Kamis, 04.04.24
No. Tanggal
Masuk RS Nama No Hp Umur L/
P Medrec Diagnosis Manajemen Assess
DPJP AOFAS FAAM DPJP
1. 21.03.24
Deni Anwar
Kana 3-3 0858-9303-8270 19 thn L 0002270629
- Post Hardware Removal, Debridement and Tibiocalcaneal fusion with screwing due to Neglected CTEV at right foot with infected wound Post Achilles tenotomy, total talectomy, and triple arthrodesis
POD II
-GV 2x/hari
-Ceftriaxone 2x1gr IV -Omeprazole 2x20mg IV -Paracetamol 3x1gr PO -Dexamethasone 3x5mg IV
Sudah RAP
2. 31.03.24
Angga Meriyanjay
a Fauji Kemuning
4 6-3
0853-2164-6223 32 thn L 0002275246
- Post Fibular lengthening due to Nonunion fracture at left medial maleolus with susp.
deltoid ligament injury and Union fracture at left fibula middle third POD III
-GV Setiap hari -Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Paracetamol 3x100 mg PO -R/ BLPL dengan terapi pulang Cefixime 2x200 mg PO, Natrium diclofenac 2x50 mg PO, Omeprazole 2x20 mg PO
Sudah RAP
3. 31.03.24
Dian Hadiana
RIK 304 0831-4792-5345 42 thn L 0001704825 - Post debridement + biopsy due to Susp. Tb arthritis at right midfoot region POD III
-GV Setiap hari -Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Paracetamol 3x1000 mg PO -R/ BLPL dengan terapi pulang Cefixime 2x200 mg PO, Natrium diclofenac 2x50 mg PO, Omeprazole 2x20 mg PO -Menunggu hasil biopsi
Sudah RAP
4. 31.03.24 Ojon
Junaedi Kana 10-1
0857-2201-5053 64 thn L 0002272769 - Post tophus excision due to Gouty tophus at left great toe and 2nd toe POD III
-GV Setiap hari -Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Paracetamol 3x1000 mg PO -R/ BLPL dengan terapi pulang Cefixime 2x200 mg PO, Natrium diclofenac 2x50 mg PO, Omeprazole 2x20 mg PO
Sudah RAP
5. 01.04.24 Nanang
IHC bed 6 - 60 thn L 0002277081
-Syok Sepsis ec selulitis pedis sinistra dengan MODS AKI, ensefalopati
-Eritroderma ec dermatitis seboroik
-Chronic open wound a/r left lateral maleolus
-Dehidrasi berat ec intake kurang diperberat GI Loss -AKI Stage II
Anesthesia Department : -Diet cair
-Paracetamol 1 gr/6 jam prn -Head up 30 derajat -Omeprazol 40 mg/12 jam -cek GDS berkala, sesuai DAAG curve
- Ceftazidime 3x2 gr - Vascon 0,3 mcg/kgbb/menit
- Drip Vascon 0.03
mcg/kgBB/mnt (Mulai Titrasi Turun)
Dermatology Department : -Vaselin album 2x/hari pada seluruh tubu
-krim desoksimetason 0.25%
pada bercak merah
Internal medicine Department : -Saran kolonoskopi setelah KU perbaikan
-Metronidazol 3x750 mg -FU Kultur darah, kultur pus, ANA Test
- Koreksi KCL 25 Meq dalam RL 100 cc/ Jam selama 4 jam Foot and Ankle division:
-Perbaikan KU
-Debridement setelah perbaikan KU
-GV Setiap hari
Sudah RAP
6. 02.04.24
Ny. Rini Budiarti Kemuing 4
5.1
081383188174 64 thn P 0002273380
-Post TCC Fusion due to Charcot arthropathyat left ankle
POD I
-GV POD II
-Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Ketorolac 2x30mg IV
Sudah RAP
7. 02.04.24 Tn. Udin Kemuning
4 7.1
085603355398 46 thn L 0002261161 -Post Release Conctrature and Ankle Arthrodesis due to Equinus deformity at right ankle joint
-Fracture related infection at right hip joint with Right
-GV POD II
-Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Ketorolac 2x30mg IV
-X ray Post Op Ankle AP Lateral
Sudah RAP
Femoral head osteolysis and anterior dislocation post ORIF P/S due to closed acetabular fracture POD 4 years POD I
-Anemia
-Electrolyte imbalance (hipokalemia)
Mortis
8. 02.04.24 Tn. Sujana Kemuning
2 9.5
089654945755 58 thn L 0001551886
-Post Ankle Arthrodesis Per Arthroscopy due to Secondary Osteoarthritis at Right Ankle Joint
POD I
-GV POD II
-Ceftriaxone 2x1gr IV -Omeprazole 2x40mg IV -Ketorolac 2x30mg IV
-X ray Post Op Ankle AP Lateral Mortis
Sudah RAP