parade dr. ali 2 sept
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7/17/2019 Parade Dr. ALi 2 Sept
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Patients Paradedr. Ali Sundoro, Sp.BP-RE
Melva2 September 2015
7/17/2019 Parade Dr. ALi 2 Sept
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Working Diagnosis :Burn injur !r ""A-""B #it$ ra# sur%a&e ' ( at anterior and posterior trun), ri!$t *an), ri!$t upper e+tremities re!io
t$at $ad been per%ormed ne&rotom debridement and SS
Operational History :• 1ste&rotom /ebridement on Mar&$ t$ 2015• 2nd e&rotom /ebridement on Mar&$ 10t$ 2015• rd e&rotom /ebridement on Mar&$ 1t$ 2015• t$ e&rotom /ebridement on Mar&$ 1t$ 2015• 5t$ e&rotom /ebridement 3 SS on Mar&$ 20t$ 2015• t$ e&rotom /ebridement on Mar&$ 2t$ 2015• 't$ e&rotom /ebridement 3 SS on April 2nd 2015• 4t$ e&rotom /ebridement 3 SS on April 't$ 2015• t$ e&rotm /ebridement 3 SS on Ma 4t$ 2015• 10t$ e&rotm /ebridement 3 SS on Ma 20t$ 2015• 11t$ e&rotm /ebridement on 6une t$ 2015• 12t$ e&rotm /ebridement on 6une 11 t$ 2015• 1t$ e&rotm /ebridement 3 SS on 6une 2t$ 2015• 1t$ e&rotm /ebridement 3 evaluate o% SS on 6une 2t$ 2015• 15t$ e&rotm /ebridement 3 SS on 6ul 0 rd 2015• 1t$ e&rotm /ebridement 3 SS on 6ul 0 t$ 2015• 1't$ e&rotm /ebridement 3 SS on Au!ust t$ 2015• 14t$ e&rotm /ebridement 3 SS on Au!ust 20 t$ 2015
1. Mr. Rendy Arie Goestina/20yo/MR: 15021726/Kemuning 4 (10.5)
Admission : March 5th, 2015Consltant : Ali Sundoro, dr., SpBP-RE!"#
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$resent %tateBP 7 1208 '5 mm9! RR 7 20 +8min
9R 7 4 +8min emp 7 .5o
:&ocal %tats :
run&us anterior 7 ra# sur%a&e 2 ( run&us posterior 7 ra# sur%a&e 1 (Ri!$t ;lan) 7 ra# sur%a&e 2,5 (Ri!$t upper e+tremit 7 ra# sur%a&e 1.5
otal 7 ra# sur%a&e ' (
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:lini&al Pi&tures 6une 11st 2015
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:lini&al Pi&tures, 6une 1t$ 2015
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:lini&al Pi&tures, 6une 2t$ 2015
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:lini&al Pi&tures, 6une 2t$ 2015
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:lini&al Pi&tures, 6ul 0rd 2015
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:lini&al Pi&tures, 6ul 0t$ 2015
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:lini&al Pi&tures, 6ul 2't$ 2015
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:lini&al Pi&tures, Au!ust t$ 201
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:lini&al Pi&tures, Au!ust 10t$ 20
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:lini&al Pi&tures, Au!ust 10t$ 20
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:lini&al Pi&tures, Au!ust 1t$ 20
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:lini&al Pi&tures, Au!ust 1t$ 20
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:lini&al Pi&tures, Au!ust 2t$ 20
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2'-4-2015
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1-4-2015
<aborator ;indin!
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<aborator ;indin!
&a'21(
0)(150*+05+2015
1+05+2015
21+05+2015
2-+05+2015
2.+05+2015
0)+0/+2015
15+0/+2015
1*+0/+2015
2.++2015
H' 10,' ,2 10, ',4 ,1 , 4. '.5 4.4 11.
Hct 2' 0 2 2 24 2 2 22
&ekosit
1.00 1'.400 20001'0
01'00
14000
2.00
14.000 1.00 11.000
rom'osit
4.000
5.000
0000
0000
524000
512000
0.000
52.000
5.000
1.000
r + Cr 480,51080.
5'80.5 .180.4
a + " 128,
218,
1108,
1128
.128
.128.
12'8.
1'8.2
3andom
4lcose
10'
Al'+ot$rot
,8,4
2,8,
2,85,'
2,85.0
2.8.4
2.8.4
.28'.'
-++2015
.+*+215
10.1 11.
' 5
11.000 10.5
25.000 15.0
128.5
.58'
<aborator ;indin!
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<aborator ;indin!&a' 22(*(15 2)(*(25 -0(*(2015
$+ A$+ 63 .482.80.1
H' . 10. 10.2
Hct 1 5
&ekosit 1.00 15.00 15.'00
rom'osit '0.000 510.000 50.000
r + Cr 48 0.5' 1180.'
a + " 158 .5 18.
3andom4lcose
11
Al'min+prottotal
.08.4
%4O+%4$ 108'
Pus :ulture =04 0 2015>
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Pus :ulture =04-0-2015>Anti'iotik Org 1
Ami)a&in S
Ampi&ilin Sulba&tam R
:e%epime S
:e%ota+ime R
:e%o+itin S
:e%ta?idime S
:ipro*o+a&in R
:otrimo+a?ole Sentam&in R
<evo*o+a&in R
Meropenem S
Pipera&ilin a?oba&tam R
/itemu)an )uman Providentia Stuartii
Pus :ulture =5 6uni 2015>
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Pus :ulture =5-6uni-2015>Anti'iotik Org 1
Ami)a&in R
Ampi&ilin Sulba&tam R
:e%epime RA?treonam "
:e%tria+one R
:e%ta?idime R
:ipro*o+a&in R
:otrimo+a?ole R
entam&in R<evo*o+a&in R
Meropenem R
Pipera&ilin a?oba&tam R
/itemu)an )uman Pseudomonas aeroginosa
:ep$a?olin R
i!e&&lin R
l = li >
7/17/2019 Parade Dr. ALi 2 Sept
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Pus :ulture =-6uli-2015>
Pus :ulture =-Au!ust-2015>
7/17/2019 Parade Dr. ALi 2 Sept
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Pus :ulture =-Au!ust-2015>
/itemu)an )uman Pseudomonas aeruginosa
Anti'iotik Org 1
Ami)a&in R
Ampi&ilin Sulba&tam R
:e%epime RA?treonam R
:e%tria+one R
:e%ta?idime R
:ep$a?olin R
:ipro*o+a&in R
:otrimo+a?ole Rentam&in R
Meropenem R
Pipera&ilin a?oba&tam R
i!e&&lin R
20 * 2015
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20(*(2015
Amo7ycyllin(Cla8 3
Ampi&illin Sulba&tam R
:e%epime R
:e@+ime R
:e%opera?one R
:e%o+itin R
:e%ta?idime R
:e%tria+one R
:e%uro+ime R
:ep$a?olin R
:ipro*o+a&in R
:lindam&in R
Cotrimo7a9ol 3
Ert$rom&in R
entam&in R
"mipenem R
<evo*o+a&in R
<ine?olid S
Meropenem R
Mo+i*o+a&in R
+a&illin R
tetra&&lin S
i!e&&lin S
an&om&in S
/itemu)an Met$i&illin Resistant Stap$lo&o&&usAureus
M t
7/17/2019 Parade Dr. ALi 2 Sept
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Mana!ement
• /iet 9i!$ :alorie and $i!$ Protein• ";/ R< 2000&&8 2 jam• R8 i!e&&lin 2+50m! drip in 100&& 0,( ramadol 2+50 m! drip• au?e Repla&ement ever da #it• Plan %or / and SS
Mr. Carban/ 39yo/MR: 15025907/ Kemuning 4
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Working Diagnosis :;ra&ture <e;ort 1 3 ;ra&ture Palatum Sa!ital 3 ;ra&tu
Mandibula
Operational History : -
$resent %tate
BP 7 10840 mm9! RR 7 20 +8min
9R 7 42 +8min emp 7 .'o :
y g
Admission : 1. Agsth, 2015Consltant : Ali Sundoro, dr., SpBP-RE!"#
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:lini&al Pi&ture
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;oto $ora+
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:- S&an18482015
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<aborator ;indin!
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<aborator ;indin!
&a' 1.(*(15 -0(*(2015
$+A$+63 ,822,480,44 .822.'80.4'
H' 12, 12.0
Hct ' 5
&ekosit 10.500 .00
rom'osit 0.000 52'.000
r + Cr 5180,'5 1080.1
a + " 1'8,2 148.
%4O+%4$ 181 22820
3andom4lcose
4 12
Al'+$rottotal
.85.4
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Mana!ement
- /iet <una)
- Cumur Betadine tiap $abis ma)an
- Plan %or R";
Mr. Wahyudi/22yo/MR: 15021726/Kemuning 2 (6.4)
Ad i i A t /th 2015
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Working Diagnosis :
Post :ranie&tom /ebridement 3 /e%e& :<osure ai open %rdepressed D 1 tab at le%t %rontal3 steomelitis at mid parietal ele&tri&al burn injur
Operational History : 6une 20t$ 2015 Arja#inan!un 9ospital :irebon 7 :ranie
debridement
Au!ust 2' :ranie&tom /ebridement 3 de%e& &losure$resent %tats :
:ompos mentis :S 15
7 120842 mm9! RR 7 20+8min
9R 7 4+8min emp 7 .':
Admission : Agst, /th, 2015Consltant : Ali Sundoro, dr., SpBP-RE!"#
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:lini&al Pi&ture
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2-04-2015
" t
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1-4-2015
F
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F-ra
Head C(%can at %m'er Waras Hospital
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ne, 20th 2015=bone dis&ontinuit at le%t %rontal>
%kll ;(ray at Hasan %adikinH i l
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HospitalAgst, 0)th 2015radio lsen at le<t <rontal and mid
parietal
<aborator ;indin!
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&a' -(*(15 1)(*(15
2*(*(2015
H' 1,' 1, 11,
Hct 4
&ekosit '.100 '.00 10,00
rom'osit 22.000 20.000 210.000
r + Cr 1'80. 1'80,'
a + " 185, 1585,
3andom4lcose
5 4'
Al'+ ot$rot
,8,4 ,08,5
Mana!ament
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Mana!ament
• euro Sur!er /epartment 7
-";/ a:l 0,( 1500 &&8da-:e%tria+one 2+1!r "
-tramadol drip 2+50m!
• Plasti& Sur!er /epartment 7
-open #ound &are- aG suture pod 2 #ee)s
Sal#a8 ♀ 8 2 o 8 BP6S 8 MR 7 1502048CEM 2 =BE/ Admission 7 2-04-2015
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Admission 7 2-04-2015:onsultant 7 Ali, dr., SpBP-RE
Working DiagnosisPost / ai :ombutio !rade ""A 21(
$resent %tate:ons&iousness7 :M9R 7 120 +8min RR7 2 +8min emp 7 . o:Hrin output 1000&&82 jam =)unin! jerni$>
&ocal %tateAr t$run) ant 7 !r ""A ( t$run) post 7 !r ""A 12( e)stremit superior d+ 7 !r ""A ( e)stremit in%erior d+ 7 !r ""A 2(
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"ntra op
:$ F =2 4 2015>
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:$est F-ra =2-4-2015>
&a'oratory =inding
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&a' 2/(*(15 -0(*(2015
H' 15. 10.
Hct 2
&ekosit .00 1.00rom'osit '4.000 24.000
r + Cr 2480,2 2180.25
a + " 148.0 18.
3andom4lcose
201 12
%4O+%4$ 814 2811
$+63+A$10.80.81
'.
Al'min+prottotal
.085.
y g
M t
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Mana!ement
• ";/ a:l 500&&8$r 3 1500&& P
• Monitor urine output
• $8 &e%ota+ime 2+00m! "
para&etamol sr +225m!
• P/ 5, ra#at lu)a terbu)a d!n Sibro pada )e
• /iet biasa tin!!i protein