parade dr. ali 2 sept

7/17/2019 Parade Dr. ALi 2 Sept

http://slidepdf.com/reader/full/parade-dr-ali-2-sept 1/54

Patients Paradedr. Ali Sundoro, Sp.BP-RE

Melva2 September 2015



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!"#



$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 ' (



:lini&al Pi&tures 6une 11st 2015



:lini&al Pi&tures, 6une 1t$ 2015



:lini&al Pi&tures, 6ul 0rd 2015



:lini&al Pi&tures, 6ul 0t$ 2015



:lini&al Pi&tures, 6ul 2't$ 2015



:lini&al Pi&tures, Au!ust t$ 201



:lini&al Pi&tures, Au!ust 10t$ 20



2'-4-2015



1-4-2015

<aborator ;indin!



<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!



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>



Pus :ulture =5-6uni-2015>Anti'iotik Org 1

Ami)a&in 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


/itemu)an )uman Pseudomonas aeroginosa

:ep$a?olin R

i!e&&lin R

l = li >



Pus :ulture =-6uli-2015>

Pus :ulture =-Au!ust-2015>



Pus :ulture =-Au!ust-2015>

/itemu)an )uman Pseudomonas aeruginosa

Anti'iotik Org 1

Ami)a&in 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


i!e&&lin R

20 * 2015



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



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



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!"#



:lini&al Pi&ture



;oto $ora+



:- S&an18482015



<aborator ;indin!



<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



E:



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



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!"#



:lini&al Pi&ture



2-04-2015

" t



"ntra op



1-4-2015

F



F-ra

Head C(%can at %m'er Waras Hospital



ne, 20th 2015=bone dis&ontinuit at le%t %rontal>

%kll ;(ray at Hasan %adikinH i l



HospitalAgst, 0)th 2015radio lsen at le<t <rontal and mid

parietal

<aborator ;indin!



&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



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



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(



2-4-2015



"ntra op

:$ F =2 4 2015>



:$est F-ra =2-4-2015>

&a'oratory =inding



&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



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



$an) ou

parade dr. ali 2 sept

Documents