Mapping 28-3-2019 Plastik.docx
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BEDAH PLASTIK
Kamis, 28 Maret 2019 RUANG
RAH/DAN/DBI/PER/WID/API/RIC/(SIW)
BED
PJ
DPJP
NAMA
U
MRS
K
PER
AM
Archi Raka 01452094
6
2/3
RIC
DE
Kabini 01450014
62
3
WID
AM
601 A
WID
AM
Miftahuddi n 01392435 Parwono
26
7
15/3 konsulan onko Konsulan B.Saraf 12/3 26/3
602 A
WID
602 D
WID
DE
604 A
WID
DE
608 C
WID
AM
611 B
WID
DE
612 A
WID
AM
612 B
WID
DE
613 B
WID
DE
902 B
RIC
DE
902 C
RIC
DE
903 C
RIC
DE
904 B
PER
904 D
RIC
DIAGNOSIS Post medikasi & non-excicional debridement ai. Combusio gr.II 40%
RGB
ICU
49
Konsulan onko 20/3 Konsulan Onko 10/3 23/3
Imron Djamil 01455117
56
27/3
Dwi Cahyo 01452439 Sutarno 01453677 Alfadite 01454089
31
24/3
443
15/3
30
19/3
Januar 01454075 Sukamto 00936200
23
19/3
37
Aguk Dwi Guntoro 01453408 Wahono 01452441
DE
AM
FL 6
FL 9
Sudarmi 01451450 Juwati 01448008 MasCuk 01454652
51
71
Post rekonstruksi mandibula a/I SCC intraoral
STATUS Post op 3/3, 6/3, 8/3, 11/3, 14/3, 18/3, 21/3, 25/3 Post-op 26/3
PLAN
BIAYA
LAB
Perawatan post op Yang sudah epitelisasi rawat terbuka Rencana Op KAMIS 28/3/19
BPJS I
2/3 alb 2,9 na 130 k 3,7 cl 102 ca 1,19
Perawatan post op
BPJS III
15/3 hb 9,9 ht 29 leu 9,9 tro 310 hbsag NR
Post scalp transposition flap + STSG a/I Wound dehisens & skull defect R.frontotemporal
Post-op 22/3
Perawatan post op Rawat STSG/5 hari, medikasi bila kasa keruh
BPJS II
8/3 hb 13,3 ht 46 leu 12,9 tro 354 hbsag NR
Fistel post rekonstruksi mandibula, post hemimandibulektomi a/I SCC mandibula B.Onk: Basal cell carcinoma R.zygoma (D) + extend orbita (D) SCC intra oral (join op) Anemia BS (leader, lepas rawat): COR OT (leader): CF clavicula 1/3 tengah (S) Allman I BP: maloklusi, fr.parasimfisis mandibula (S), fr.dislokasi condyle(S),vulnus terjahit r.frontal (S) [Maloklusi, fr.of mandible, multiple open wound of head] BP: Fr.NOE, fr.rima orbita lateral (D), fr maxilla (D) fr.ramus (D) mandibula OT: CF tibia BS: COR
Pre op
Pro Revisi. Cek lab ikterik B.Onk: Pro wide excisi
BPJS II
-
Tanya ketersediaan bone graft, costocondral graft,konfirmasi dr.Galuh,SpBPRE BS: konservatif, alih leader ke OT OT: ORIF elektif BP: diit cair, oral hygiene, urgent Reconstruction of mandible, Other repair & reconstruction of skin & subcutaneous tissue
BPJS II
10/3 hb 11,1 ht 36 leu 5,6 tro 243 alb 4,2 hbsag NR
Post medikasi + NPWT a/I Raw surface R.cruris (D) Post debridement cito a/i/ vulnus berbentuk flap R. pedis (S) BP: Maloclusion, fr.of malar & maxillar bone open. (fr. Proc alveolaris maxilla, fr. Palatum) OT: CF distal radius D & S
Pre-op Pre op Pre-op
Pre-Op
Post-op Post op 15/3, 25/3 Pre-op
Post-op
18/3
BP: Post ORIF a/I fr. Mandibula OT: CF metacarpal 2-3 manus S, CF clavicula S NPWT a/I Vulnus granulosum
35
17/3
Post ORIF a/I Fr.corpus mandibula (D)
Post-op
23
5/3
Siswanto 01454049
68
19/3
Alip Budi 01449960
27
22/3
Pre-op
Post debridement, fasciotomi, medikasi a/I Post op Combutio listrik gr.II-III 38,5% & Sindrom 5/3, 12/3, Kompartemen 19/3, 26/3 BS:COR E4V5M6 Pre-op BP: Susp Fr.Maxilla (D), multiple vulnus terjahit R.frontal, vulnus apertum R.labia oris sup, R.manus (D), vulnus terjahit R.genu (D) Susp fr.genu Post tutup defek a/I Raw surface R. occipital + Post-op bone expose
BP: ORIF elektif. Maxilla + NOE = adaption plate. Rima orbita = orbita plate. Mandibula = mandibular plate + arch barr. OT: ORIF elektif BS: Konservatif Perawatan post op Perawatan post op, pesan PICO BP: other recinstruction of other facial bone, openreduction of maxillary fr., oral hygiene, diit cair. MMF + arch barr bila OT op OT: ORIF elektif BP: diit cair, oral hygiene POLIKLINIS Kultur ulang. Medikasi, ganti dressing. AB sesuai kultur, tabur ke luka Graft rencana KAMIS 28/3 Perawatan post op
Perawatan post op Medikasi light dressing. BLPL, pasang spalk kedua tangan, rawat tulle +burnazin BS: konservatif BP: MMF + arch barr bila OT op
Perawatan post op
UMUM II
BPJS II
Jamsostek II Jamsostek I
23/3 hbsag NR
26/3 hb 16,3 ht 45 leu 13,6 tro 271
-
BPJS I UMUM (skrg) BPJS I
19/3 hb 15,9 ht 47 leu 15,8 tro 187 hbsag NR
BPJS III
-
BPJS III
-
UMUM
5/3 hb 16,9 ht 52 leu 12,5 tro 385 alb 5,5 hbsag NR
BPJS
BPJS III
18/3 hb 10,2 ht 31, leu 17,3 tro 208 hbsag NR
-
904 E
RIC
AM
Sariyono 01449915
61
10/3
Post debridement + ekstensi lengan + slab a/i Vulnus granulosum R.antebrachii (S) post snake bite grade II Kontraktur R.manus (S), riw release kontraktur [Contracture of muscle hand] Post palatoplasty a/I Palatoschizis
Post-op 12/3, 15/3
905 B
RIC
AM
30
24/3
906 D
RIC
AM
20
24/3
906 E
RIC
AM
17
15/3
907 A
RIC
DE
46
908 B
RIC
AM
908 C
RIC
AM
Kusniyati 01412624 Putri Ayu 01450600 Tiara 01453562 Wagimin 01450529 Deni Fitriya 01449692 Asep Sopiyan
908 E
RIC
AM
910 A
RIC
AM
910 D
RIC
DE
Kuwati 01455187 Prasetyo Hendri P. 01395379 Hari Supriyanto 01454616
11/3
Post repair vulnus a/I Vulnus + ORIF a/I fr. Nasal + fr. Rima orbita Neurofibroma
Post-op 19/3, 25/3 Post op
18
26/3
Vulnus apertum r.calcaneus
Post op
33
15/3
Post-op
64
27/3
6
24/3
BP: Post ORIF Arch zygoma + rima orbita OT: CF tibia BS: COR BD: post laparotomi ec peritonitis Snake bite gr. I pedis (D) (Alergi Penicillin) Post aff hecting + regrafting a/I Kontraktur R.colli, post release kontraktur R.colli
13
22/3
1002 A
RIC
AM
Suryanto 01449778
55
1002 B
RIC
DE
Dwi Suseno 01449086
28
1005 B
RIC
AM
41
1009 B
RIC
AM
Suwarni 01454435 Maryanto 01021474
18/8 konsulan onko 19/3 konsulan onko 24/3
40
20/3
1011 C
API
DE
Sutarno 01453978
42
18/3
1011 E
RIC
DE
36
25/3
1012 A
API
DE
Arie Basuki 01454748 Agung T. 01454350
17
20/3
1013 A
RIC
DE
Atmo 01454629
73
23/3
FL. 10
BPJS III
Pre-op
Perawatan post op, medikasi/hari Saat medikasi slab tetap terpasang Medikasi + Mebo foto klinis Ro manus ap/oblique, rencana konsul ortho
Post-op
Perawatan post op
BPJS III
Oral hygiene, diit cair, perawatan post op Evaluasi luka, BLPL hari ini Perawatan post op BLPL Cito debridement +repair vulnus
UMUM
Pre-op Post-op
BP: Fr. Maxilla (D)&(S), fr. Rima orbita inf (D)&(S), Pre-op fr. rima orbita sup (S), fr. Arch zygoma (D), multiple Vulnus excoriasi Grouping: fr. Orbital floor, fr.of malar & maxillary bone, multiple open wound of head BS: COR E3V55M6, EDH, SDH, udem cerebri, pneumotocele Post wide eksisi + frozen section a/I Basal cell Post-op carcinoma R.maxilla (D)
BP:Perawtan post op, penyerahan ke OT OT: ORIF elektif BS: Konservatif BD: perawatan post op Konservatif Cek PT/APTT 24 jam Perawatan post op
BP: ORIF elektif, diit cair, oral hygiene Grouping: open reduction of mallar zygomatic fr., open reduction of maxillary fr.
B.Onk: Post Hemimandibulektomy a/I ameloblastoma R. mandibula (D)
Post-op
Post medikasi + skin graft a/I Vulnus granulosum
Post-op
Perawatan post op
BP: Fr. Rima orbita sup (D), fr. Maxilla (S) BS: COR E3V5M6 BS: COR, udem cerebri BP: Post ORIF a/I Fr. Rima orbita inf (D) extend to zygoma (D) & maxilla (D), multiple VE BS (Leader, lepas rawat): COR BTKV: Pneumothorax, post tube thoracostomy BP: fr.arch zygoma (S), multiple excoriasi R.facialis, vulnus terjahit R.supraciliar (S)
Pre-op Post-op
Pre-op
BPJS -
BPJS III
-
Kerja sama III BPJS
-
BPJS III
-
BPJS III
-
BPJS
-
22/3 hb 14,0 ht 41 leu 27,1 tro 356, hbsag NR
BS: konservatif
Perawatan post op Evaluasi kornea, benang jahitan dekat mata potong pendek. Aff drain handscoon Perawatan post op
BS: COR, udem cerebri, SDH Pre-op BP (leader): fr.condyle mandibula (D) KJ: gangguan afektif bipolar BS: COS E3V3M5, udem cerebri Post op BP: maloklusi, fr.tripod, ruptur duct nasolacrimalis, 19/3 vulnus apertum R.palpebra inferior
-
BS: konservatif, penyerahan ke plastik BP: pro ORIF KJ: Tx farmaka & psikoedukasi BS: Konservatif BP: Oral hygiene, diit cair, ORIF elektif, cito debridement + repair vulnus + repair ductus nasolacrimalis BS: konservatif BP: ORIF elektif, diit cair, oral hygiene BS: konservatif BP: perawatan post op BS: penyerahan ke Plastik BTKV: perawatan post op BP: diit cair, oral hygiene, open reduction of mallar & zygomatic fr., debridement. Rawat
BPJS III
BPJS III
-
BPJS III
BPJS
20/3 hb 17,1 ht 53 leu 16,4 tro 232 hbsag NR
18/3 hb 12,1 ht 37 leu 18,7 tro 346
Jasa Raharja BPJS
24/3 hb 13,1 ht 39 leu 9,7 tro 180 hbsag NR
UMUM III
22/3 hb 11,4 ht 35 leu 15,9 tro 296 hbsag NR
-
[Fr.of mallar & maxillary bone, multiple open wound of head]
IGD
luka dengan MEBO
Kamis, 28 Maret 2019 RUANG
RAH/DAN/DBI/PER/WID/API/RIC/(SIW)
BED
PJ
DPJP
NAMA
U
MRS
K
PER
AM
Archi Raka 01452094
6
2/3
RIC
DE
Kabini 01450014
62
3
WID
AM
601 A
WID
AM
Miftahuddi n 01392435 Parwono
26
7
15/3 konsulan onko Konsulan B.Saraf 12/3 26/3
602 A
WID
602 D
WID
DE
604 A
WID
DE
608 C
WID
AM
611 B
WID
DE
612 A
WID
AM
612 B
WID
DE
613 B
WID
DE
902 B
RIC
DE
902 C
RIC
DE
903 C
RIC
DE
904 B
PER
904 D
RIC
DIAGNOSIS Post medikasi & non-excicional debridement ai. Combusio gr.II 40%
RGB
ICU
49
Konsulan onko 20/3 Konsulan Onko 10/3 23/3
Imron Djamil 01455117
56
27/3
Dwi Cahyo 01452439 Sutarno 01453677 Alfadite 01454089
31
24/3
443
15/3
30
19/3
Januar 01454075 Sukamto 00936200
23
19/3
37
Aguk Dwi Guntoro 01453408 Wahono 01452441
DE
AM
FL 6
FL 9
Sudarmi 01451450 Juwati 01448008 MasCuk 01454652
51
71
Post rekonstruksi mandibula a/I SCC intraoral
STATUS Post op 3/3, 6/3, 8/3, 11/3, 14/3, 18/3, 21/3, 25/3 Post-op 26/3
PLAN
BIAYA
LAB
Perawatan post op Yang sudah epitelisasi rawat terbuka Rencana Op KAMIS 28/3/19
BPJS I
2/3 alb 2,9 na 130 k 3,7 cl 102 ca 1,19
Perawatan post op
BPJS III
15/3 hb 9,9 ht 29 leu 9,9 tro 310 hbsag NR
Post scalp transposition flap + STSG a/I Wound dehisens & skull defect R.frontotemporal
Post-op 22/3
Perawatan post op Rawat STSG/5 hari, medikasi bila kasa keruh
BPJS II
8/3 hb 13,3 ht 46 leu 12,9 tro 354 hbsag NR
Fistel post rekonstruksi mandibula, post hemimandibulektomi a/I SCC mandibula B.Onk: Basal cell carcinoma R.zygoma (D) + extend orbita (D) SCC intra oral (join op) Anemia BS (leader, lepas rawat): COR OT (leader): CF clavicula 1/3 tengah (S) Allman I BP: maloklusi, fr.parasimfisis mandibula (S), fr.dislokasi condyle(S),vulnus terjahit r.frontal (S) [Maloklusi, fr.of mandible, multiple open wound of head] BP: Fr.NOE, fr.rima orbita lateral (D), fr maxilla (D) fr.ramus (D) mandibula OT: CF tibia BS: COR
Pre op
Pro Revisi. Cek lab ikterik B.Onk: Pro wide excisi
BPJS II
-
Tanya ketersediaan bone graft, costocondral graft,konfirmasi dr.Galuh,SpBPRE BS: konservatif, alih leader ke OT OT: ORIF elektif BP: diit cair, oral hygiene, urgent Reconstruction of mandible, Other repair & reconstruction of skin & subcutaneous tissue
BPJS II
10/3 hb 11,1 ht 36 leu 5,6 tro 243 alb 4,2 hbsag NR
Post medikasi + NPWT a/I Raw surface R.cruris (D) Post debridement cito a/i/ vulnus berbentuk flap R. pedis (S) BP: Maloclusion, fr.of malar & maxillar bone open. (fr. Proc alveolaris maxilla, fr. Palatum) OT: CF distal radius D & S
Pre-op Pre op Pre-op
Pre-Op
Post-op Post op 15/3, 25/3 Pre-op
Post-op
18/3
BP: Post ORIF a/I fr. Mandibula OT: CF metacarpal 2-3 manus S, CF clavicula S NPWT a/I Vulnus granulosum
35
17/3
Post ORIF a/I Fr.corpus mandibula (D)
Post-op
23
5/3
Siswanto 01454049
68
19/3
Alip Budi 01449960
27
22/3
Pre-op
Post debridement, fasciotomi, medikasi a/I Post op Combutio listrik gr.II-III 38,5% & Sindrom 5/3, 12/3, Kompartemen 19/3, 26/3 BS:COR E4V5M6 Pre-op BP: Susp Fr.Maxilla (D), multiple vulnus terjahit R.frontal, vulnus apertum R.labia oris sup, R.manus (D), vulnus terjahit R.genu (D) Susp fr.genu Post tutup defek a/I Raw surface R. occipital + Post-op bone expose
BP: ORIF elektif. Maxilla + NOE = adaption plate. Rima orbita = orbita plate. Mandibula = mandibular plate + arch barr. OT: ORIF elektif BS: Konservatif Perawatan post op Perawatan post op, pesan PICO BP: other recinstruction of other facial bone, openreduction of maxillary fr., oral hygiene, diit cair. MMF + arch barr bila OT op OT: ORIF elektif BP: diit cair, oral hygiene POLIKLINIS Kultur ulang. Medikasi, ganti dressing. AB sesuai kultur, tabur ke luka Graft rencana KAMIS 28/3 Perawatan post op
Perawatan post op Medikasi light dressing. BLPL, pasang spalk kedua tangan, rawat tulle +burnazin BS: konservatif BP: MMF + arch barr bila OT op
Perawatan post op
UMUM II
BPJS II
Jamsostek II Jamsostek I
23/3 hbsag NR
26/3 hb 16,3 ht 45 leu 13,6 tro 271
-
BPJS I UMUM (skrg) BPJS I
19/3 hb 15,9 ht 47 leu 15,8 tro 187 hbsag NR
BPJS III
-
BPJS III
-
UMUM
5/3 hb 16,9 ht 52 leu 12,5 tro 385 alb 5,5 hbsag NR
BPJS
BPJS III
18/3 hb 10,2 ht 31, leu 17,3 tro 208 hbsag NR
-
904 E
RIC
AM
Sariyono 01449915
61
10/3
Post debridement + ekstensi lengan + slab a/i Vulnus granulosum R.antebrachii (S) post snake bite grade II Kontraktur R.manus (S), riw release kontraktur [Contracture of muscle hand] Post palatoplasty a/I Palatoschizis
Post-op 12/3, 15/3
905 B
RIC
AM
30
24/3
906 D
RIC
AM
20
24/3
906 E
RIC
AM
17
15/3
907 A
RIC
DE
46
908 B
RIC
AM
908 C
RIC
AM
Kusniyati 01412624 Putri Ayu 01450600 Tiara 01453562 Wagimin 01450529 Deni Fitriya 01449692 Asep Sopiyan
908 E
RIC
AM
910 A
RIC
AM
910 D
RIC
DE
Kuwati 01455187 Prasetyo Hendri P. 01395379 Hari Supriyanto 01454616
11/3
Post repair vulnus a/I Vulnus + ORIF a/I fr. Nasal + fr. Rima orbita Neurofibroma
Post-op 19/3, 25/3 Post op
18
26/3
Vulnus apertum r.calcaneus
Post op
33
15/3
Post-op
64
27/3
6
24/3
BP: Post ORIF Arch zygoma + rima orbita OT: CF tibia BS: COR BD: post laparotomi ec peritonitis Snake bite gr. I pedis (D) (Alergi Penicillin) Post aff hecting + regrafting a/I Kontraktur R.colli, post release kontraktur R.colli
13
22/3
1002 A
RIC
AM
Suryanto 01449778
55
1002 B
RIC
DE
Dwi Suseno 01449086
28
1005 B
RIC
AM
41
1009 B
RIC
AM
Suwarni 01454435 Maryanto 01021474
18/8 konsulan onko 19/3 konsulan onko 24/3
40
20/3
1011 C
API
DE
Sutarno 01453978
42
18/3
1011 E
RIC
DE
36
25/3
1012 A
API
DE
Arie Basuki 01454748 Agung T. 01454350
17
20/3
1013 A
RIC
DE
Atmo 01454629
73
23/3
FL. 10
BPJS III
Pre-op
Perawatan post op, medikasi/hari Saat medikasi slab tetap terpasang Medikasi + Mebo foto klinis Ro manus ap/oblique, rencana konsul ortho
Post-op
Perawatan post op
BPJS III
Oral hygiene, diit cair, perawatan post op Evaluasi luka, BLPL hari ini Perawatan post op BLPL Cito debridement +repair vulnus
UMUM
Pre-op Post-op
BP: Fr. Maxilla (D)&(S), fr. Rima orbita inf (D)&(S), Pre-op fr. rima orbita sup (S), fr. Arch zygoma (D), multiple Vulnus excoriasi Grouping: fr. Orbital floor, fr.of malar & maxillary bone, multiple open wound of head BS: COR E3V55M6, EDH, SDH, udem cerebri, pneumotocele Post wide eksisi + frozen section a/I Basal cell Post-op carcinoma R.maxilla (D)
BP:Perawtan post op, penyerahan ke OT OT: ORIF elektif BS: Konservatif BD: perawatan post op Konservatif Cek PT/APTT 24 jam Perawatan post op
BP: ORIF elektif, diit cair, oral hygiene Grouping: open reduction of mallar zygomatic fr., open reduction of maxillary fr.
B.Onk: Post Hemimandibulektomy a/I ameloblastoma R. mandibula (D)
Post-op
Post medikasi + skin graft a/I Vulnus granulosum
Post-op
Perawatan post op
BP: Fr. Rima orbita sup (D), fr. Maxilla (S) BS: COR E3V5M6 BS: COR, udem cerebri BP: Post ORIF a/I Fr. Rima orbita inf (D) extend to zygoma (D) & maxilla (D), multiple VE BS (Leader, lepas rawat): COR BTKV: Pneumothorax, post tube thoracostomy BP: fr.arch zygoma (S), multiple excoriasi R.facialis, vulnus terjahit R.supraciliar (S)
Pre-op Post-op
Pre-op
BPJS -
BPJS III
-
Kerja sama III BPJS
-
BPJS III
-
BPJS III
-
BPJS
-
22/3 hb 14,0 ht 41 leu 27,1 tro 356, hbsag NR
BS: konservatif
Perawatan post op Evaluasi kornea, benang jahitan dekat mata potong pendek. Aff drain handscoon Perawatan post op
BS: COR, udem cerebri, SDH Pre-op BP (leader): fr.condyle mandibula (D) KJ: gangguan afektif bipolar BS: COS E3V3M5, udem cerebri Post op BP: maloklusi, fr.tripod, ruptur duct nasolacrimalis, 19/3 vulnus apertum R.palpebra inferior
-
BS: konservatif, penyerahan ke plastik BP: pro ORIF KJ: Tx farmaka & psikoedukasi BS: Konservatif BP: Oral hygiene, diit cair, ORIF elektif, cito debridement + repair vulnus + repair ductus nasolacrimalis BS: konservatif BP: ORIF elektif, diit cair, oral hygiene BS: konservatif BP: perawatan post op BS: penyerahan ke Plastik BTKV: perawatan post op BP: diit cair, oral hygiene, open reduction of mallar & zygomatic fr., debridement. Rawat
BPJS III
BPJS III
-
BPJS III
BPJS
20/3 hb 17,1 ht 53 leu 16,4 tro 232 hbsag NR
18/3 hb 12,1 ht 37 leu 18,7 tro 346
Jasa Raharja BPJS
24/3 hb 13,1 ht 39 leu 9,7 tro 180 hbsag NR
UMUM III
22/3 hb 11,4 ht 35 leu 15,9 tro 296 hbsag NR
-
[Fr.of mallar & maxillary bone, multiple open wound of head]
IGD
luka dengan MEBO
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