Emergency ReportMonday, May 18th 2015

Referred from Private Clinic

Name : Anggi Setiawan

Sex : MaleAge : 10 years oldAddress : Cimareme, Bandung

Religion : MoeslemMarital Status : Not marriedMedical Rec No. : 1500013855

Time of admission : 03.00 pm

PS : Swelling at the right lower jaw

S: A 10 y.o male patient came with swelling at the right lower jaw. ±14 days prior to admission, patient complaint of toothache at his right lower jaw, then the patient went to the Cimareme primary health care and was given amoxycillin, paracetamol. ± 7 days ago, swelling was appeared at his right lower jaw, then patient went to Mitra Sehat Clinic and was given metronidazole and paracetamol. ± 10 days ago, cause the swelling at his right lower jaw got bigger, the patient went to Mitra Sehat Clinic for control, but there was nothing done there, then patient was referred to Hasan Sadikin Hospital.

O:

Conciousness : alert

VAS 6/10

Vital Sign

• HR : 114 x /mnt

• Temp : 36,7º C

• RR : 20 x/mnt

General status :

•Skin : Turgor (+)•Head : asymmetrical face, swelling at the right lower jaw

Eye : conjunctiva non anemic, no icteric sclera, •Neck : JVP not increased,

submandible lymph node not palpable, no pain•Thorax : Symmetrical shape and movement

Pulmo : VBS R=L, Rh -/-, Wh-/- Cor : Regular pure heart sounds•Abdomen : Soft and flat, bowel sound (+) N •Extremity : Warm, cyanosis -/-, edema -/-, CRT < 2”

Local status :•Extra Oral Asymmetrical face, swelling at right right lower jaw with 4x4x2 cm in size, redness, localized, febrile temperature, soft consistency, fluctuation (+), pain on palpation (+),

Intra Oral :- Gingiva : edema and redness at teeth 85,46- Lips : within normal limit- Vestibule : within normal limit- Buccal mucosa : within normal limit- Tongue : within normal limit- Floor of the mouth : within normal limit- Palate : within normal limit- Tonsils : T1-T1

8 7 6 5 V 4 3 2 1 1 2 3 4 V 5 6 7 8

8 7 6 5 V 4 3 2 1 1 2 3 4 IV 5 6 7 8

Odontogram

Plaque, Calculus (+)

UE

UE

UE

UE GPGP GR

GR GR

Laboratory findings :

• PT : 12,7 (8,7-12,7) second• INR : 1,19 (0,83-1,16) second• APTT : 26,5 (15,3-35,3) second• Hb : 12,4 (11,4-15,5) g/dL• Ht : 36 (35-45) %• WBC : 21.000 (4.500-13.500) /mm3

• RBC : 4,51 (4,43-6,02) million/uL

• Platelet : 847.000 (150.000-450.000) /mm3

A: • Subcutaneus abscess at the right right lower jaw due to

gangren pulp of tooth 46 and gangren radix of tooth 85

P : Treatment from oral surgery dept• Routine blood count, PT-APTT

• O2 Nasal Canul 2 liters/minute

• IVFD RL maintenance 16 drops/minutes

• Tapping pus ( ±0,5 cc) Culture resistance + sensitivity of AB

• R/ Ceftriaxone inj 1 gr IV

Metronidazole infus 300 mg IV

Ranitidine inj 50 mg IV

Ketolorac inj 30 mg IV

• Extraction of teeth 85, 46

• Incision and drainage EO → ± 30 cc

• Application of penrose drain EO

• Bandage application extraorally

Suggestion :• Plan to perform panoramic x-ray•Oral hygiene instruction•Regular diet•R/ Cefadroxil syr 250 mg 2 x1cth PO Metronidazole tab 3 x 250 mg PO Ibuprofen syr 200 mg 2x1cth PO•Plan to perform extraction of teeth 55, 65, 74 at OMFS departement on days and hours of work•Plan to perform scalling of upper and lower teeth at Periodontology departement on days and hours of work•Replace bandage 1x/day•Replace penrose drain 1x/3 days•Removal of penrose drain after the production of pus minimal•Control at OMFS Departement on Tuesday May 19th 2015

Discharged

Irsan, drg/ Melita S.,drg., SpBM

Tapping pus

Durante Treatment

Post Treatment