You are on page 1of 20

Emergency Report

Saturday, September 19th 2015

Referred from Majalaya Hospital
Name
Sex
Age
Address
Bandung
Religion
Status
Medical Rec No.
Time of admission

: Cecep Andrian
: Male
: 25 y.o
: Kp. Cibodas, Kabupaten
: Moslem
: Not Married
: 0001480088
: 9.30 PM

bleeding from ear and nose (-).PS: Bleeding From Mouth S: A 25 y.o male patient referred from Majalaya Hospital with bleeding from mouth. Then the patient was referred to Hasan Sadikin Hospital Emergency Department. bleeding from mouth (+). ± 4 hours prior to admission. History using helmet (+) half face. when the patient was riding a motorcycle in medium speed under alcohol influenced at Majalaya area. history of unconciousness (-). . nausea and vomiting(-). The patient was taken to Majalaya Hospital but no treatment was received. suddenly the patient lost his balance then hit a tree and fell down with mechanism his mouth hit the asphalt first.

Light reflex +/+. Parese-/-. Ronkhi -/-. pupil : round equal ODS ϕ 3mm. VBS right=left. Pulse= 76 x/minutes D: GCS 15 (E4M6V5). Secondary Survey : Within normal limit .O: Primary Survey A: Clear B: Symmetrical shape and movement . Wheezing -/C: BP = 120/80mmHg. RR= 20x/minutes.

Wh-/Cor : Regular pure heart sounds • Abdomen : Soft. bowel sound (+) N Hepatic & Lien : not palpable • Extremity : Warm. no pain • Thorax : Symmetrical shape and movement Pulmo : VBS right=left. Rh -/-. non icteric sclera : JVP not increased Submandible lymph nodes : not palpable.General status : • Skin • Head Eyes • Neck : Turgor (+) : Symmetrical face : non anemic conjunctiva. cyanosis -/-. oedema -/-. CRT < 2” . flat.

Local status : Extra Oral : • Symmetrical face .

Intra Oral : • • • • • • • • Lips : Oedem at upper and lower lips. bone based Lacerated wound at gingiva of teeth 32-42 with 2x0.5x1 cm in size irregular edge. with 2x1 cm in size irregular edge Punctured wound at lower lip with 2x2 cm in size and 3x2 cm in size irregular edge Gingiva : Lacerated wound at gingiva of teeth 12-22 with 2x0. punctured wound at upper lip.5x1 cm in size irregular edge. bone based Vestibule : Within Normal limit Tongue : Within normal limit Floor of the mouth : Within normal limit Buccal mucosa : Within normal limit Palate : within normal limit Tonsils : T1-T1 .

Odontogram Mob °3 avulsion 8 7 6 5 4 3 2 1 8 V 7 V 6 5 4 3 2 1 # avulsion Mob °3 1 2 3 4 5 6 7 8 1 2 3 4 5 X 6 7 8 # segmented dentoalveolar Open Bite anterior (+) .

2 : 134 : 3.1 : 15.000 : 15 :9 : 24 : 0.6.5) g/dL (35.35 : 193.16) second (14.7-1.5) mEg/L .9 : 0.000)/mm3 (U/L <37 C) <37 ( U/L <37 C) <41 (15-50) mg/dL (M: 0.000-450.84-1.6-34.45) % (4400-11300) /mm3 (4.8 : 45 : 10900 : 5.5) /uL (150.Laboratory finding : • • • • • • • • • • • • • • • • • PT INR APTT Hb Ht WBC RBC Platelet AST (SGOT) ALT (SGPT) Ureum Creatinine Random blood glucose Alfa Amilase Lipase Sodium (Na) Potassium (K) : 9.5-6.92 : 23.5 (9-13) second (0.2 ) mg/dL (<140) mg/dL 26-100 U/L 37oC 13-60 U/L 37oC (135-145) mEg/L (3.78 : 110 : 92 : 20.5-17.5.6) second (13.

Chest X-Ray Impression : •No visible of traumatic wet lung or lung contusion •No visible of fracture on the costae. scapulae. clavicle •No visible of cardiomegaly .

Skull PA-Lateral X-Ray # Impression : Segmented Dentoalveolar fracture of teeth 32-42 .

Cervical X-Ray Impression : Within normal limit .

FAST USG Impression : • No sign of fluid collection at hepatorenal space • No sign of fluid collection at splenorenal space • No sign of fluid collection at vesikaurinaria space .

BS . Schedel AP-Lateral. Sp. cervical X-Ray Respectfully dr. MZ Arifin . PT-APTT • Observation of GCS • Head up 30° • IVFD NaCl 0.Neurosurgery Department Status A: Mild HI + Alcohol Intoxication Suggestion • Complete Blood count.9% 2000 cc/day • R/ Ceftriaxone inj 1 gram IV Ranitidine inj 50 mg IV Ketorolac inj 30 mg IV • O2 2 litre/minute via nasal canul • Thorax.

no special treatment from our department Thank you dr. 21.General Surgery Department Status A: • • • • Mild HI + Alcohol Intoxication Fracture dentoalveolar of teeth 12-22 with avulsion of teeth 11. Irene . 22 + Fracture of segmented dentoalveolar of teeth 32-42 Punctured wounds at upper and lower lip Lacerated wounds at gingiva of teeth 12-22 and gingiva of teeth 32-42 There is no sign of abnormalities on thorax and abdomen. mobility grade 3 of teeth 12. Bobby Eko /dr.

mobility grade 3 of teeth 12.A: • Mild HI + Alcohol Intoxication • Fracture dentoalveolar of teeth 12-22 with avulsion of teeth 11. 21. 22 + Fracture of segmented dentoalveolar of teeth 32-42 • Punctured wounds at upper and lower lip • Lacerated wounds at gingiva of teeth 12-22 and gingiva of teeth 32-42 .

P: Treatment : • Injection of ATS and TT • Necrotomy debridement • Alveolectomy of alveolar bone at teeth region 11-21 • Suturing at lacerated wounds IO • Interdental wiring at upper jaw (14-24) and lower jaw (35-45) .

on office hours Plan to perform tooth extraction of teeth 46.SpBM .Suggestions : • • • • • • • • • • • • Plan to perform Panoramic X-Ray Oral Hygiene instruction Soft diet R/ Cefadroxil caps 2x500 mg PO Ibuprofen tab 3x400 mg PO Ranitidine tab 2x150 mg PO Mouth rinse with Povidone iodine gargle after every meal Application of Hyaluronic acid gel at post suturing IO Application of chloramphenicol zalf at post suturing EO Control to OMFS on Monday September 21th 2015 on office hours Suture removal at POD VII (September 26th 2015) Plan to perform selective grinding of teeth 42 at OMFS dept.47 at OMFS dept. Discharged Nurul drg..drg.Harmas Yazid Yusuf. on office hours Another therapy according our fellow Neurosurgery dept./ Prof.Dr.

Post Debridement .

Post Treatment .