Kontrol 1 minggu

Sudah 90 84 RAP

12. 23.02.24 _Anzasmara^Triani - 28 thn P 0002121377 - TB arthritis at right ankle

- Xray ulang ankle joint - Cek lab led crp ulang - ibuprofen 3x400 mg po - lanjutkan OAT - kontrol 1 bulan

Sudah 65 47 RAP

(23)

13. 23.02.24 _Wibawa^Randy 082117463110 29 thn L 0001599591

- Post ATFL Reconstruction with brostrom procedure due to ATFL tear at right ankle POD XVI

-GV, aff hecting

-boot slab convert to boot cast -Cefixim 2x200 mg po -Ibuprofen 3x400 mg po -Kontrol 2 minggu

Sudah 68 56 RAP

14. 23.02.24 ^Mardiani^Dian (Eksekutif)

- 33 thn P 0001874211 - Ankle sprain grade II -Soft casting

-Kontrol 1 minggu Sudah RAP

15. 23.02.24 (Eksekutif)^Nurhaeni - 58 thn P 0001084499

- Post debridement and primary suture due to Celulitis at right leg post debridement

- Post FDL tenotomy and arthrodesis with k-wire due to Hammer toe at right 2nd - 3rd toe POD X

-Aff hecting

-Kontrol 08.03.24 Sudah RAP

16. 23.02.24 ^{Ani Hadiah}(Eksekutif) - 71 thn P 0001618583

- Post ankle fusion + SMO + Plantar fascitis

- Radiculopathy

-Plan : Remove implant

-Plantar fasciotomy Sudah RAP

Rabu, 21.02.24

Assess

DPJP AOFAS FAAM DPJP

Kitwana 082126263535 20 thn P 0002080085

- Post ATFL reconstruction with Brostrom procedure due to Left Chronic Ankle instability with flat foot POD XIV - Post calcaneal osteotomy +

- GV - aff hecting

- Clindamycin 2x300mg PO - Ibuprofen 3x400mg PO - Kontrol minggu depan untuk

ganti soft cast.

Sudah 62 56 RAP

2. 21.02.24 Gunadiputra^Boby

085795924909

082121352947 19 thn L 0002156097

- Post joint and ligament reconstruction with medial capsulorraphy, lateral capsule release + augmentation with internal brace due to Neglected dislocation at 1st MTP joint of right foot POD XIX

- TB Abdomen on OAT (bulan ke-8)

- GV

- Aff hecting.

- FWB

- Kontrol 1 bulan

Sudah 81 61 RAP

3. 21.02.24 ^Riyatun 085759150767 43 thn P 0002265156 - Sinus tarsi syndrome and - Persiapan Operasi ( Lab, xray Sudah 71 63 RAP

(24)

Arthrofibrosis at left ankle joint

thorax, EKG, TFP ) - Rencana Ankle arthroscopy

debridement / open sinus tarsi debridement.

4. 21.02.24 Imas Sadiah 083101517063 54 thn P 0002269383 - D/ Septic Arthritis at left ankle joint with chronic osteomyelitis

- Saran Arthrodesis - Persiapan Operasi dari

Orthopaedic oncolofy division.

Sudah 62 56 RAP

5. 21.02.24 Rita Urianti 081313199711 59 thn 0002255864

- Post Hallux valgus correction due to Halux valgus at left foot POD XIX

- GV, Aff hecting - Cilostazole 2x1 PO - Pregabalin 2x75 mg PO - Carmed salep

- ROM Ankle exercise

Sudah 87 68 RAP

6. 21.02.24 Wahyu 087824138340 73 thn L 0002179168

- Post Remove implant + arthrodesis with intramedullary nailing due to Implant failure post TTC fusion with plate and screw due to suspect TB arthritis dd/ Charcott arthropathy at left ankle joint POD 2,5 months POD XIX

- GV

- Calcium 2x1 PO - pertahankan boot slab

- kontrol 2 minggu ( Xray ulang, rencana aff slab )

Sudah 71 46 RAP

7. 21.02.24 ^Matheus_Mado 081222918870 54 thn L 0002044910

Post screw removal due to Screw pull out Post TTC Fusion with plate and screw, bone graft insertion, fibula osteotomy, and culture POD IX due to : - Post ORIF Screwing with intramedullary wire due to closed fracture at right fibula

comminutive displaced Tscherne Classification grade 1

- Chronic Osteomyelitis POD 1.5 months

-GV

-Kontrol 1 bulan -Fisioterapi

Sudah 66 48 RAP

- Post Ankle reconstruction, TTC fusion with plate and screw, and midfoot reconstruction due to Neglected talipes equinovarus at right foot POD XXI

- GV, Aff hecting - pertahankan boot slab - Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Pregabalin 2x75mg po - Gentamycin saleb dioleskan

pada sisi lateral.

Sudah 69 74 RAP

9. 21.02.24 Ladiva Nur 087857482387 23 thn P 0002269648 - Heterotopic ossificans at right

ankle. - Persiapan Operasi (Lab, Xray,

EKG, TFP) Sudah 87 68 RAP

(25)

Jumat, 16.02.24

Assess

DPJP AOFAS FAAM DPJP

Kitwana 082126263535 20 thn P 0002080085

- Post ATFL reconstruction with Brostrom procedure due to Left Chronic Ankle instability with flat foot POD IX - Post calcaneal osteotomy +

- GV

- Pertahankan boot slab - Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Kontrol 1 minggu  convert to

boot cast

Sudah 62 56 RAP

2. 16.02.24 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 8 months

- GV

- Mecobalamin 3x500 mg po - Pregabalin 2x75 mg PO prn - Konsul IKFR  Quadriceps

strenghtening exercise - Rendam air hangat - Kontrol 1 bulan

Sudah 71 56 RAP

3. 16.02.24 Eni Rohaeni 089620064208 37 thn P 0001669482

- Post plantar fascia release and gastrocnemius resection with strayer procedure due to plantar fascitis at right foot POD 5 weeks

- Injeksi triamsinolon + lidocain - Kontrol 1 bulan / bila ada

keluhan

Sudah 82 74 RAP

4. 16.02.24 ^{Elsa Dewi}_Sulastri 081111123238 42 thn P 0000379112

- Post TTC fusion with ETN due to secondary OA at left ankle joint due to neglected closed fracture ankle joint POD 2 month

- Aff casting

- PWB 30 kg dengan 2 tongkat - Omperazole 2x20 mg PO - Ibuprofen 3x400 mg PO - Kontrol 1 bulan

Sudah 76 65 RAP

5. 16.02.24 Joko Suparno 081224602100 53 thn L 0002090847 - Post Implant revision and Intramedullary nailing due to Post ankle arthrodesis with TTC fusion Ankle arthritis at right ankle joint Takakura classification stage IV POD 3 weeks

- GV

- Ibuprofen 3x400 mg po - Pregabalin 2x75 mg po - Omeprazole 2x20 mg po - Konsul H-2

- R/ debridement (ODS) Selasa 20.02.24

Sudah 64 52 RAP

(26)

- Post Remove implant + TTC fusion with intramedullary nail due to Implant failure post ankle arthrodesis with plate and screw due to neglected closed fracture at left bimaleolar ankle POD 3 weeks

- GV, aff hecting - Slab convert to boot cast - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Pregabalin 2x75mg po - Kontrol 1 bulan

Sudah 85 84 RAP

7. 16.02.24 Sisca 087778999989 _{33 thn} _P _0002257766

- Post Tendinitis excision (Calcaneoplasty), re-attachment of Achilles tendon + FHL tendon transfer due to Achilles tendinitis with Haglund Defomity at right foot

- GV

- Cefixim 2x200 mg - Pregabalin 2x75 mg - Ibuprofen 3x400 mg - Metilprednisolon 2x8mg - Kontrol 1 minggu

Sudah 76 65 RAP

8. 16.02.24 ^Iin 082121513939 60 thn P 0002200438

- Post wound debridement, exploration, ORIF screw, and immobilization with boot slab due to open right ankle injury Lauge Hansen Classification SAD stage 2 POD 3 months

- Rendam air hangat - Latihan stretching - Omeprazole 2x20 mg PO - Ibuprofen 3x400 mg PO - Pregabalin 2x75 mg PO - Kontrol 1 bulan

Sudah 85 84 RAP

9. 16.02.24 Yudha 081394516684 28 thn L 0002268801 - Closed right ankle injury

- Xray right ankle joint AP/Lat/mortise, Thorax - Lab, EKG, TFP persiapan

operasi - R/ ORIF

Sudah 43 32 RAP

10. 16.02.24 _Kurniasih^Nia 081392337295 38 thn P 0002139120

- Post remove screw, augmentasi plate, and Bone grafting due to arthritis TB at left talonavicular joint Post talonavicular fusion POD 2 weeks

- GV, aff hecting - NWB 1 bulan

Sudah 69 64 RAP

11. 16.02.24 _Komariah^Nur 081224816473

081293349569 44 thn P 0002215203

- Post remove Syndesmotic screw due to Open right ankle injury Lauge Hansen classification PER stage IV Gustillo Anderson Gr III A Post debridement, exploration, and ORIF Plate and Screw POD 2 weeks

-GV,aff hecting -Ibuprofen 3x400mg PO -omeprazole 2x20mg PO

- kontrol 1 bulan

Sudah 85 84 RAP

12. 16.02.24 Euis Maryati 085738199082 75 thn P 0002257762 - post hallux valgus correction due to Halux valgus at right foot POD XI

- GV

- Cefixim 2x200 mg po - Omeprazole 2x20mg PO - Ibuprofen 3x400 mg PO -Pregabalin 2x75mg PO -Kontrol 2 minggu lagi  aff

Sudah 78 72 RAP

(27)

hecting

13. 16.02.24 _Wibawa^Randy 082117463110 29 thn L 0001599591

- Post ATFL Reconstruction with brostrom procedure due to ATFL tear at right ankle POD IX

-GV

-Pertahankan boot slab -Cefixim 2x200 mg po -Ibuprofen 3x400 mg po -Kontrol 1 minggu  covert to

boot cast

Sudah 68 56 RAP

14. 16.02.24 (eksekutif)^Okta 08122139057 53 thn L 0002114354 - Achilles tendinitis at right foot -MRI Sudah 85 63 RAP

15. 16.02.24 ^{Max Devon}(eksekutif) 081214109001 19 thn L 0002268823 - Left achilles tendon contracture

+ equinus deformity -Xray Thorax

-Lab, EKG, TFP persiapan operasi Sudah RAP

16. 16.02.24 Nurjanah^Enung

(eksekutif) 081809475906 74 thn P 0001750353

- Post release plantar fascia due to Plantar fascitis at right foot POD

3 weeks -kontrol Sudah 87 83 RAP

Selasa, 13.02.24

Nama No Hp Umur L/

Assess

DPJP AOFAS FAAM DPJP

1. 13.02.24 Rita Urianti 081313199711 59 thn P 0002255864

- Post Hallux valgus correction due to Halux valgus at left foot POD XI

- Post 2nd and 3rd toe amputation due to diabetic foot POD 4 years - Diabetes Mellitus terkontrol

- GV

- Cefixim 2x200 mg po - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Pregabalin 2x75 mg po

- Konsul IPD untuk regulasi gula darah

Sudah 87 68 RAP

2. 13.02.24 Komarudin 083838002874 61 thn L 0002228040 - Post debridement, external fixation revision, and soleus flap due to wound defect and Osteomyelitis at right tibia POD XXI

- Post CRIF with screw due to closed fracture at left medial maleollus POD 2 months

- Post ORIF plate and screw due to Closed fracture at left fibula distal third comminutive displaced POD 2 months

- Union fracture at left clavicle - Union fracture at left inferior

Plastic surgery department:

- GV, aff hecting

- rencana re-debridement + tutup defek --> dijadwalkan dari Poli - Jaga kebersihan area sekitar luka Foot and Ankle Division:

- GV Sesuai TS B.Plastik

- Knee and ankle active ROM exercise as tolerated

- Omeprazole 2x20 mg po - Paracetamol 3x500 mg po - coamoxiclav 3x625 mg po

Sudah 43 37 RAP

(28)

pubic rami

Senin, 12.02.24

Nama No Hp Umur L/

Assess

DPJP AOFAS FAAM DPJP

- Post Ankle reconstruction, TTC fusion with plate and screw, and midfoot reconstruction due to Neglected talipes equinovarus at right foot POD XII

- GV

- pertahankan boot slab - Cefixim 2x200 mg po - Omeprazole 2x20 mg po - Ibuprofen 3x400 mg po - Dexametason 3x0.5 mg po - Carmed cream dioleskan pada

sisi lateral

Sudah 69 74 RAP

2 12.02.24 Boby

Gunadiputra

085795924909

082121352947 19 thn L 0002156097

- Post joint and ligament reconstruction with medial capsulorraphy, lateral capsule release + augmentation with internal brace due to Neglected dislocation at 1st MTP joint of right foot POD X

- TB Abdomen on OAT (bulan ke- 8)

- GV

- Ibuprofen 3x400 mg po - pregabalin 2x75mg po - OAT dilanjutkan - kontrol 1 minggu

Sudah 81 61 RAP

3 12.02.24 Wahyu 087824138340 73 thn L 0002179168

- Post Remove implant + arthrodesis with intramedullary nailing due to Implant failure post TTC fusion with plate and screw due to suspect TB arthritis dd/

Charcott arthropathy at left ankle joint POD 2,5 months POD X

- GV

- cefixim 2x200 mg po - ibuprofen 3x400 mg po - omeprazole 2x20 mg po - pregabalin 2x75 mg po

- pertahankan boot slab, kontrol 1 minggu

Sudah 62 56 RAP

4 12.02.24 Ade Jaelani 085600239078 39 thn L 0002255731

- Post ORIF P/S and ORIF Screwing closed reduction and immobilization with posterior slab due to closed left ankle

injury Lauge-Hansen

Classification PER type III POD XII

- GV

- ibuprofen 3x400 mg po (bila nyeri)

- konsul IKFR untuk ROM exercise

- kontrol 1 minggu untuk aff hecting

Sudah 63 52 RAP

Rabu, 07.02.24

(29)

Assess

DPJP AOFAS FAAM DPJP

1. 07.02.24 Mamat 0895345172208 51 thn L 0002051989

- Post ankle arthroscopic debridement + Posterior and anterior ankle decompression with stieda process resection + Implant removal +

Immobilization with boot slab due to Anterior and posterior ankle impingement + Union fracture at right talar neck POD 6 months

- Injeksi intraartricular ankle joint - Rendam air hangat

- Latihan strecthing - Pregabalin 1x75mg PO - Ibuprofen 2x400mg PO - Kontrol bila ada keluhan

Sudah 82 74 RAP

2. 07.02.24 Neneng

Wilyana 089606393968 76 thn P 0001525920

- Tarsal tunnel syndrome + Metatarsalgia + Bunion at bilateral foot

- Konsul IKFR

- Ibuprofen 3x400 mg po - Pregabalin 2x75mg po - Omeprazole 2x20 mg po

Sudah 81 73 RAP

3. 07.02.24 Herwindo 08122135306 46 thn L 0002114917

- Post debridement and amputation due to diabetic gangrene at right 3^rd toe POD 1 years

- GV

- Kontrol 1 bulan - Imiquimod salep

Sudah 67 51 RAP

4. 07.02.24 Rainor Azizi 087823863444 17 thn L 0002154186

- Post Debridement, Keystone Flap, STSG and immobilization with boot slab due to wound dehiscence at right lower leg POD 1 month

- Post supramalleolar osteotomy, ORIF P/S and mid foot reconstruction due to Pes cavus at right foot POD 1.5 month

-GV, aff hecting

-Latihan berjalan dengan 2 tongkat -Cefixim 2x200 mg po

-Ibuprofen 3x400 mg po -Kontrol 2 minggu

Sudah 69 74 RAP

5. 07.02.24 Nia

Kurniasih 081392337295 38 thn P 0002139120

- Post remove screw, augmentasi plate, and Bone grafting due to arthritis TB at left talonavicular joint Post talonavicular fusion POD 1 week

- GV

- NWB 1 bulan

Sudah 69 64 RAP

6. 07.02.24 Dede

Maelani 08816656649 22 thn P 0002037478

- Post transtibial amputation deu to chronic infection Post TTC fusion due to open left ankle injury POD XX

- GV, aff hecting - Pregabalin 2x75 mg po - Mecobalamin 3x500 mg PO - Konsul IKFR

- Rujuk balik RS Avisena

Sudah 72 68 RAP

(30)

082118185563 /

085722330198 45 thn P 0002266796 - Charcot arthropathy at right

ankle joint - R/ TTC fusion

- acc H-2 Anestesi Sudah 69 74 RAP

8. 07.02.24 Enoy Sari

(eksekutif) 085294944414 71 thn P 0002213447

- Implant failure post ankle fusion with plate and screw due to left charcot foot with neglected fracture of left ankle POD 3 weeks

- GV Sudah 80 74 RAP

9. 07.02.24

Enung Nurjanah (eksekutif)

081809475906 74 thn P 0001750353

- Post release plantar fascia due to Plantar fascitis at right foot POD

XIV - GV Sudah 87 83 RAP

10. 07.02.24 Kafka Diaz Chandra (eksekutif)

081617475535 17 thn L 0002221563

- Peroneal retinaculum tendon reconstruction and deepening fibular groove due to Peroneal Tendon dislocation POD 2 months

- FWB

- Injeksi intraartricular Sudah 89 64 RAP

Jumat, 02.02.24

Assess

DPJP AOFAS FAAM DPJP

1. 02.02.24 Ita Juwita 083105339650 54 P 0001816380 - Hallux valgus at bilateral foot

- R/ Hallux valgus correction (kanan lebih dahulu)

- Persiapan operasi (EKG TFP, lab , xray, Konsul

kardiopulmonal IPD dan konsul)

Sudah 77 75 RAP

2. 02.02.24 Joko Suparno 081224602100 53 thn L 0002090847

- Post Implant revision and Intramedullary nailing due to Post ankle arthrodesis with TTC fusion Ankle arthritis at right ankle joint Takakura

classification stage IV POD VIII

- GV

- Ibuprofen 3x400 mg po - Pregabalin 2x75 mg po - Omeprazole 2x20 mg po - Kontrol 1 minggu

Sudah 64 52 RAP

3. 02.02.24 ^Ersanda_Azka 087722319836 15 thn P 0001794638 - Sinus tarsi syndrome at left foot

- R/ arthroscopy debridement sinus tarsi

- Persiapan operasi (EKG TFP, lab , xray)

Sudah 90 84 RAP

4. 02.02.24 _Supratman^Maman 083820551555 68 thn L 0001435783

- Post ankle arthrodesis at right ankle joint POD 4 years - Compression fracture at VL2

- Ibuprofen 3x400 mg PO - Pregabalin 2x75 mg PO - PWB dengan 1 tongkat - Kontrol jika ada keluhan - Konsul divisi Spine

Sudah 71 69 RAP

(31)

5. 02.02.24 ^Matheus_Mado 081222918870 54 thn L 0002044910

• Post Hardware Removal with TTV Fusion with plate and screw, bone graft insertion, fibula osteotomy, and culture due to : -Post ORIF Screwing with

intramedullary wire due to closed fracture at right fibula

comminutive displaced Tscherne Classification grade 1

-Chronic Osteomyelitis POD 1.5 month

Post remove OREF convert to plate and screw with autobone graft insertion at right humerus due to non union fracture of right humerus POD 3,5 weeks

-R/ remove screw (ODS) -Persiapan operasi (EKG TFP,

lab , xray, Konsul kardiopulmonal IPD dan konsul) -PWB dengan 2 tongkat

-Omeprazole 2x20 mg PO -Na diclofenac 2x50 mg PO

Sudah 62 56 RAP

6. 02.02.24 _Setiawan^Irfan 087820233313 45 thn L 0002173887

- Post biopsy + Debridement + TTC fusion + Bone graft insertion due to TB Synovial at left ankle joint POD 5 months

-R/ TTC fusion with intramedullary nailing  pasien mau berunding

-PWB dengan dengan 1 tongkat -Diclofenak 2x50mg po -Pregabalin 2x75mg po

-OAT dilanjutkan sesuai poli DOTS (Selasa,06.02.24) -Kontrol 2 bulan

Sudah 67 51 RAP

- Post Remove implant + TTC fusion with intramedullary nail due to Implant failure post ankle arthrodesis with plate and screw due to neglected closed fracture at left bimaleolar ankle POD XI

- GV

- Slab dipertahankan - Ibuprofen 3x400 mg po - Omeprazole 2x20 mg po - Pregabalin 2x75mg po - Kontrol 1 minggu

Sudah 85 84 RAP

8. 02.02.24 _Komariah^Nur 081224816473

081293349569 44 thn P 0002215203

- Post remove Syndesmotic screw due to Open right ankle injury Lauge Hansen classification PER stage IV Gustillo Anderson Gr III A Post debridement, exploration, and ORIF Plate and Screw POD IV

-GV

-Ibuprofen 3x400mg PO -omeprazole 2x20mg PO -kontrol 1 minggu

Sudah 85 84 RAP

(32)

Rabu, 31.01.24

Assess

DPJP AOFAS FAAM DPJP

1. 31.01.24 Rini

Susilawati 082316276585 45 th P 0002260239 - Plantar fasctis at left foot

- R/ Release plantar fascia - Persiapan operasi (EKG, TFP,

x-ray, lab lengkap, konsul kardiopulmonal IPD dan konsul H-2 Anestesi)

Sudah 78 74 RAP

2. 31.01.24 Irvan

Firdaus 089603954074 29 thn L 0002264090 - TB arthritis at right foot - R/ Debridement join dengan Recon dan Sport injury jika rencana operasi

Sudah 75 71 RAP

3. 31.01.24 Ayu Septi 083842315717 28 thn P 0002261691

- Equinus deformity at right ankle joint

- Bone loss at right 2^nd metatarsal - G3P2A0 12-13 minggu

gravidarum

- Xray right ankle joint AP/Lat/Mortise - Konsul Obsgyn untuk

konfirmasi acc tindakan orthopaedi

- R/ ATL dan MTP Arthrodesis - Persiapan operasi (EKG, TFP,

Sudah 68 66 RAP

4. 31.01.24 Arief

Huzaeni 085624079380 68 thn L 0002266403

- Closed Ankle injury at left ankle with calcanaeofibular ligament tear

-Xray right ankle joint AP/Lat/Mortise -Ibuprofen 3x400 mg PO -Omperazole 2x20 mg PO -Pregabalin 2x75 mg PO -R/ Ligament repair

-Persiapan operasi (EKG, TFP, x- ray, lab lengkap, konsul kardiopulmonal IPD dan konsul H-2 Anestesi)

Sudah 77 74 RAP

5. 31.01.24 Sujana 089654945755 58 thn L 0001551886 - Secondary arthritis at right ankle joint

-R/ Arthrodesis

- Persiapan operasi (EKG, TFP, x-ray, lab lengkap, konsul kardiopulmonal IPD dan konsul H-2 Anestesi)

Sudah 66 64 RAP

6. 31.01.24 Fajar

Setiawan 085314304144 42 thn L 0002266437 - Ankle instability at left ankle

-R/ Ligament reconstruction - Persiapan operasi (EKG, TFP,

Sudah 78 68 RAP

7. 31.01.24 Ayi hikmat 08987131930 52 thn L 0002176671 - Post ankle arthrodesis due to

Diabetic charcot neuropathy at - Aff casting

- GV

Sudah 78 63 RAP

(33)

left foot POD 1,5 month

- Diabetes Mellitus Type 2 - Immobilization with boot cast - Kontrol 1 bulan

8. 31.01.24 Dede

Maelani 08816656649 22 thn P 0002037478

- Post transtibial amputation deu to chronic infection Post TTC fusion due to open left ankle injury POD X

- GV

- Cefixime 2x200 mg PO - Omeprazole 2x20 mg PO - Ibuprofen 3x