Morning Case Report

Thursday, December 16th 2021

Oral & Maxillofacial Surgery Department
Hasan Sadikin General Hospital
Bandung
No Ruangan Total Pasien Total Pasien Total Pasien
Operasi Emergensi Follow Up
1. Kana 1 3 pasien 0 pasien
4 pasien
2. Asnawati 3
3. Fresia II 2
4. RIK III 1

TOTAL (7)
 Operation Thursday, December 16th 2021
No Supervisor Operation
1. Winarno Priyanto, drg., Sp.BM(K) • Plan to perform Partial
glossectomy + Frozen margin
section + Frozen section diagnostic
join op Oncology surgery
• Plan to perform Fistula repair +
Rhinoplasty
• Plan to perform Odontectomy
18,28,38,48
PRE OP
 1. Yati Haryati/M/43 y.o/0446258/21120556/RIK 3 (324)
Date of admission : 15/12/2021 Cell Phone No : 08121052757
Pre Op
Supervisor: Winarno Priyanto, Sp.BM(K)
•Diagnose : Soft tissue tumor at tongue region
•Treatment : Plan to perform Partial glossectomy + Frozen margin section +
Frozen section diagnostic join op Oncology surgery
department/Operation on today, Thursday, December 16th 2021 at COT 311 (I)
•Ass Op. I  : , drg
•Ass Op. II : , drg
•Objective :
Date 15/12/21 16/12/21

BP
(mmHg) 110/70 120/70
P
(x/minute) 82 88
R
(x/minute) 21 20

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 15/12/21
PCR SARS CoV2 Negative
Laboratory
Findings HEMATOLOGY 08/12/21
Hb 12.4
Ht 36.1
WBC 4.30
RBC 4.47
Platelet 152,000
PT 13.0
APTT 34.80
INR 0.92
Timely Glucose 93
SGOT 17
SGPT 17
Ureum 30.0
Creatinine 0.62
Natrium 139
Kalium 3.9
Profile Photo
Intra Oral
 Chest X – Ray
(Hasan Sadikin General Hospital, Desember 08th 2021)
 USG Colli
(Hasan Sadikin General Hospital, December 08th 2021)
 2. Ayunda/F/7 y.o/1405616/21120557/Kana (2.1)
Date of Admission : 15/12/2021 Cell Phone No: 087808753909
Pre Op
Supervisor: Winarno Priyanto, Sp.BM(K)
• Diagnose : Post palatoplasty fistula + Gnatoschizis
• Treatment : Plan to perform Fistula repair + Rhinoplasty/Operation on
today, Thursday, December 16th 2021 at COT 405 (I)
• Ass Op. I  : , drg
• Ass Op. II : , drg
• Objective :
Date 15/12/21 16/12/21
BP
(mmHg) 105/70 120/70
P
(x/minute) 82 88
R
(x/minute) 20 20

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 15/12/21
PCR SARS CoV2 Negative
Laboratory
Findings Hb
HEMATOLOGY 22/11/21
13.3
Ht 41.4
WBC 7.31
RBC 5.14
Platelet 352,000
PT 14.0
APTT 37.60
INR 1.26
Timely Glucose 94
SGOT 35
SGPT 26
Ureum 17.0
Creatinine 0.38
Natrium 136
Kalium 5.2
Profile Photo
Intra Oral
 Chest X-ray
(Hasan Sadikin General Hospital, November 22 nd
2021)
 3. Sandi Lesmana/M/24 y.o/0411770/21120555/Asnawati(2.2)
Date of Admission : 15/12/2021 Cell Phone No: 085100587140
Pre Op
Supervisor: Winarno Priyanto, Sp.BM(K)
• Diagnose : Impacted of teeth 18,28,38,48
• Treatment : Plan to perform Odontectomy of teeth 18,28,38,48/Operation
on today, Thursday, December 16th 2021 at COT 405 (II)
• Ass Op. I  : , drg
• Ass Op. II : , drg
• Objective :
Date 15/12/21 16/12/21
BP
(mmHg) 105/70 120/70
P
(x/minute) 82 88
R
(x/minute) 20 20

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 15/12/21
PCR SARS CoV2 Negative
Laboratory
Findings Hb
HEMATOLOGY 08/12/21
17.6
Ht 50.8
WBC 6.17
RBC 5.86
Platelet 277,000
PT
APTT
INR
Timely Glucose 79
SGOT 19
SGPT 24
Ureum 20.0
Creatinine 0.96
Natrium 135
Kalium 4.4
 Chest X-ray
(Bandung Health Laboratory November 25 th 2021)
 Panoramic X-ray
(Bandung Dental Hospital, November 8th 2021)
 4. Enok/F/62 y.o/1951201/21120558/Fresia II (9.3)
Date of admission : 15/12/2021 Cell Phone No : 085220715011
Pre Op
Supervisor: Seto Adiantoro, Sp.BM(K)
• Diagnose : Soft tissue tumor at tongue region suspected Malignan dd/
SCC
• Treatment :
• Ass Op. I  : , drg
• Ass Op. II : , drg
• Objective : Date 15/12/21 16/12/21

BP
(mmHg) 110/70 120/70
P
(x/minute) 82 88
R
(x/minute) 21 20

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 15/12/21
Antigen SARS CoV2 Negative
Laboratory
Findings Hb
HEMATOLOGY 30/11/21
9.5
Ht 25.5
WBC 7.49
RBC 2.93
Platelet 423,000
PT 12.7
APTT 28.90
INR 0.90
Timely Glucose 99
SGOT 50
SGPT 48
Ureum 16.0
Creatinine 0.34
Natrium 129
Kalium 2.9
Profile Photo
 Chest X – Ray
(Hasan Sadikin General Hospital, November 30th 2021)
Intra Oral
POST OP
 5. Tedi/M/31 y.o/1977950/21120553/Asnawati (2.7)
Date of Admission :14/12/2021 Cell Phone No: 082216870211
POD I
Supervisor: Melita Sylviana, drg., Sp.BM(K)

• Diagnose : Post Refracturing + ORIF on indication of Le Fort 1 Fracture +

Left tetrapod fracture + Left mandible corpus fracture + Left coronoid
fracture
• Ass Op. I  : Deny Rakhman, drg.
• Ass Op. II : Bambang Hudiworo, drg.
• Objective : Date 14/12/21 15/12/21

BP
(mmHg) 110/80 120/70
P
(x/minute) 82 88

R
(x/minute) 22 24

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 14/12/21
PCR SARS CoV2 Negative
Laboratory HEMATOLOGY 26/12/21
Findings Hb 11.8
Ht 36.3
WBC 9.67
RBC 4.00
Platelet 501,000
PT 12.7
APTT 30.00
INR 0.86
Timely Glucose 99
SGOT 27
SGPT 61
Ureum 11.3
Creatinine 1.08
Natrium 138
Kalium 4.2
Profile Photo
Intra Oral Photo
 Chest X-ray
(Hasan Sadikin General Hospital, November 10 th
2021)
 Panoramic X-ray
(Hasan Sadikin General Hospital, October 27th
2021)
 Cervical Ap Lateral X-ray
(Hasan Sadikin General Hospital, October 16th 2021)
 Waters X-ray
(Hasan Sadikin General Hospital, October 16th 2021)
 3D Head CT Scan
(Hasan Sadikin General Hospital, November 29th 2021)
Intra Op
POD I
 6. Graha Sabilah/M/20 y.o/1970300/21120552/Asnawati (7.4)
Date of Admission :14/12/2021 Cell Phone No: 085871791957
POD I
Supervisor: Melita Sylviana, drg., Sp.BM(K)
• Diagnose : Post Odontectomy 18, 28, 38, 48 + Extraction of tooth 25
Impacted teeth 18,28,38,48 + Palatoversion of tooth 25 + B20
• Ass Op. I  : Deny Rakhman, drg.
• Ass Op. II : Bambang Hudiworo, drg.
• Objective :
Date 14/12/21 15/12/21 16/12/21

P
(x/minute) 82 88

R
(x/minute) 22 24

T
(°C) 36.6 36.5
Laboratory
Finding
HEMATOLOGY 14/12/21
PCR SARS CoV2 Negative
Laboratory
Findings HEMATOLOGY 29/11/21
Hb 15.4
Ht 46.3
WBC 7.53
RBC 5.36
Platelet 218.000
PT 15.60
APTT 30.80
INR 1.08
Timely Glucose 95
SGOT 40
SGPT 76
Ureum 12.0
Creatinine 0.78
Natrium 140
Kalium 4.5
 Chest X-ray
(Hasan Sadikin General Hospital, November 15th
2021)
 Panoramic X-ray
(Cipadung Medical Clinic, September 4th 2021)
Intra Op
 7. Tarsa/M/47 y.o/2000778/21120554/Fresia II (3.6)
Date of Admission :14/12/2021 Cell Phone No : 082219486762
POD I
Supervisor : Winarno Priyanto, drg., Sp.BM(K)
• Diagnose : Incision drainage at left buccal and left temple region
+ Extraction of teeth 15,16,17,18,25,37,38,46,47,48 on
indication of Left buccal abscess extended to left
temporal due to gangrene pulp of tooth 25 + Chronic
apically periodontitis due to gangrene pulp of teeth
15,18,46,47 and radices of teeth 16,17,36,37,48
• 1st Chief on Duty : Albertin Jane, drg.
• 2nd Chief on Duty : Erza Kurniawan, drg.
• Objective :
Date 14/12/21 15/12/21 16/12/21

BP
130/80 130/80 130/70
(mmhg)
P
81 80 82
(x/minute)
R
20 21 20
(x/minute)
T
36.6 36.7 36.6
(°C)
Laboratory Findings HEMATOLOGY 14/12/21
Hb 15.3
Ht 45.7
WBC 19.49
RBC 5.24
Platelet 381,000
PT 10.5
APTT 26.20
INR 0.93
Timely Glucose 93
SGOT 17
SGPT 31
Ureum 37.0
Creatinine 0.93
Natrium 138
Kalium 4.2
Laboratory Findings
HEMATOLOGY 14/12/21
MRT Sars Cov-2 Negative
Profile Photo
Intra Oral
 Chest X – Ray
(Hasan Sadikin General Hospital, December 14th 2021)
Tapping Pus
Durante Op
Post Treatment
POD I
EMERGENCY
 1. Tarsa/M/47 y.o/2000778/21120554/Emergency Room
Date of Admission :14/12/2021 Cell Phone No : 082219486762
EMERGENCY
Supervisor : Winarno Priyanto, drg., Sp.BM(K)

A 47 years old male patient came with swelling at left cheek region. ± 2 weeks
prior to admission, the patient complained of toothache at left upper jaw region,
but he didn’t seek any treatment. ± 5 days prior to admission, the patient
complained of swelling at left cheek region and he went to private clinic at
Cimahi area and was given 2 kinds of medicine (Lincomisin and Mefenamic
acid). ± 3 days prior to admission the swelling got bigger and extended to the
temporal region and the patient back to the clinic and was given the same
medicine. ± 6 hours prior to admission the swelling got bigger and painful then
he was brought to Hasan Sadikin Hospital Emergency Department for further
treatment History of toothache (+) ± 5 days prior to admission at left cheek
region. History of dental treatment (-). Altered voice (-) hot potato voice (-),
hoarseness (-), neck stiffness (-), History of systemic disease was denied.
• Diagnose : Left buccal abscess extended to left temporal due to
gangrene pulp of tooth 25 + Chronic apically periodontitis
due to gangrene pulp of teeth 15,18,46,47 and radices of teeth
16,17,36,37,48
• Therapy : Incision drainage at left buccal and left temple region +
Extraction of teeth 15,16,17,18,25,37,38,46,47,48 under local anesthesia
• 1st Chief on Duty : Albertin Jane, drg.
• 2nd Chief on Duty : Erza Kurniawan, drg.
• Objective :

Date 14/12/21 15/12/21

BP
130/80 130/80
(mmhg)

P
81 80
(x/minute)

R
20 21
(x/minute)

T
36.6 36.7
(°C)
Laboratory Findings HEMATOLOGY 14/12/21
Hb 15.3
Ht 45.7
WBC 19.49
RBC 5.24
Platelet 381,000
PT 10.5
APTT 26.20
INR 0.93
Timely Glucose 93
SGOT 17
SGPT 31
Ureum 37.0
Creatinine 0.93
Natrium 138
Kalium 4.2
Laboratory Findings
HEMATOLOGY 14/12/21
MRT Sars Cov-2 Negative
Profile Photo
Intra Oral
 Chest X – Ray
(Hasan Sadikin General Hospital, December 14th 2021)
Tapping Pus
Durante Op
Post Treatment
SUPERVISOR ATTENDANCE LIST
THANK
YOU