No

1.

2.

Identitas
Tn. Devi Ria
Kurniawan/
22thn/C527497
/ 8077799
BPJS NPBI
Ny Tuti
anggreani/27th
n/C438552

Ruang
R1B
7.4

MRS
20-5-2015

DPJP
APR

Diagnosis
Ischaligia bilateral ec canalis
stenonis L I-II ec spondiloditis c/
TB
Spondilitis Vth 8-9

Tindakan
Laminektomi
PSRS
5-06-15

R2A
5.1

26/5/15

APR

Delayed union fr femur dextra Aff FSE

post FSE
Debridement
Kontraktur genu dextra
Post amputasi above knee sinistra
ATL, Gips
Post amputasi dig II pedis dextra

Rencana
,

Keterangan
Menolak foto post op

09-06-15

3.

Ny.
Veronica
/B214463/60
thn

R2A
7.1

12/5/2015

DID

4.

Ny Suyati/ 56
R2A
th/
6.2
C530396/NPBI

23/4/2015

APR

Ny.
R2A
Yamtini/B3995 6.1
5/61thn/JKN
PBI
Ny. Priyanti/
R2A
31th/
C535974/
BPJS

7/5/2015

Ny.Partini/39
th/C537759
Umum

03-06-15

5.

6.

7.

R2A

22-5-15

APR

DRY

DID

Necglected dislokasi hip joint

dextra posterior
Osteoarthritis hip joint sinistra
Skoliosis V. Lumbal
Nefrolitiasis sinistra
Paraparese
inferior
ec
Spondilolithesis VL 4-5

Skeletal traksi
22/5/15
31 beban 15 kg

OA Genu Bilateral

TKR genu sinistra

kamis 28/5/2015
Drain 10 cc

Fraktur dislokasi collum humeri

dextra post ORIF + Reposisi tbk
Rupture a. axillaris Post repair
arteri
Necrosis antebrachii dextra, post
amputasi above elbow
Redislokasi shoulder joint dextra
Fr tibia dextra 1/3 tengah
cominutif ttp nk
Fr fibula dextra 1/3 tengah oblique
ttp nk
1

Pro THR
11-05-15

Laminektomi+
PSRS jumat
29/5/2015

Post amputasi
above elbow
(thorvask)

Post ORIF
05-06-15

555/555

Menunggu korset
1
Konsul RM
Walker 9-6-16
Pro debridement,
reposisi terbuka
+ internal fiksasi
10-6-16

Rawat luka

8.

Tn Bambang
Sulisno/30thn/
C514703

R2B
7.2

26/5/15

9.

Tn Suwadi/
C495812

R2B
5.1

06/05/2015 DID
Konsulan
APR
neuro

Fr femur dextra 1/3 prox

trensverse displaced ttp nk
Fr basis metarcarpal sinistra digiti
V
Fr shaft metacarpal sinistra digiti
IV
Non union fr femur dex 1/3 tengah
kominutif tertutup NK
Joint stiffness genu dex ec
mobilisasi lama
Paraparese inferior ec canalis
stenosis multiple e.c HNP L3-4,
L 4-5. Drop foot dextra

10.

Tn Karsono/ 52 R2B
th/C537072
1.6
Umum

30-5-15

Coxitis , sacroilitis

11.

Tn.Sunardi/43
th/ C538063
Jamkesmas

04-06-2015 DRY

12.

Ny Markamah/ R2B
56 th/
C532081/
umum( tanggu
ngan penabrak)

28/4/2015

13.

Tn.Marzuki
santoso/32
th/C535887
BPJS PBI

R2B
3.4

05-06-2015 DRY

14.

Tn.Giyanto/37
th/C538286
JAMKESKOT

R2B
3.3

06-06-2015 DID

R2B
1.5

DID

APR

DID

ORIF
09-0615

1
Foto masih di radiologi

Post PSRS
1-06-15
post debridement
+ PA + kultur
3-6-16

Fraktur ramus pubis superior

Konservatif
sinistra
dengan analgetik
Fraktur ramus pubis inferior
kuat
sinistra
Fr basis metacarpal V
ORIF
pelvis Post rekontruksi
Disruption sacro iliaca joint dx
acetabulum dx tgl pelvis (04-06-15)
Fr Acetabulum dekstra
6-5-2015
Fr ramus superior pubis sin
Fr ramus inferior pubis dx et sin
Neglected fraktur dislokasi hip
joint sinistra
Union fraktur tibia 1/3 tengah ttp
nk
Union fraktur tibia 1/3 tengah ttp
nk
Fraktur calcaneus dex

Korset sudah ada dan sedang 1

latihan mobilisasi jalan
Nyeri kaki kanan
Drain 30 cc serous
Kruk sudah ada dan sedang dilatih 1
oleh bagian RM
Nyeri hilang dg analgetik iv
Kultur..??????
1

Pro THR

ACCAN (-)

Pro ORIF

ACCan ( +).. steinmen pin, K wire, 1

canulated screw tdk ditanggung
Keluarga setuju bayar sendiri 3jtan

15.

Tn. Kasmui/56
th/

R2B
5.2

Konsulan
dari bagian
urologi

APR

Abses region flank dext dg severe

sepsis post debridement 26-5-16
Fr kompresi VL IV ec c/TB

16.

Tn.Muh Jafar
50 th /
C536101 /
8083363

R5A
2.4

24-5-2015

APR

Tetra parese ec canalis stenosis

vertebra
cervical
IV-V
ec
Spondilosis vertebra cervical IV-V

17.

Tn
Muhammad
Syafii/
C536778
34thn

R6B

26/5/2015

APR

Spondilitis TB vertebrata
L I-II

Pro PSRS

555/115
1
Kultur pseudomonas aeruginosa,
tdk ada AB yg sensitive
PA: radang kronik non spesifik
Acc (-) pedicle screw 8, crosslink
1, nut 8, rod 1 pasang
Anterior cervikal 444/444
1
disektomi
444/444
( dekompresion ) Konsulan neuro
and fusion / ACCan (+) anterior graft plate
ACDF
(cervical plate) alat masih
belum ada
Pro PSRS

Paraparese inferior
TBC kategori I (OAT h-10)

Motorik ext sup 555/555

1
Ext inf
333/333
2bln yll pasien nyeri di
tulang belakang
Na/k/cl

118/2,8/84

ACC (+) rod 1, cross link

1, nut 6, pedicle screw 6
Alat (-)
Imbalance
elektrolit,
hipoalbumin, OAT H-15
18.

19.

Tn.Rosmidi 35
th / C532714
/NPBI

Ny Mei
Listiyana 22

MRK D
6.3

MRKD
5.1

8-5-2015

02-06-15

APR

APR

Paraparesis inferior ec. Spondilitis PSRS hari sabtu

TB VTh 11-12
tgl 30-5-2015
Abcess reg. lumbal
Jam 11.00

Paraparesis inferior ec spondilitis

TB, kompresi V.Th 7-10
3

555/555
555/555
Mobilisasi jalan,
hematoserous/hari
Hasil kultur pus
pengecatan (-)
PA: spondylitis TB
OAT ..
Konsulan neuro
555/555

1
drain
kuman

30cc
dan

th / C537110

20.

Tn. Galieh
Febri/ 23 th/
NPBI

MRK 1

22-5-2015

APR

21.

Ny Soemartani/ MRK 1
61th/ NPBI

22-5-2015

APR

22.

Tn Fx Rais
Haryono, 72 th
Ny. Sri
Murwani/
54th/
C247119/
Umum
Ny Tri Lestari
40 th

GERD

31-5-15

DID

KPD
3.3

23-5-15

DRY

MRK 1
3.2

28-5-15

ERY
DID

25.

Tn. Yusron 54
th / C537508
BPJS

KTL
9.1

01-06-15

APR

26.

Tn Ahmad
Fahmi Karami/
27th/ C527498
Umum

KTL

7-06-15

DID

27.

Ny.
HCU
Sulistyowati 40
th / C538401

07/06/15

DRY

23.

24.

444/444
Acc (+) pedicle screw 8, nut 8, rod
1 ps, crosslink 1
Raber bedah plastic
1
Raber Gizi Klinik
ACC (+) cervical plate, alat (-)

Paraplegi inferior, paraparese

superior ec burst fraktur vertebra
cervical V, fr tibia plateu sinistra
schatzer type III ttp, ulcus
decubitus gr IV reg sacrum
OA genu bilateral

Fr sub trochanter femur sinistra ttp

NK
Fraktur
femur
dextra
1/3
proksimal obliq displaced tertutup
nk
Malformasi vaskuler
Hepatitis C
SOL
Fr tibia fibula dext 1/3 tgh comm.
Ttp nk
Ulcus granulosum regio cruris
dextra
Fr. Tibia dekstra 1/3 tengah trans
displ ttp NK
Fr. Fibula dekstra segmental ttp
NK
Total tear anterior ACL sinistra
Longitudinal tear lateral meniscus
Horizontal tear medial meniscus
Avulsion
fraktur
condylus
femoralis sinistra
Lesi condylus femoralis lateralis
medialis sinistra
Fr. Intercondyler femur dex comm
tbk gr IIIB
Fr. Os pubis ramus superior et
4

Pro TKR sin

(11-06-15)

Craniotomi
ORIF 2-6-15

Deridement
skeletel traksi

ACC (+)

ORIF 08/06/15

ORIF batal
Konservatif dg
skin traksi 5 kg

Evaluasi x foto femur dextra tiap 2 1

minggu

Pro STSG

Rawat luka

Pro ORIF, bone

graft SIAS

Acc (+) tibia locking plate 12 hole

Konsul anestesi (+)
Alat di farmasi (-)

Pro Artroscopy
10-06-15

+ ORIF pelvis +
FSE femur dex

28.

Tn.Maryanto /
50 th /
C538778
BPJS NPBI

R2B
1.3

09 / 06 /15

APR

inferior dex et sin tbk gr IIIB

Disrupsi sacroiliac joint dex
Fr. Maksilla dex
Fraktur colles

Pro ORIF

ACCAN (-)