2.

Tuesday, October 15th 2019 (Unhas Dental Hospital)

Name : Mr. Dian Alif

Sex : Male
Age : 19 y.o
Address : 26th, Halimun Street, Antang, Makassar
Phone number : 082336434554
Status : Single
Medical Record : 04.44.26
Time of Admission : 16.00 PM
Working Time : 180 minutes
PS : Difficult To Open The Mouth
S: The patient was being complaint difficult to opened his
mouth after being hitten ± 5 hours of SMRS. The patient is
heading to class and then called by his seniors, then the patient
is being hitten by his seniors from the bottom left upwards
using his hands as slapped. Then the patient goes to his class
again and starts feeling pain at the mandible, dizziness and
suddenly weakness. The patient was brought over by his friend
to the Barombong Polyclinic and then he was referred to
RSGM UNHAS. The infusion has been installed and has been
given ketorolac. The patient was being surgery in April 2019 at
RSGM Unhas to repair the mandible plate and then wire the
upper and lower teeth.
O:
Vital Signs
Wong Baker Scale : 5/10
Consciousness : Fully alert

BP : 110/70 mmHg
HR : 68 x/minutes
RR : 22 x/minutes
Temp : 36,5 oC
General Status
• Skin : Turgor (+)
• Head : Asymmetric Face
• Eyes : Non anemic conjunctiva, Non icteric sclera
• Neck : JVP did not increase,
right submandible lymph node :
not palpable, no pain
left submandible lymph node :
palpable, soft, 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, no pain
• Extremity : Warm, CRT < 2”
Local Status
Extra Oral :
• Asymmetric Face
• Tenderness in the area periauricular sinistra
Local Status
Intra Oral :

Gingiva : Normal
Vestibule : Normal
Floor of mouth : Normal
Lip : Normal
Buccal mucosa : Normal
Palate : Normal
Tongue : Normal
Tonsil : Difficult to Assessed
OPG X-Ray (October, 15th 2019)
Assessment :

Pain er mandible sinistra ec blunt trauma, post ORIF POD

186
 Treatment
- Panoramic X-ray
- Observation
- Medication :
• R/Ibuprofen 400 mg/ 8 hours / PO
• R/Eperison 50 mg/ 8 jam / PO
Suggestions :
• Soft Diet
• Warm water compress
• Oral Hygiene Instruction
• Control in Dental Hospital on Friday 18 th, October 2019

• Medication:
R/ Ibuprofen 400 mg/ 8 hours / PO
R/ Eperison 50 mg/ 8 jam / PO
 Team on duty

Consultant : A. Tajrin, drg., Sp.BM., M.Kes (K)

Senior on duty : Husnul, drg., Fadli Rum., drg
Junior on duty : Lely, drg., drg, Ochta