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

PS: Bleeding From Mouth

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

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

General status :
Skin
Head
Eyes
Neck

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

Local status :
Extra Oral :
Symmetrical face

Intra Oral :

Lips

: Oedem at upper and lower lips, punctured wound at upper lip,

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 2x0,5x1 cm
in size irregular edge, bone based
Lacerated wound at gingiva of teeth 32-42 with 2x0,5x1 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 (+)

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)

: 9.9
: 0.92
: 23.1
: 15.8
: 45
: 10900
: 5.35
: 193.000
: 15
:9
: 24
: 0.78
: 110
: 92
: 20.2
: 134
: 3.5

(9-13)
second
(0,84-1,16)
second
(14.6-34.6)
second
(13.5-17.5)
g/dL
(35- 45)
%
(4400-11300)
/mm3
(4.5-6.5)
/uL
(150.000-450.000)/mm3
(U/L <37 C)
<37
( U/L <37 C)
<41
(15-50)
mg/dL
(M: 0.7-1.2 )
mg/dL
(<140)
mg/dL
26-100
U/L 37oC
13-60
U/L 37oC
(135-145)
mEg/L
(3.6- 5.5)
mEg/L

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

Neurosurgery Department Status

A:
Mild HI + Alcohol Intoxication
Suggestion
Complete Blood count, PT-APTT
Observation of GCS
Head up 30
IVFD NaCl 0,9% 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, Schedel AP-Lateral, cervical X-Ray

Respectfully
dr. MZ Arifin , Sp.BS

General Surgery Department Status

A:

Mild HI + Alcohol Intoxication

Fracture dentoalveolar of teeth 12-22 with avulsion of teeth 11, 21,
mobility grade 3 of teeth 12, 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, no special
treatment from our department
Thank you
dr. Bobby Eko /dr. Irene

A:
Mild HI + Alcohol Intoxication
Fracture dentoalveolar of teeth 12-22 with avulsion of
teeth 11, 21, mobility grade 3 of teeth 12, 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)

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. on office hours
Plan to perform tooth extraction of teeth 46,47 at OMFS dept. on office hours
Another therapy according our fellow Neurosurgery dept.
Discharged
Nurul drg./ Prof.Dr.Harmas Yazid Yusuf,drg.,SpBM

Post Debridement

Post Treatment