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  • Dr. Alma 1 September 2015 (Alma)

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    Alma Wijaya
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    1. The document summarizes information on two patients seen by Dr. Almahitta on August 31, 2015. 2. The first patient, a 29-year-old man, was admitted on August 23rd following craniotomy for head injuries from an accident. Examinations showed stable vitals and healing surgical wounds. 3. The second patient, a 12-year-old boy, has a history of recurrent keloid scars and has undergone multiple previous excisions. Examinations found keloid scars on his ear and both groins. Further excision and steroid injections are planned.

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    1. The document summarizes information on two patients seen by Dr. Almahitta on August 31, 2015. 2. The first patient, a 29-year-old man, was admitted on August 23rd following craniotomy for head injuries from an accident. Examinations showed stable vitals and healing surgical wounds. 3. The second patient, a 12-year-old boy, has a history of recurrent keloid scars and has undergone multiple previous excisions. Examinations found keloid scars on his ear and both groins. Further excision and steroid injections are planned.

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    9 views14 pages

    Dr. Alma 1 September 2015 (Alma)

    Uploaded by

    Alma Wijaya
    1. The document summarizes information on two patients seen by Dr. Almahitta on August 31, 2015. 2. The first patient, a 29-year-old man, was admitted on August 23rd following craniotomy for head injuries from an accident. Examinations showed stable vitals and healing surgical wounds. 3. The second patient, a 12-year-old boy, has a history of recurrent keloid scars and has undergone multiple previous excisions. Examinations found keloid scars on his ear and both groins. Further excision and steroid injections are planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 14

    PATIENT PARADE

    Almahitta. dr.,
    SpBP-RE
    September 1st ,
    2015

    Opan/ 29 yo / BPJS / MR : 15060848/KEM 4 (BED 10.2)


    Admission : 23-08-2015
    Consultant : Almahitta, dr., SpBP-RE
    Working Diagnosis
    Post evacuation craniotomy d.t Epidural Hematome at right
    frontoparietal region + closed linier fracture at right
    frontoparietal + skull Base Fracture anterior fossa + fracture
    of right orbital rim + fracture of right maxilla + fracture os
    nasal + fracture of right parasimpisis mandible
    Present State
    GCS : 15
    BP: 120/80
    HR: 80 x/min
    36.7 oC

    RR: 20 x/min

    Temp :

    Local State
    Ar palpebra superior bilateral et ala nasi dx : post remove
    suture

    Clinical Picture (31/8/15)

    Post Primary Suture

    Chest X-ray (23-8-2015)

    CT-Scan

    Schedel AP-LAT

    Laboratory Finding
    Lab

    23-8-15

    31-8-15

    Hb

    14.8

    11.8

    Hct

    43

    34

    Leukosit

    14.800

    10.200

    Trombosit

    187.000

    408.000

    Ur / Cr

    20/0.96

    39/0.92

    Na / K

    142/3.7

    135/5.3

    Random
    Glucose

    128

    135

    SGOT/SGPT

    164/75

    21/17

    PT/INR/APT
    T

    10.8/0.99/
    23.4

    10.1/0.93/21.
    5

    Management
    R/ Plan to ORIF

    Dani Ramdani/ 12 yo / BPJS / MR : 15026074/KEM 2 (BED 10.1)


    Admission : 26-08-2015
    Consultant : Almahitta, dr., SpBP-RE

    Working Diagnosis :
    Reccurent keloid scar at auricle region + inguinal region
    Operating History
    1st keloid removal on 2012
    2nd keloid removal + FTSG on Mei 2015
    7 times excision at rajawali hospital during 2012-2015
    Present State
    CM
    BP : 110/70 mmHg
    HR : 78 x/min

    RR : 18 x/min

    Local Status :
    Keloid scar 10x6x4 cm at left auricle region
    Keloid scar 4x2x1cm at right inguinal region
    Keloid scar 6x2x1cm at left inguinal region

    clinical picture 31/8/2015

    Laboratory Finding
    Lab

    31/08/15

    Hb

    12.8

    Hct

    35

    Leukosit

    8.300

    Trombosit

    342.000

    Ur / Cr

    39/0.62

    Na / K

    137/3.8

    GDS

    114

    SGOT/PT

    28/22

    PT/INR/APTT

    14.7/39.1/1.12

    Management
    Plan to do keloid excision
    Continue with intralession triamcinolone
    injetion

    TERIMA KASIH

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