DISCHARGE SUMMARY MRS RATNA

INDICATION FOR HOSPITALIZATION:

Patient was planning to undergo functional endoscopic surgery after being consulted to dental
surgeon and optimal antibiotic treatment for one week.

PRE ELIMINARY DIAGNOSIS:

Odontogenic Pansinusitis on Left Side

MEDICAL HISTORY:

Patient mentioned that she had had her left maxillary’s first molar extracted about a month
ago. Two weeks after the tooth extraction, she sometimes experienced intermittent pain in her
left cheek and forehead. She also mentioned that she was experiencing nasal congestion,
purulent discharge, and foul odor from left nose in the same period.

PHYSICAL EXAMINATION:

Nasal endoscopy findings: purulent nasal discharge from left middle meatus with a congested
nasal mucosa

MEDICAL SUPPORT RESULT:

CT SCAN of the paranasal sinus findings: opacification of the left maxillary sinus, left
ethmoid sinus, left sphenoid sinus, and left frontal sinus

PROCEDURE:
Functional endoscopic sinus surgery

THERAPY:
- Ceftriaxone 2 g IV once daily
- Ketorolac 30 mg IV three times a day
- Tranexamic acid 500 mg IV three times a day
- Ranitidine 50 IV twice a day
- Posterior nasal packing in left nose  removed after 2 days
- Patient was discharged 2 days after surgery