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Weekly Report

RSGM

January 13th 20th 2017


1. Friday, Januari 13th, 2017
Name : By. M. Dzulkifli
Medrec no. : 2017-00237
Sex/Age : M/ 5 month
Diagnosis : Labioschizis unilateral incomplete sinistra
Therapy : Labioplasty (Milard II)
Duration : 95 minutes
Supervisor : drg. Ida Ayu Astuti, Sp.BM
Assistant I : drg. Leidy Valentina
2. Friday, Januari 13th, 2017
Name : By Mutiara Nur
Medrec no. : 2017-00455
Sex/Age : F/ 18 month
Diagnosis : Palatognatoschizis unilateral complete dextra
Therapy : Palatoplasty
Duration : 2 hours 55 minutes
Operator : drg. Ida Ayu Astuti , Sp.BM
Assistant I : drg Alvin
Assistant II : drg Leidya
3. Monday, January 16th, 2016
Name : Riswandy
Medrec no. : 2017-00452
Sex/Age : M/4 y.o
Diagnosis : Labioschizis unilateral incomplete dextra
Therapy : Labioplasty (Millard)
Duration : 1 hours
Supervisor : drg. Endang Syamsuddin, Sp.BM
Operator : drg. Leidya
4. Monday, January 16th, 2016
Name : Keiko
Medrec no. : 201510749
Sex/Age : M/18 m.o
Diagnosis : Palatoschizis bilateral complete + gnatoschizis unilateral dextra
Therapy : Palatoplasty ( two flap pushback)
Duration : 2 hour 40 minutes
Supervisor : drg. Abel T. Sp.BM
Operator : drg. Leidya
5. Wednesday, January 18th, 2016
Name : Amelia Sari
Medrec no. : 2017-00506
Sex/Age : F/11 y.o
Diagnosis : Defect nasal + tongue tie
Therapy : Nasal Reconstruction+ Frenectomy
Duration : 1 hours 22 minutes
Supervisor : Prof . DR drg. Sunardi, Sp.BM
Assistant : drg. Retno
6. Wednesday, January 18 th, 2016
Name : M Fikri
Medrec no. : 2017-00379
Sex/Age : M/15 y.o
Diagnosis : Defect nasal + Scar post labioplasty+ gnatoschizis dextra
Therapy : Rhinoplasty + repair scar post labioplasty + gnatoplasty
Duration : 4 hours
Supervisor : drg. Ida Ayu Astuti, Sp.BM
Assistant : drg. Retno
Emergency Report
Wednesday, January 18th 2016
Name : Moch Irfan
Sex : Male
Age : 17 years old
Address : Cianjur, Bandung
Religion : Moslem
Status : Single
Medical Rec No. : 2017-00942
Time of admission : 23.00 PM
Phone Number : 081220634309
Working Time : 1 hours
PS: Swelling on the left cheek
S : A 17 y.o. male patient came with swelling on left cheek region. 4
days prior to admission, the patient complain of toothache on the left
lower jaw, then he bought a medicine in the stall but the patient did not
remember name of medicine. 1 day prior to admission, the swelling
occurred on his left gingival accompanied with a fever. But the patient
did not seek treatment. 12 hours prior to admission the swelling got
bigger so the patient went to Unpad Dental Hospital Emergency Dept.
History of systemic disease was denied, altered voice (-), neck stiffness
(-), history to visit dentist (-), history of toothache (+) at posterior lower
jaw.
O:
Vital Signs
VAS : 3/10
Consciousness : Fully alert

BP : 120/80 mmHg
HR : 85 x/minutes
Temp : 36.8 oC
RR : 20 x/minutes
General Status :
Skin : Turgor (+)
Head : Asymmetrical face, swelling at left cheek
Eye : Conjunctiva non anemic, sclera non icteric
Neck : JVP not increase,
Right submandible lymph nodes: not palpable, no pain
Left submandible lymph nodes: not palpable, no pain
Chest : Symmetrical shape and movement
Pulmo : VBS right=left, Rh-/-, Wh -/-
Cor : Pure regular heart sound
Abdomen : Flat and soft, bowel sound (+) normal
Hepar & lien: Not palpable
Extremity : Warm, CRT <2
Local Status :
Extra Oral :
Asymmetrical face, swelling at left cheek, with 5x3x1 cm in size, reddish (+),
febrile temperature (+), fluctuation (-), diffuse (-), pain on palpation (+).
Intra Oral :
Vestibule : Elevated
Buccal Mucosa : Elevated
Lips : within normal limit
Gingival : within normal limit
Palate : within normal limit
Tongue : within normal limit
Floor of the mouth : within normal limit
Tonsils : T1-T1
Odontogram

UE UE
CM
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
GP
Mob grade 2

Calculus (+)
A:
Celulitis at vestibular region that extend to buccal region due to
Gangren Pulp 36
P: Treatment from oral surgery department:

Tapping pus at left mucosa buccal region (-)


R/ Cefadroxil caps 500 mg P.O
Metronidazole tab 500 mg P.O
Ranitidine tab 150 mg P.O
Ibuprofen tab 400 mg P.O
Extraction of tooth 36
Incision drainage at vestible region of tooth 36
Insertion of penrose drain at left vestibule buccal region
Suggestions :
Oral hygiene instruction
Plan to perform panoramic x-ray
Regular diet
R/ Cefadroxil caps 2x500 mgP.O
Metronidazole tab 3x500 mg P.O
Ranitidine tab 2x150 mg P.O
Ibuprofen tab 3x400 mg P.O
Mouth rinse with povidone iodine gargle every after meal
Plan to perform dental scalling on Periodontia UNPAD Dental Hospital in office
hours
Plan to perform dental filling of tooth 16 at conservative departement UNPAD
Dental Hospital in office hour
Replace penrose drain 1x/3 days
Control at minor polyclinic at OMFS Dept. UNPAD Dental Hospital in Office hours
(January 19th 2017)
Respectfully,

drg. Andri H., Sp. BM / Leidya, drg


Tapping Pus
Durante OP
Post OP
Team On Duty

1st Chief on duty : Leidya Valentina , drg


2nd Chief on duty : Evan Yulius Saputro., drg
Senior on duty : Sulfiana, drg
Idawati Muhajir, drg
Riki Indra Kusuma, drg
Junior on duty : Joni Putra, drg
Akmalia Hardini, drg
Irma kusumawati, drg
Cahyadi Siauw,drg