Emergency Report

Saturday, December 5th , 2015

Name
: Mr. Aja Pahruji
Sex
: Male
Age
: 41 years old
Address
: Buniaga, Ciherang, Cianjur
Religion
: Moslem
Status
: Married
Medical Rec No. : 0001497982 / 1500032799
Time of arrival : 1.50 pm
Phone Number : 0819122700021

PS: Swelling on the left cheek

S:
A 41 y.o male patient came with swelling on the lower cheek
bilateral. 10 days prior to admission, patient was complaining of
pain on his left lower tooth accompanied with swelling on the left
cheek. 5 days prior to admission the patient was taken to
private hospital Dr Hafiz at Cianjur area and received of
medicine (the patient didnt remember the name of medicine).
Because of his complaint didnt decrease, 6 hours prior to
admission the patient was taken and suggested to Hasan Sadikin
Hospital. History of toothache (+) 1 month ago on his left lower
teeth, history pain when swallowing (-), history of dental
treatment (-), History of diabetes was denied.

O:
Vital Signs
Consciousness : CM
VAS
: 4/10
Vital Signs
BP = 170/90 mmHg
P = 91 x/minutes
Temp = 39,5 oC
RR = 29 x/minutes

General status :
Skin
Head

: Turgor (+)
: Asymmetrical face, swelling at the left buccal cheek, left
submandible and submental region
Eye
: Non anemic conjunctiva, non icteric sclera
Neck
: JVP not increased, submandible lymph nodes :
R=not palpable, not pain ; L= difficult to assess
Thorax : Symmetrical shape and movement
Pulmo : VBS R=L, Rh -/-, Wh-/Cor
: HS 1=HS 2, pure regular sound
Abdomen : Soft and flat, bowel sound (+) N
Hepar & Spleen : not palpable
Extremity : Warm, edema -/-, CRT < 2,Pitting test (+)

Local status :
Extra Oral :
Asymmetrical face, swelling at the left and the right buccal cheek that extend
to left and right submandible and s ublingual region redness, febrile
temperature, localized, soft consistency, fluctuations (+), pain on palpation

Intra Oral :
Ginggival
: Swelling at left buccal mucosa 1x1x1 cm in size, redness,
febrile temperature, localized, soft consistency, fluctuations,
on palpation
Floor of the mouth : elevation
Mucosa Buccal
:within normal limit
Palate
: within normal limit
Lips
: within normal limit
Vestibulae
: within normal limit
Tongue
: within normal limit
Tonsils
: Cannot inspection

pain

Odontogram

CP

8 7 6 5 4 3 2 1
8 7 X6 X5 X
4 3 2 1
X

CM GR GR

CP

1 2 V
3 V
4 5 6 X
7 8
1 2 3 V4 5 6 7 8
CM

Mouth opening 1 cm
Calculus (+)

GR

CM

Laboratory findings :
-

PT : 13.5
(8.8-12.8) second
INR : 1.18
(0.82-1.17) second
APTT : 26.7
(14.7-34.7) second
Hb
: 13.3
(13.5-17.5) g/dL
Ht
: 37 (40-52) %
WBC
: 9.600 (4.400-11.300) /mm3
RBC: 4.49
(4.5-6.5 million/uL)

Platelet

: 272.000 (150.000-450.000)/mm3

-Lactate : 0.6 (0.7-2.5) mmol/L

- Ureum : 44 (15-50) mg/dL
- Creatinine : 0.69
(M: 0.7-0.9) mg/dL
- AST (SGOT): 50 (U/L 37 C)
- ALT (SGPT) : 34 (U/L 37 C)
- Random blood glucose : 89 (<140) mg/dL
- Sodium (Na) : 136
(135-145) mEg/L
- Potassium (K)
: 3.1 (3.6- 5.5) mEg/L

Blood gas analyzed

-

pH
: 7.446
M: 7.34-7.44 mmol/L
PCO2
: 28.1
M: 35-45
mm Hg
PO2
: 111
69-116
mm Hg
HCO3
: 18.8
22-26
mEq/L
TCO2
: 35.8
22-29
mEq/L
Base Excess
: -2.7
(-2) (+3) mEq/L
Oxygen Saturation : 97.8
95-98
%

Chest X-Ray

Impression :
No sign of cardiomegaly
No sign of active lung Tuberculosis

STL AP-Lateral X-Ray

Impression :
-Air collumn at laryng and pharyng within normal limit
-Retreopharyngeal and retrolaryngeal space did not widen
-Epiglotis and valecula within normal limit
- No sign of opaque shadow or calcification of the soft tissue

A:

Phlegmon enlargement to anterior colli

P : Therapy of oral surgery dept

Complete Blood count, PT-APTT, Blood Gas Analysis, Lactate
Chest, STL AP-Lateral X Ray
O2 Simple mask 8 Litre/m
IVFD RL maintenace 25 gtt/m
Tapping pus at inferior mentale, left and right submandible 2cc Culture & Antibiotic
resistance + sensitivity
R/ Ceftriaxone inj 1 gr IV
Metronidazole inf 500 gr IV
Ketorolac inj 1 amp IV
Ranitidine inj 1 amp IV
Incisi drainage through and through
Penrose drain
Verban

Suggestions
Obs of vital sign
IVFD maintenace 25 gtt/m
R/
Ceftriaxone inj 2 x 1 gr IV
Metronidazole inf 3 x 500 gr IV
Ketorolac inj 2 x 30 mg IV
Ranitidine inj 2 x 50 mg IV
Plan to perform Odontectomy 28 at OMFS clinic on office hours
Plan to perform incision and drainage at OMFS clinic on office hours
Plan to perform scalling of upper and lower teeth at dental clinic,
periodontology dept on office hours
Check of culture of sensitivity and resistence of AB at POD VII (December
12th, 2015)
Hospitalized

Yudi, drg/ Melita,drg.,SpBM

Durante OP