EMERGENCY REPORT

Friday, March 18th 2016 - Tuesday,

March 22th 2016

Emergency Report
Friday, March 18th 2016

Referred from Bayu Asih Hospital

Name
Sex
Age
Address
Religion
Status

: Jayani
: Male
: 25 years old
: Pondok Salam, Purwakarta
: Moslem
: Not married
Medical Rec No. : 0001524724
Time of arrival
: 09.20 PM
Phone Number
: 085321949002

PS : Broken of left cheek bone

S:
A 25 y.o male patient referred from Bayu Asih Hospital with
broken of left cheek bone. 24 hours prior to admission, while
he was riding a motorcycle with medium speed at Pondok Salam
area, suddenly came a motorcycle from opposite direction and
caused the patient crashed and fell down with mechanism his left
face hit the asphalt first. History of using Helmet (-). History of
unconciousness (-), nausea and vomitting (-), bleeding from nose
(+), bleeding from mouth (-), bleeding from ear (-). Then the
patient was brought to Bayu Asih Hospital, and was performed
infusion, injection of medication (patient forgot name of
medication), situational suturing, X-ray and CT scan imaging.
Then the patient was referred to Hasan Sadikin Hospital
emergency department.

Primary survey
A : Clear with C Spine control
B : Symmetrical shape and movement, VBS R=L , R : 20 x/min
C : BP : 130/90 mmHg P : 82 x/min,
D : GCS 15 (E4M6V5) Pupils round equal ODS 3 mm
light reflex (+/+), motoric : Paresis M. Rectus inferior at left
orbita
Secondary Survey
Swelling and hematoma at left hand region
Lacerated wound at left foot with 7x4 cm in size irregular edge,
muscle based

General status :
Skin
Head

: Turgor (+)
: Asymmetrical face, oedema and hematoma at
both of Periorbital rim and left cheek region
Eye : Sub conjunctiva haemorrage at left orbita, non
icteric sclera
Neck
: JVP not increased Submandible lymphe 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
Hepar/Lien : not palpable
Extremity : Warm, cyanosis (-), CRT < 2

Local status :
Extra Oral :
Asymmetrical face, oedema and hematoma at both of periorbital
rim and left cheek region
Post suturing at forehead region with 3,5x1 cm insize and left
cheek region with 3x1 cm insize

Intra Oral :
Buccal mucosa : hematoma at left buccal mucosa region
Lips
: within normal limit
Vestibule
: within normal limit
Gingiva
: within normal limit
Palate
: within normal limit
Tongue
: within normal limit
Floor of the mouth : within normal limit
Tonsils
: T1-T1

Odontogram

PE

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

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

Open bite of left posterior occlusion

Laboratory findings :
- PT
: 12.1
(9-13)
second
- INR
: 1.10
(0.84-1.16)
second
- APTT : 23.2
(12.7-32.7)
second
- Hb
: 13.8
M(13.5-17.5)
g/dL
- Ht
: 41
M(40-52)
%
- WBC
: 26,800
(4,400-11,300)
/mm3
- RBC
: 4.54
M(4.5-6.5)
million/uL
- Platelete : 303,000 (150,000 450,000)
/mm3

Blood gas analyzed

-

pH
: 7.473
M: 7.34-7.44
PCO2
: 33.1
M: 35-45
PO2
: 137.0
M: 69-116
HCO3
: 24.0
22-26
TCO2
: 45.8
22-29
Base Excess
: 1.4
(-2) (+3)
Oxygen Saturation : 99.0
95-98

mmol/L
mm Hg
mm Hg
mEq/L
mEq/L
mEq/L
%

Chest X-ray

Impression:
No sign of cardiomegaly
No sign of fracture

Skull X-Ray

#
#
#

#
#

Impression :
Complex fracture of left zygoma
Fracture of right orbital rim inferior aspect
Fracture of left orbital rim inferior aspect
Fracture of nasal
Susp. Fracture of left condyle

Cervical X-Ray

Impression :
within normal limit

Manus and Pedis X-Ray

Impression :
Fracture oblique of left metatarsal manus
Fracture incomplete of left phalanx distal digiti 1 pedis

CT Scan
#

Impression :
blow out of left orbital rim fracture

NeuroSurgeryDeptStatus
A:
Mild HI + SBF anterior + lacerated wound at region frontal +
lacerated wound of left zygoma region + lacerated wound of left
pedis region + closed fracture of left metacarpal
P:
Observation GCS + TNSR
Head Up 30o
Nasal canule 2-4 LPM
IVFD NaCl 0.9% 1500 cc/day
R/ Ceftriaxone inj 1x1g IV
Ranitidine inj 2x50 mg IV
Ketorolac inj 2x30 mg IV
Cervical, thorax, pelvis, pedis X-ray

OrthopedicDeptStatus
A:
Closed fracture chipping based metatarsal digiti 3 at left foot +
Closed fracture of left 3rd metacarpal oblique displaced
P:
Elastic bandage + wood splint
Suturing primer
Anterior splint

Assesment:

Mild HI + SBF anterior

Complex fracture of left zygoma + blow out of left orbital rim
fracture + Fracture of right orbital rim inferior aspect +
Fracture of left orbital rim inferior aspect + Fracture of nasal +
Susp. Fracture of left condyle
Lacerated wound of forehead region and left of cheek region
Closed fracture of left 3rd metacarpal oblique displaced +
suspect fracture around left foot

Treatment

Waters x-ray
Injection of ATS-TT
Wound debridement
Resuturing of lacerated wound EO

Suggestions :

Plan to perform panoramic x-ray

Oral Hygiene Instructions
Reguler diet
Mouth rinse with Povidone Iodine gargle every after meal
Application of Chloramphenicol zalf at post suturing EO
Plan to perform elective ORIF under general anasthesia by OMFS
Suture removal at OMFS department at POD VII (March 25 th 2016) in office hour
Plan to consult ophthalmology dept.
Another therapy according General surgery, Neuro Surgery, Orthopedic Dept.
The patient will be follow up at ward
Force Discharged,
Asri Arumsari, drg., Sp. BM (K) / Nurul Ramadhanty,

drg.

Post Debridement

Post Treatment

Team on duty
1st Chief on duty
2nd Chief on duty
Senior on duty
Junior on duty

: Nurul Ramadhanty, drg.

: Heinz F. Simanjuntak, drg.
: Adria Putra, drg.
Fajar Rezandaru, drg.
: Nyoman Ayu Anggayanti, drg.
Puji Yuli Christiani Purba, drg.
Riki Indra Kusuma, drg.
Jessica Weynata, drg.

Emergency Report
Friday, March 18th 2016

Reffered from Majalaya Hospital

Name
: Yadi Mulyadi
Sex
: Male
Age
: 17 years old
Address
: Ebah Area, Majalaya
Religion
: Moslem
Status
: Not Married
Medical Rec No. : 0001513636
Time of arrival : 18.10 PM
Phone Number : 085294184810

PS : Bleeding from mouth

S:
A 17 yo male patient referred from Majalaya Hospital with
bleeding from mouth. 9 hours prior to admission, when he was
riding a motorcycle with medium speed at Majalaya area. While
he was turn right suddenly he was hit by another motorcycle
from behind and fell down with unknown mechanism. History of
using helmet (-). History of unconsciousness (+) 30 minutes,
nausea and vomitting (-), bleeding from mouth (+), bleeding from
ear and nose (-). Then he was brought to Majalaya Hospital at
Majalaya area and was perform infusion, oxygenation and
situational sutured at right forehead region. Then the patient was
referred to Hasan Sadikin Hospital emergency department.

Primary survey
A : Clear
B : Symmetrical shape and movement, VBS R=L , R : 20 x/min
C : T: 120/80 mmHg,
P : 88 x/min,
D : GCS 15 (E4M6V5) Pupils round equal ODS 3 mm
light reflex (+/+), motoric : No paresis
Secondary Survey
Within normal limit

General status :
Skin
Head

: Turgor (+)
: Asymmetrical face, oedema at right temple and
forehead
Eye : Non anemic conjunctiva, non icteric sclera
Neck
: JVP not increased
Submandible lymphe 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
Hepar/Lien: not palpable
Extremity : Warm, cyanosis -/-, edema -/-, CRT < 2

Local status :
Extra Oral :
Asymmetrical face, oedema and abbrasive wound at forehead
with 3 x 0,5 cm in size and oedema and post sutured at right
forehead region with 3 cm in size
Lacerated wound at Nasolabial 3 x 0,5x 0,5 cm. in size ,irregular
edge, muscle based
Lacerated wound at mentale 5 x 0,2 x 0,3 cm in size, irregular
edge, muscle based

Intra Oral :
Lips
: Lacerated wound at upper lip with 1x0,5x0,3
cm in size, irregular edge, bone based,
Abrasive
wound at upper and lower lip
Vestibule
: Lacerated wound at vestibule of upper lip at
teeth 11- 21 with 0.5x0.2x0,3 cm in size,
irregular edge, muscle based
Gingival
: Abrasive wound at gingiva of teeth 31-43
Palate
: within normal limit
Buccal mucosa : within normal limit
Tongue
: within normal limit
Floor of the mouth : within normal limit
Tonsils
: T1-T1

Odontogram

UE

CP

8 7 6 5 4 3

1 1 2 3 4 5 6 7 8

8 7 6 5 4 3

1 1 2 3 4 5 6 7 8

UE

UE

UE

Intact Occlusion (+)

Calculus (+)

Laboratory findings:

PT
APTT
INR
Hb
Ht
WBC
RBC

Platelet : 347.000
(150.000-450.000) /mm3
SGOT : 20
< 37
U/L
SGPT : 8
< 41
U/L
Ureum : 25
15-50
mg/dL
Creatinine : 0,92
M 0.7-1.2
mg/dL
Random Blood Glucose : 130 < 140
mg/dL
Sodium : 137
135-145
mEq/L
Potassium : 4,2
3.6-5.5
mEq/L

: 10,9
(9-13)
: 21,6
(12,7-32,7)
: 1,00
(0,84-1,16)
: 12,2
M: (13,5-17,5)
: 40
M: (40-52)
%
: 20.600
(4.500-13.000)
: 6,09
M: (4,5-6,5)

second
second
second
g/dL
/mm3
million/uL

Chest X-ray

Impression : Within Normal Limit

Skull AP Lat X-ray

Impression : Open fracture deppresed at right temporal

Cervical X-ray

Impression : Within Normal Limit

Neuro Surgery Departement Status

A:
- Mild HI + Open fracture deppresed < 1 tabula at right temple
- Lacerated wound at right frontalis
Treatment :
- Observation of vital sign
- Head up 300
- O2 with nasal canule 3L/minute
-

Infusion of NaCl 0,9% 1500cc/24 hour

R/ Ceftriaxone inj 1gr iv
Cetorolac inj 30 mg iv
Ranitidine inj 50 mg iv
Skull AP laretal, Chest, Cervical X-Ray
Debridement + resutured at right frontalis region
Rhonas,dr / Bilzardy,dr.,Sp. BS

General Surgery Departement Status

A:
- Mild HI + Open fracture deppresed < 1 tabula at right temple
- Lacerated wound at right frontalis
Treatment :
- Thoracoabdominal currently within normal limits
- There was no special treatment from our deptartement

Boby,dr / Tommy R,dr.,Sp.B-KBD

Assesment:

Mild HI + Open fracture deppresed < 1 tabula at right temple +

lacerated wound at right frontalis
Lacerated wound at Upper lip et sulcus nasolabialis et Mentale
et vestibule of teeth 11-21

P : Treatment
Injection of ATS TT
Necrotomy debridement
Suturing at Lacerated wound IO + EO

Suggestions :

Oral Hygiene Instructions

Reguler diet
Mouth rinse with povidon iodine after every meal
Application of hyaluronic acid gel at post suturing IO
Application chloramphenicol zalf at post suturig EO
Plan to perform scalling at dental clinic periodontia department in office hour
Plan to perform dental filling of tooth 14 at conservation departement in office
hour
Control to OMFS department on Sunday 20th of march 2016
Suture removal at OMFS department POD VII (26 th 2016) at office hour
Discharged,
Nurul, drg/Asri Arumsari,drg.,Sp.BM

Post Debridement

Post Treatment

Team on duty
1st Chief on duty
2nd Chief on duty
Senior on duty
Junior on duty

: Nurul R, drg
: Heinz, drg
: Adria P, drg
Fajar R, drg
: Riki Indra, drg
Puji Yuli C, drg
Anggayanti, drg
Jessica W, drg

Emergency Report
Monday, March 21st 2016

Referred from Garut Hospital

Name
: Andri Muhammad Sayuti
Sex
: Male
Age
: 16 years old
Address
: Garut
Religion
: Moslem
Medrec No.
: 1600008980 / 0001524916
Time of admission
: 01.00 AM
No. Telp
: 08170817878

Ps: Bleeding from mouth

S:
A 16 y.o male patient referred from Garut Hospital with
bleeding from mouth. 12 hours prior to admission, when
the patient was riding a motorcycle at Garut area with
medium speed, suddenly came another motorcycle from
the opposite direction and hit him so he lost his balance
and fell down with unknown mechanism. Helmet (-)
,history of unconsciousness (+) about 15 minutes, nausea
and vomiting (-), bleeding from mouth (+), bleeding from
nose and ear (-). Then the patient was taken to Garut
Hospital, the patient got wound debridement and
situational suturing at lower lip. Then the patient referred
to Hasan Sadikin Hospital Emergency Department.

Primary Survey
A
B
C
D

: Clear with c spine control

: Symmetrical shape and movement, RR: 21 x/min
: BP: 120/80 mm Hg P: 85 x/min
: GCS 14 (E3M6V5) round pupil isokor 3mm, ODS: LR
+/+, Parese -/-

Secondary Survey
- Lacerated and abrasive wound at right calf
- Abrasive wound at left knee

General Status
Skin : Turgor (+)
Head : Asymmetrical face, edema and hematoma at
left cheek region, chin region, and both of periorbita region.
Eyes : Pupils round equal ODS 3 mm, light reflex (+/+),
motoric : no paresis, no anemic conjunctiva,
no icteric sclera, subconjungtival bleeding at left eye
Neck : JVP did not increase, submandible lymph node
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 (+) N
Hepatic & Lien : not palpable
Extremity : Warm, CRT <2

Local Status
Extra Oral :

Asymmetrical face, edema and hematoma at left cheek region, chin

region, and both of periorbita region.
Lacerated wound at left palpebra with 0,5x0,5x0,3 cm in size,
irregular edge, muscle based.
Post suturing at lower lip with 5cm in size

Intra Oral :
Lips : -Lacerated wound at upper lip with 1,5x1x0,5 cm in
size, irregular
edge, muscle based
-Post suturing at lower lip with 5 cm in size
Vestibulae : Lacerated wound at vestibulae of teeth 25-27 with 4x2x2 cm in
size, irregular edge, muscle based
Gingiva: Lacerated wound at gingival teeth 32-33 with 0,2x0,2x0,2 cm in size,
irregular edge, bone based
Floor of mouth : Edema and hematoma at floor of mouth
Tongue : Within normal limit
Buccal mucosa : Within normal limit
Palate : Within normal limit
Tonsil : 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

UE

GP
#
Occlusion (-)

UE

Laboratory findings :

PT :11,9
(8,9 12,9) second
INR:1,08
(0,83-1,16) second
APTT :24,6
(20-40) second
Hb : 10,4 M(13,5-17,5)
g/dL
Ht
: 31 M(40-52) %
WBC
: 14.400 (4.500-13.000) /mm3
RBC
: 3,44 M(4,5-6,5) million/uL

Platelet : 216.000
(150.000-450.000)/mm3
Ureum : 47 (15-50) mg/dL
Creatinine : 0.81 (M: 0.7-1.2) mg/dL
AST (SGOT)
: 45
(<37)U/L 37 C)
ALT (SGPT) : 19
(<41)U/L 37 C)
Random Blood Glucose : 134 < 140 mg/dL
Alfa Amilase: 48
28-100 U/L 37 C
Lipase : 10,9 13-60 U/L 37 C
Sodium (Na)
: 138
(135-145) mEg/L
Potassium (K) : 3,9
(3.6- 5.5) mEg/L

Chest X - Ray

Impression :
- No visible of cardiomegaly
- No visible of traumatic wet lung or lung contusion
- No visible of fracture on the costae, scapulae, clavicle

Skull PA-Lat X - Ray

#
#
#

Impression : -Fracture of le fort II

-Fracture of left zygoma
-Suspect Fracture of bilateral condyle
-Fracture of symphysis of mandible

Waters X-Ray

#
#

Impression : -Fracture of le fort II

-Fracture of left zygoma
-Fracture of symphysis of mandible

Cervical X - Ray

Impression : within normal limit

USG FAST

Impression : No collection of free fluid in hepatorenal space

No collection of free fluid in splenorenal space
No collection of free fluid in posterior vesica urinaria

Neuro Surgery Dept Status

A:
Mild HI
P:
Observation vital signs & GCS
Head Up 30o
O2 3 L with nasal canul
Complete blood count, PT-APTT
R/ Ceftriaxone inj 2x1 g IV
Ketorolac inj 2x30 mg IV
Ranitidine inj 2x50 mg IV
IVFD NaCl 0.9% maintenace 1500 cc/ 24 hours

dr. Agung Budi , Sp.BS,Ph.D

General Surgery Departement Status

A: -Open fracture of right tibia comminuted displaced middle 3 rd
-Closed fractre of right fibula comminuted displaced middle 3 rd
-Fracture of le fort II
-Fracture of left zygoma
-Fracture of bilateral condyle
- Fracture of symphysis of mandible
-Currently there is no sign of emergency in thoracoabdominal
P: Currently there is no special treatment from our department

Alex,dr/Avit, dr.,Sp.B

Orthopaedics and Traumatology

Status

Dept

A:
-Open fracture of right tibia comminuted displaced middle 3 rd
-Closed fractre of right fibula comminuted displaced midle 3 rd
P:
Analgetic, antibiotic,ATS, TT
Cruris, Cervical, Chest, Pelvis and Ankle X-ray
Wound cleansing and immobilization with wood splint

dr. Achmad R , Sp.OT

Ophthalmology Dept Status

A:
-Lacerated wound at upper left palpebra
-Abrasive wound at lower left palpebra
-Subconjungtival bleeding at left eye
P:
Cold compress at left eye
The patient will be evaluate for given of metyl prednisolon IV

dr. Bambang, Sp.M

Assessment :
- Mild HI
-Fracture of le fort II + Fracture of left zygoma + Fracture of
bilateral condyle + Fracture of symphysis of mandible +
Lacerated wound at upper lip + Post suturing at lower lip +
Lacerated wound of vestibulae of teeth 25-27 region+ Lacerated
wound at gingival teeth 32-33
- Subconjungtival bleeding at left eye
- Lacerated wound at left upper palpebra
-Open fracture of right tibia comminuted displaced middle 3rd
-Closed fractre of right fibula comminuted displaced middle 3rd

OMFS Therapy:

Waters X-Ray
Wound Debridement
Suturing at lacerated wound IO
Resuturing of lower lip
Interdental Wiring at teeth 37-47

Suggestions :

Plan to perform panoramic X-Ray

Vital Sign Observation

Oral Hygiene Instructions
Soft diet HCHP 1650 kcal/day
IVFD RL maintenance 20 drops/minute
Spooling with Nacl 0,9 % 2x/day
Mouth rinse with povidone iodine gargle every after meal
Application of hyalurnic acid gel at post suturing intra oral
Application of chlorampenicol zalf at post suturing extra oral
Plan to perform ORIF elective under GA by OMFS dept
Plan to filling of teeth 14 in Conservation Dept at Office hour
Plan to extraction of teeth 36 in OMFS department at office hour
Suture removal at POD VII (March,28th 2016) in OMFS department at office hour
The patient will be followed up at ward
Other therapy according to Orthopaedics and Traumatology Dept
Hospitalized,
Abel Tasman, drg., Sp. BM/ Susanti Bulan, drg

Post Debridement

Post Treatment

Refusal Letter
The undersigned below, I named Lilis, 32 y.o female, lived in Garut.
Hereby declare to refused medical treatment Resuturting Lacerated Wound EO from
oral surgery dept.to my children, Andri 16 y.o,male, lived in Garur, medical record
0001524916.
I understand the need for and benefits of such measures as described as above to me,
I am fully responsible for any consequences that may arise as a result of denial of
medical action planned by the doctor.
Bandung, date March 21-3-2016,time 10.30 AM
that state
name and signature
Lilis

Team on duty
1st Chief on duty
: Susanti Bulan, drg
2nd Chief on duty
: Lira Masri, drg
Senior on duty
: Willy Bernadi, drg
Evan Saputro, drg
Junior on duty
: Deka Dharma Putra, drg
Andi Arfandi A, drg
Siti Deinar A, drg
Puji Yuli Christiani, drg

Emergency Report
Monday, March 21st 2016

Referred from Majalaya Hospital

Name : Mr. Lili Ahyari
Sex
: Male
Age
: 64 y.o
Address : Majalaya
Religion : Moslem
Status : Married
Medrec no. : 0001525301 / 1600009103
Time of arrival : 10.50 PM
Phone number : 0851068835425

PS: Unable to close his mouth

S:
A 64 y.o male patient was referred from Majalaya Hospital with
unable to close his mouth. 5 hours prior to admission when the
patient was yawning at his house at Majalaya area, suddenly his
lower jaw locked and he couldnt close his mouth. Then he went
to Majalaya Hospital but nothing was performed there and and the
patient was referred to Hasan Sadikin hospital Emergency
department. History of the same complaint (-) and history of
chewing on one side (+) left side.

O:
Conciousness: CM
VAS: 3/10
Vital Sign
BP : 110/70 mmHg
HR : 78 x /mnt
T : 36,6 C
RR : 18 x/mnt

General status :
Skin
: Turgor (+)
Head : Asymmetrical face, deviation of lower jaw to the
left
Eye : Round pupil equal ODS 3 mm. light reflect +/+
motoric paresis -/Conjunctiva not anemic, sclera not icteric
Neck : JVP not increased
submandible lymph nodes : not palpable, no pain
Chest : Symmetrical shape and movement
Pulmo :VBS right=left, Rh -/-, Wh-/Cor
:Pure regular heart sound, murmur (-)
Abdoment :Soft, flat, bowel sound (+) N
Hepatic & Lien : not palpable
Extremity :Warm, cyanosis -/-, edema -/-, CRT < 2

Local Status
EO : Asymmetrical face, deviation of lower jaw to the left

Intra Oral :

Gingiva
: Generalized hyperemia and oedema
Lips
: within normal limit
Vestibule
: within normal limit
Palate
: within normal limit
Buccal mucosa : within normal limit
Tongue
: within normal limit
Floor of the mouth : within normal limit
Tonsile
: T1-T1

Odontogram

GR GR GR

GR GR

GR

8 7X
6X5XXX
4 3V2V1V V
1V2XX
3 X4VX
5X
6 7 8
8 7X6VX
5V
4 3 2 1 1 2V3 X4XX
5 6 7
GR
GR
GR GP
8
o

3
Oclussion (-),
Calculus (+)

A:
Unilateral TMJ Dislocation

P : Treatment
R/ Eperisone HCl 50 mg PO
Diclofenac potassium tab 50 mg PO
Reposition of TMJ
Application of Head bandage

Suggestions

Plan to perform panoramic X-ray

Oral hygiene instruction
Soft Diet
R/ Eperisone HCl tab 3 x 50 mg
Diclofenac potassium tab 3 x 50 mg
Instruction to not open mouth too wide
Plan to perform scalling at periodontia Dept in office hours
Plan to perform tooth extraction of teeth
13,12,11,21,22,26,35,34,32,31,41,42,43,44,45,47 at OMFS Dept in office
hours
Plan for dental prosthesis at prosthodontics Dept in office hours
Maintain headbandage until POD III Thursday, March 24 th 2016
Discharged
Winarno P., drg., Sp.BM / Irsan, drg.

Post Treatment

Team on duty:
1st Chief on Duty : Irsan K., drg
2nd Chief on Duty : Ronal, drg
Senior on Duty : Jenadi, drg
: Fajar R., drg
Junior on Duty : Idawati, drg
N.A.Anggayanti, drg
Jessica W., drg
Riki, drg

Emergency Report
Tuesday, March 22th 2016
(RSGM)

Name
: M. Syadli Pratama
Sex
: Male
Age
: 39 years old
Address
: Tubagus Ismail Bawah No 7
Religion
: Moslem
Status
: Not Married
Medical Rec No. : 2013-07257
Time of arrival : 9.30 AM
Phone Number : 08998888382

PS : Bleeding from mouth

S:
A 39 y.o patient came with bleeding from mouth. 2 hours prior
to admission, when he was jogging at Dipatiukur area, suddenly
he felt dizzy and fell down with mechanism his mouth hit the
sidewalk first. History of unconsciousness (-), nausea and
vomiting (-), bleeding from mouth (+), bleeding from ear and
nose (-). Then he was brought to Dental Hospital Padjadjaran
University.

Primary survey
VAS 2/10
A : Clear
B : Symmetrical shape and movement, VBS R=L , R : 19x/min,
C : BP: 120/80 mmHg P : 89 x/min
D : GCS 15 (E4M6V5) Pupils round isokhor ODS 3 mm
light reflex (+/+), motoric no paresis

Secondary Survey
Within normal limit

General status :
Skin

: Turgor (+)
Head
: Symmetrical face
Eye
: Non anemic conjunctiva, non icteric sclera.
Neck
: JVP not increase,
Submandible lymphe 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
Hepar/Lien: Not palpable
Extremity : Warm, cyanosis -/-, edema -/-, CRT < 2

Local status :
Extra Oral :
Symmetrical face
Abrasive wound at left chin 3x4 cm in size

Intra Oral :
Lips
irregular
Gingiva

Tongue
Vestibule
Palate
Buccal mucosa
Floor of mouth
Tonsils

: Multipe lacerated wounds at upper lip 0.3x0.3x0.3

cm in size, lower lip 1x0,3x0,3 cm in size
edge, muscle based
: Lacerated wound at gingival of teeth 12-23 with
4x0,3x0,2 cm irregular edge bone based
: Within normal limit
: Within normal limit
: Within normal limit
: Within normal limit
: Within normal limit
: T1-T1

Odontogram
# dentoalveolar

# 1/ 3
Crown

Avuls
ion

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

# 1/ 3
# 2/ 3
Crown
Crown
+ 3

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

Intact occlusion

Panoramic X-Ray

Impression: Dentoalveolar fracture of teeth 12-23

A:
Dentoalveolar fracture of teeth 12-23 with avulsion of
tooth 11 and mobility grade 3 of teeth 21, 22 and 1/3
crown fracture of teeth 12,22 and 2/3 crown fracture of
tooth 23
Lacerated wound at gingival of teeth 12-23, upper lip,
and lower lip

P : Treatment
Panoramic x-ray
R/ Ciprofloxacin caps 2 x500 mg PO
Natrium diclofenac tab 2x50 mg PO

Debridement
Extraction of teeth 22, 23
Alveolectomy at teeth 11, 22-23 region
Suturing at lacerated wound IO

Suggestions :
Oral Hygiene Instructions
Regular diet
R/ Ciprofloxacin caps 2 x500 mg PO
Natrium diclofenac tab 2x50 mg PO
Mouth rinse with povidon iodine gargle after every meal
Application of Hyaluronic acid gel at post suturing IO 2x/day
Application of chloramphenicol zalf at abrasive wound EO 2x/day
Control at POD I (March 23th ,2016) at OMFS Minor Clinic at office hour.
Suture removal at OMFS Minor Clinic at POD VII (March 29th ,2016) at office
hour.
Discharged
Mantra., drg., Sp. BM / Yudi, drg.

Post Debridement

Post Treatment

Letter of Refusal Treatment

After getting explanation from oral surgeons, hereby I declare refusal of
interdental wiring, to my self, named M. Syadli, 39 y.o male, lived in
Tubagus Ismail Bawah No 7
Medical Record Number 2013-07257
I understand the need for and benefits of such measures as discribed as above
to me, and fully responsible for any consequences that may arise as a result of
denial of medical action planned by the doctor
Bandung, Tuesday March 22th , 2016

Syadli

Team on duty:
1st Chief on Duty
: Yudi, drg
2nd Chief on Duty
: Farah, drg
Senior on Duty
: Sabella , drg
Annisa Muharty, drg
Junior on Duty
: Deka ,drg
Yossi Y., drg
Jihad , drg
Yohanes H., drg

Emergency Report
Tuesday, March 22nd 2016

Referred from Cibabat General Hospital

Name
: Agung Hidayat
Sex
: Male
Age
: 4,5 years old
Address
: Pangkalan village
Religion
: Moslem
Medrec No.
: 1525629/1600009191
Time of admission
: 05:39 PM
Phone Number
: 085811679550

Ps: Bleeding from mouth

S:
A 4,5 y.o boy patient came with bleeding from mouth. 1 hour
prior to admission, when the patient was playing at a mosque yard in
Ngamprah area, suddenly he slipped and fell down with mechanism
his face hit the ground first. History of unconsciousness (-), nausea
and vomiting (-), bleeding from mouth (+), bleeding from ear and
nose (-). Then the patient was taken to public health center at
Ngamprah area, no treatment was performed. Then he was referred
to Cimareme hospital and no treatment was performed, he was then
referred to Cibabat hospital, no treatment was performed. Then the
patient was referred to Hasan Sadikin Hospital Emergency
Department. History of complete immunization (+)

Primary Survey:
VAS : 3/10
A
B
C
D

: Clear
: Symmetrical shape and movement, RR: 29 x/min
: P: 113 x/min
: GCS 15 (E4M6V5) round pupil isokor 3mm, ODS: LR
+/+, Parese -/-

Secondary Survey:
Within normal limit

General Status
Skin : Turgor (+)
Head : Asymmetrical face, oedema and hematome at
frontal region, oedema and hematome at left
periorbital, multiple
abrasive wound at facial region
Eyes : Non anemic conjungtiva, non icteric sclera
Neck : JVP did not increase, submandible lymph node
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 (+) N
Hepatic & Lien : not palpable
Extremity
: Warm, CRT <2

Local Status
Extra Oral :

Oedema and hematome at frontal region, oedema and

hematome at left periorbital
Multiple abrasive wound at facial region

Intra Oral :
Tongue
: Punctured wound at dorsal region of tongue
with 2,5 cm x 1 cm, irregular edge
Lips
: Oedema and hematome at upper lip
Palate
: Hematome at hard palate region
Floor of mouth : Within normal limit
Gingiva
: Within normal limit
Vestibule
: Within normal limit
Buccal mucosa : Within normal limit
Tonsil
: T1-T1

Odontogram
CP

CM CM

CM

V
IV III II I

I II III IV
V

V IV III II I

I II III IV V

CP CP

GP

Intact occlusion

Laboratory findings :
Hematology

PT : 12,1 (9,2-13.2) second

INR: 1,06 (0.84-1,16) second
APTT : 23,0 (12,7-32,7) second
Hb : 11,7 (11,5-13,5) g/dL
Ht : 34
(24-30) %
WBC
: 28.300 (5.500-15.500) /mm3
RBC
: 4,53 (3,95-5,26) million/uL
Platelet : 437.000
(150.000-450.000) /mm3

Chemical blood component

SGOT : 27 <37 U/L 37C
SGPT : 9 < 41
U/L 37C
Ureum : 39 (15-50)
mg/dL
Creatinine : 0.37 (0.31-0.47) mg/dL
Alfa Amilase: 130
28-100 U/L 37C
Random blood glucose : 129
(<140) mg/dL
Sodium (Na) : 139
(135-145) mEq/L
Potassium (K) : 4.0
(3.6- 5.5)
mEq/L

Chest X-Ray

Impression: Within Normal Limit

Skull AP-Lat X-Ray

Impression: within normal limit

Cervical X-Ray

Neuro Surgery Department Status

A:
Mild Head Injury
P:
- Observation of vital sign
- Routine blood count, PT-APTT
- Head up 30 degrees
- O2 2L/m via nasal canule
- IVFD NaCl 0,9% 500 cc/24 hours
- R/ Ceftriaxone inj 300 mg IV
Ranitidine inj 25 mg IV
Ketorolac inj 10 mg IV
- Cervical x-ray, Skull AP-Lat x-ray, Chest x-ray
- Conservative treatment
Respectfully,
dr. Yogi Rosbianto/ dr. Selvy Oswari, Sp.BS

A:
Mild Head Injury
Punctured wound at dorsal and ventral region of tongue

P:
Treatment :

Injection of ATS, TT
R/ Diazepam rectal 10 mg supp
Wound Debridement
Suturing at punctured wound IO

Suggestions :

Oral Hygiene Instruction

Soft diet
R/ Amoxicillin syr 125 mg 3 x 2 cth PO
Paracetamol syr 120 mg 3 x 2 cth PO
Application of Hyaluronic acid gel at post suturing IO
Application of chloramphenicol zalf at abrasive wound EO
Plan to perform teeth extraction of 51,54,55,64,74,84,85 at pedodontic
department at office hour
Plan to perform dental filling of teeth 52,53,62 at pedodontic department at office
hour
Control at POD I March, 23th 2016 at OMFS department at office hour
Suture removal at POD VII March, 29 th 2016 at OMFS department at office hour
Discharged
Seto Adiantoro,drg., Sp.BM /Yudi Wijaya, drg.

Post Debridement

Post Treatment

Team on duty
1st Chief on duty : Yudi Wijaya, drg
2nd Chief on duty : Farah Asnely, drg
Senior on duty : Annisya Muharty, drg
Sabella T, drg
Junior on duty : Yossy Y, drg
Jihad Harun S, drg
Deka Dharma P, drg
Yohanes H, drg

Emergency Report
Wednesday, March 23rd ,2016

Referred From Private Hospital

Name
: Noviandi Anggara
Sex
: Male
Age
: 26 years old
Address
: Jakarta Street, Kebun Waru
Religion
: Moslem
Medrec No.
: 1525673
Time of admission
: 06.09 AM
Phone Number
: 081313220566

Ps: Bleeding from mouth

S:
A 26 y.o male patient came with bleeding from mouth. 7 hours
prior to admission, when the patient was riding a motorcycle under
influence of alcohol with medium speed at Riau street area,
suddenly came another car from the opposite direction with medium
speed so that the patient lost his balance and fell down with
mechanism his chin hit the asphalt first. History of using helmet (+)
half face, history of unconsciousness (-), nausea and vomiting (-),
bleeding from mouth (+), bleeding from ear and nose (-). Then the
patient was taken to Private Hospital in Dago area and was given
anti tetanus injection (ATS and TT), and some medications
(ketorolac, ranitidine, and ceftriaxone injection), wound toilet and
bandages at right leg. Then the patient was referred to Hasan Sadikin
Hospital Emergency Department.

Primary Survey
VAS : 4/10
A : Clear, with C-spine control
B : Symmetrical shape and movement, RR: 16 x/min
C : BP: 110/70 mm Hg P: 90 x/min
D : GCS 15 (E4M6V5) pupils round isokhor 3mm ODS
Light Reflex (+/+), Motoric : No parese

Secondary Survey
Deformity and lacerated wound at right leg

General Status
Skin : Turgor (+)
Head : Asymmetrical face, Lacerated wound at right eyelid
and chin region
Eyes : Non anemic conjunctiva, non icteric sclera
Neck : JVP not rising, submandible lymph node
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 (+) N
Hepatic & Lien : not palpable
Extremity
: Warm, CRT <2, deformity and multiple lacerated
wound at right lower leg

Local Status
Extra Oral :
Asymmetrical face
Lacerated wound at right eyelid with 2,5 x 1,5 x 1cm in size, and
chin region 1 x 1 x 0,5 cm in size, irreguler edge, muscle based
Abrassive wound at right cheek region 5 x 2 cm

Intra Oral :
Lips

: Oedem and hematome at lower lip

Lacerated wound at lower lip, 2 cm x 1 cm x 1 cm in
size, irregular edge, muscle based
Gingiva
: Lacerated wound at tooth region of 11-14 with 3 x 1 x
0.3 cm in size, irregular edge, bone based
Vestibule
: Within normal limit
Palate
: Within normal limit
Buccal mucosa : Within normal limit
Tongue
: Within normal limit
Floor of mouth : Within normal limit

Tonsil

: T1-T1

Odontogram
# dentoalveolar with mob o2
UE

UE

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

UE
Intact occlusion

UE

Laboratory findings :

PT
: 10,6
(9.2-13.2)
second
INR
: 0,94
(0.84-1.16) second
APTT
: 18,0
(12.7-32.7) second
Hb
: 13,2
M(13.5-17.5) g/dL
Ht
: 39
M(40- 52)
%
WBC
: 24.300
(4400-11.300) /mm3
RBC
: 4.28
M(4.5-6.5)
million/uL
Platelet
: 239.000
(150.000-450.000) /mm3
SGOT
: 98
<37
U/L 37oC
SGPT
: 60
<41
U/L 37oC
Ureum
: 27
(15-50)
mg/dL
Creatinine
: 1.3
(M: 0.7-1.2) mg/dL
Alfa Amilase
: 48
(28-100)
U/L 37oC
Lipase
: 11.6
(13-60)
U/L 37oC
Random blood glucose : 117
(<140)
mg/dL
Sodium
: 144
(135-145)
mEq/L
Potasium
: 4.2
(3.6- 5.5)
mEq/L

Chest X ray

Impression: No sign of cardiomegaly

No sign of liquid collection
No sign of fracture

Skull X-Ray

Impression Fracture of dentoalveolar teeth region of 11-12

Cervical X Ray

Impression : Within normal limit

Orthopaedic Dept Status

A:
Open Fracture of right tibia middle 3rd
Open Fracture of right fibulae middle 3rd segmental displaced

P:
Treatment :
Complete blood count, PT, APTT
Cervical X-ray, Head X-ray, chest X-ray, Hip X-ray, Thigh X-ray, Right
ankle X-ray
Immobilisation and splint
IVFD NaCl 0.9% 1500cc/day
R/ Fosmycin 2 g in D5% 100cc
Cefazolin 2 x 1 g IV
Ketorolac 2 x 30 mg IV
Plan for emergency surgery
Respectfully,
dr. Dicky M,Sp.OT/ dr. Rahmat

Plastic Surgery Dept Status

A:
Lacerated wound at right upper eyelid
P:
Plan to performed debridement and suturing

Respectfully,
dr. Irra, Sp.BP-RE(K)/ dr. Fitriyanti

A:
Open Fracture of right tibia middle 3rd
Open Fracture of right fibulae middle 3rd segmental
displaced
Fracture of dentoalveolar teeth region of 11-12 with
mobility grade 2 of 11, 12
Lacerated wound at gingiva of teeth region 11-14
Lacerated wound at right eyelid, lower lip and chin
region

OMFS Therapy:
Wound Debridement
Suturing at lacerated wound IO & EO

Suggestions :

Plan to perform Panoramic x-ray

Oral Hygiene Instructions
Spooling IO with NaCl 0,9% 2x/day
Mouth rinse with povidone iodine gargle every after meal
Application of Hyaluronic acid gel at post suturing IO 2x/day
Application of chloramphenicol zalf at post suturing EO 2x/day
Suture removal POD VII on March, 30th 2016 at OMFS dept at office hours
Another therapy according to orthopaedic dept
The patient will be followed up at ward
Hospitalized,

Yudi W, drg./ Seto Adiantoro,drg., Sp.BM

Post Debridement

Post Treatment

Team on duty
1st Chief on duty : Yudi W, drg
2nd Chief on duty : Farah A, drg
Senior on duty : Annisya M, drg
Sabella T, drg
Junior on duty : Yossy Y, drg
Deka D, drg
Jihad H, drg
Yohanes H, drg