Emergency Report

Tuesday, February 08th 2018

Referred from General Hospital at Cibabat area

Name : Dadang Hermawan

Sex : Male
Age : 25 years old
Address : Gadobangkong, Ngamprah
Religion : Moslem
Medrec No. : 0001665690 / 18120101
Phone Number : 081320956000
Time of admission : 17:09 PM
Working Time : 1 hour
Ps: Swelling at left lower jaw extended to chin region extended left
lower jaw (Swelling at bilateral lower jaw and chin region)

S: A 25 y.o male patient referred from General Hospital in at Cibabat

area with swelling at left lower jaw. +/- ?? days prior to admission,
the patient complained of toothache at right lower jaw accompanied
with swelling arised at his right lower jaw. The patient was brought
to public health centre at Cimareme area and was given 2 kind of
medicines (Amoxicillin and Paracetamol). The swelling got bigger
and extended to chin region. +/- 10 hours prior to admission the
swelling got bigger and extended to left lower jaw region and pain
in swallowing (hapus aja pain in swallowing), then he was brought
to General Hospital at Cibabat area. There he was perfomed routine
blood count and then the patient referred to Hasan Sadikin Hospital
Emergency Department. Hoarseness (-), altered voice (-), neck
stiffness (+), pain and difficulty on swallowing (+), hot potato voice
(+ -). History of systemic disease was denied.
O:
Vital Signs
VAS : 3/10
Consciousness : Fully Alert

•BP : 110/80 mmHg

•HR : 110 x/minutes
•Temp : 38,3 oC
•RR : 23 x/minutes
•SpO2 : 98 % (without O2)
General Status
• Skin : Turgor (+)
• Head : Asymmetrical face, swelling at right lower jaw
extended to chin region extended to left lower
jaw
Eye : Conjunctiva non anemic, sclera non icteric
• Neck : JVP did not increase, right submandible node not
palpable, no pain, left submandible lymph node
was difficult to asses
• Chest : Symmetrical shape and movement
Pulmo : VBS right=left, Rh-/-, Wh -/-
Cor : Pure regular heart sound
• Abdomen : Flat and soft, bowel sound (+) N
Hepar & lien : Not palpable
• Extremity : Warm, CRT <2”
Localized status :
Extra Oral :
Asymmetrical face, swelling at at right lower jaw extended to chin
extended to left lower jaw with 10x4x2 cm in size, reddish (+),
febrile temperature (+), localized (+), fluctuation (+), pain on
palpation (+) spontaneous drainage (+) intraoral at tooth 48 region
(hapus spontaneous blabla, masukkin io vestibule).
Intra Oral

• Floor of mouth : Elevated

• Gingiva : Hyperemia
• Lips : Within normal limit
• Buccal mucosa : Within normal limit
• Vestibule : Within normal limit (masukkin spontaneou
bla bla, naikkin di atas floor of mouth)
• Tongue : Within normal limit
• Palate : Within normal limit
• Tonsils : T1-T1
 Odontogram

CM CS CP CP CP CP CP GP CP CP CM
8 7 √6 √5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 X6 5 4 3 2 1 1 2 3 4 5 X
6 7 8
GP GP GP CS

Mouth Opening : ± 1,5 cm

Calculus (+)
Laboratory Findings: (lab darah rutin pt aptt gds)
1. Hematology
• PT : 11.30 9.1-13.1 second
• INR : 1.04 0.8-1.2 second
• APTT : 31.20 14.2-34.2 second
• Hb : 14.3 M(14-17.4) g/dL
• Ht : 41.4 M(41.5-50.4) %
• WBC : 20.95 (4.5-11.0) 10^3/uL
• RBC : 4.73 M(4.4-6.0) million/uL
• Platelet : 273.000 (150.000-450.000)/mm3

2. Chemical Blood Component

• Random blood glucose : 68 <140 mg/dl
• SGOT : 21 (15-37) U/L
• SGPT : 17 (16-63) U/L
• Ureum : 23.0 15-39 mg/dL
• Creatinin : 0.84 0.8-1.3 mg/dL
• Natrium : 138 135 – 145 mEq/L
• Kalium : 4.4 3.5 – 5.1 mEq/L
 Chest X – Ray
(Hasan Sadikin Hospital, February 08th 2018)

Impression:
• No sign of cardiomegaly
• No sign of active pulmonary tuberculosis
 Neck Soft Tissue AP-Lat XRay
(Hasan Sadikin Hospital, February 08 th 2018)

Impression :
• Swelling of soft tissue at right submandible with radiolusen
of multiple air density within, suggestive of abscess.
• Air column still open
Please consult and therapy management of our patient,
Name : Dadang Hermawan
Age
WD/
Consult to ENT Department
: 25 years old
: Phlegmon due to gangrene pulp of teeth 48,47,37
In examination we found pain and diffuclty on swallowing (+), hot potato voice (hapus potato
voice), and neck stiffness (+).

Thanks for your help and cooperation.

Respectfully,

Asri Arumsari., drg., Sp.BM (K) / Ronal, drg

Hostpitalized,
 ENT Department Status

A: Submandible abscess + Sublingual abscess + Suspect Parapharing abscess +

Submental abscess (diagnosa tht ?)
Treatment :
- There was no special treatment from ENT Department
- Other Treatment according to Oral and Maxillofacial Surgery Depart

Respectfully,

dr. Agung D, Sp. THT-KL(K)/ dr. Dina Riana

A:

• Phlegmon due to gangrene pulp of teeth 48,47,37

• Chronic apically periodontitis due to gangrene pulp of teeth 12,24 +

Gangrene radices of teeth 16,15

• Pulpitis Irreversible of teeth 14,11,21,22,25,27 Hapus bukan diagnosa lsng

infeksi

• Pulpitis Reversible of teeth 18,17,28,38 sama ini juga hapus

• O2 Nasal Canule 3 lt/minute

• Chest and Neck Soft Tissue X-Ray

• Consult to ENT dept

• Tapping pus at right submandible (± 3 cc), chin region (± 2 cc), and left
submandible (± 2cc)

• R/ Ceftriaxone drip 1 gr IV

Metronidazole inf 500 mg IV

Ranitidine inj 50 mg IV

Ketorolac inj 30 mg IV

• Extraction of tooth 48,47,37,16,15

• Insision and drainage through and through at left submandible right nya
mana, chin region (± 20cc)
Suggestions :
• Oral hygiene instruction
• Plan to perform panoramic X-Ray
• Regular diet high calories high protein 1380 kcal/ day BB nya brp?
• IVFD RL maintenance 19 drops/minutes
• R/ Ceftriaxone drip 2x1 gr IV
Metronidazole inf 3x500 mg IV
Ranitidine inj 2x50 mg IV
Ketolorac inj 2x30 mg IV
• Mouth rinse with povidone iodine gargle every after meal
• Spooling intraoral with NaCl 0.9 % 2x/day
• Replace penrose drain every 3 days
• Replace bandage twice a day
• Mouth opening exercise with ice cream stick
• Plan to perform dental scalling at Periodontia dept at office hours
• Plan to perform dental filling of teeth 18,17,14,11,21,22,25,27,28,38 at
Conservation dept at office hours
• Plan to perform extraction of teeth 12,24 at Conservation dept at office hours naik
di atas scaling
• Check culture and antibiotic sensitivity results
Hospitalized,chief blkg siapa ?
Tapping Pus hapus tapping yg
pake jarum
Durante OP
Post Op hapus yg foto muka dari bwh
 Team On Duty
1st Chief on duty : Ronal, drg

2nd Chief on duty : Sulfiana, drg

Senior on duty: Riki Indra Kusuma, drg

Akmalia Hardini, drg

Junior on duty : Jihad Harun Sandiah, drg

Hirzi Asdyaksa, drg

Shinta Kartika Sari, drg

Kalia Labitta, drg

Tri Nurrahman, drg nama elu stlh jihad