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Lap Ok RSGM Ronal Huda
Lap Ok RSGM Ronal Huda
Lap Ok RSGM Ronal Huda
RSGM
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: