PATIENT REPORT

RSCM
Friday, June 17 th 2022
Operation team
◦ Attending Oral and Maxillofacial Surgeon: drg. Wenny Yulvie, SpBM(K)
◦ Sr. Resident: drg. Muskab
◦ Jr. Resident: drg. Rae, drg. Makka
 Identity
◦ Name: Mrs. S
◦ Gender: female
◦ Age: 57 years old
◦ Med. Rec: 458-32-28
◦ Insurance: BPJS
Chief complaint
◦ The patient was referred by ENT Division with pseudo angina Ludovici as the working diagnosis.
History of present illness
◦ A patient was referred by ENT division with pseudo angina ludovici as the working diagnosis. She came
with pain on the neck since five days ago, initially a swelling was appeared on the right part of the chin,
and then it extended to the left part of the chin, it also got bigger as well. She was feeling a fever, when
the swelling appeared. She then visited a clinic a day ago, and prescribed mouthwash and antibiotic. She
only took the medicine once, and she was only able to eat soft food such as porridge since two days ago.
This morning the patient visited ENT at Proklamasi Hospital, she was the referred to Cipto
Mangunkusumo Hospital. History of toothache was over 5 years ago. Now she is feeling pain on her
neck. Complaint of dizziness, nausea, shortness of breath was denied, a complaint of swallowing
difficulty was present. Fluid diet through NGT is good, she was able to sit with assistance but not capable
to stand on her own.
History of past illness
◦ History of hypertension on amlodipine since 2021, history of uncontrolled DM since 2019 on metformin
since 2022.
◦ History of cardiac diseases, asthma, lung diseases, gastritis, allergic to food and medicine were denied.
◦ History of covid-19 or close contact with covid-19 suspects were denied.
◦ History of stroke was present, hospitalized at Mintoharjo Hosital six months ago
General status
Primary survey Secondary survey

◦ General condition: moderate pain, CM ◦ Head: normocephalic

◦ A: clear
◦ B: Spontaneous, RR: 23x/min, SatO2: 97%
◦ C: BP: 167/113 mmHg, HR: 123x/menit
◦ D: GCS 15 E4M6V5
◦ Eye: Conjunctiva non icteric, Sclera non
anemia
◦ Heart: normal, no murmurs or gallop
◦ Lung: vesicular, no rhonchi or wheezing

◦ E: T: 36.7C ◦ Abdomen: Supel, no pain on palpation, bowel

sounds positive, tympani
◦ Extremity: warm acral, CRT < 2 sec.
Extra Oral
Extra Oral
◦ Facial asymmetry was present.
◦ Swelling in the submandibular dextra and sinistra regionextending to colli region sized 12x10x2 cm. hard
consistency, no fluctuation, unclear border, it’s color was redder than surrounding area, it’s temperature
was higher than surrounding area, no ulcus on the surface, pus and blood discharge were denied.
◦ Mouth opening 25 mm
◦ NGT was applied, clampped
Intra oral
Intra oral
◦ Poor oral hygiene
◦ A swelling on 48 region sized 0.5x0.2x0.2 cm, soft consistency, it’s redder than surrounding area, it’s
temperature was higher than surrounding area, food impaction was present, no pus and blood discharge.
◦ Tooth 38 mobility grade 2
◦ Tooth 36, 37 missing
◦ Raised tongue was present
◦ Pus and blood discharge were absent
 Pemeriksan Flag Result Normal Range

Hb 14.1 12.0- 15.0 gr/dL

Ht 41 36.0 – 46.0%

Leu 14720* 4000-10000/µL

Tro 320000 150.000 – 410.000 /µL

PT 10.0(11.6) 9.0-12.6

RSCM Lab. Result APTT

SGOT
33.9 (32.0)

10
31-47

5-34

June, 10th 2022 SGPT

Ureum
13

30
0-55

15-40

Creatinin 0.8 0.55 - 1.08

Natrium 131* 136-145

Kalium 4.4 3.5-5.1

Chloride 91.4* 96 – 107.0

GDS 396*

PCR negatif
Thorax RSCM
June, 10th 2022
◦ Cardiomegaly with aorta
elongation and calcification
◦ No abnormalities in heart and
lungs
Soft Tissue
June, 10th 2022
◦ Soft tissue thickening on
submandibular and prelaryngeal
region which constrict oropharyngeal
to airway approximately 44%
◦ No prevertebral soft tissue thickening
◦ Osteofit formation on the C3-C6
anterior corpus vertebrae
 CT
Nasopharynx/Oropharynx/
Larynx/Neck Contras
June 10th 2022

◦ Sublingual abscess with

extention, no extention to colli
region. Patent airway
◦ Lymphadenopathy colli level
1
◦ Multple thyroid nodul
bilateral
◦ Hipodense lesion on left
cerebellum hemisphere dd/
mega cisterna magna
 Diagnosis
◦ Angina Ludwig ec Impacted 48
◦ Periodontitis 48
◦ Uncontrolled DM
◦ Uncontrolled Hypertension
Treatment plans
◦ General condition and vital signs monitoring
◦ Pro evacuation of focus infection tooth 48, 38 join operation with ENT Div.
◦ Pro Panoramic imaging
◦ Pro Nasal canule 3 lpm if shortness of breath was present
◦ Medication in accordance with ENT
◦ Maintain oral hygiene
 ENT Medication
◦ Captain: ENT
ENT treatment plan:
◦ Consult to Internal medicine dept. for
Hypertension treatment, Diabetes treatment,
operation tolerance and methylprednisolone
medication
◦ Deep neck exploration surgery
◦ ENT Medication :
◦ R/ Ampicilin Sulbactam 4x1.5 gr IV
◦ R/ Methylprednisolone 1x125 mg IV
◦ R/Omeprazole 1x40 mg IV
◦ R/ Ketorolac 3x30 mg IV
Internal Medicine Medication
◦ Blood gas analysis and HBA1C
◦ Liquid diet via NGT 1500 ml
◦ IVFD loading 1000 ml in 2 hours
◦ R/ amlodipine 1x10 mg PO
◦ Back up ICU
◦ Blood sugar level pre operation regulation
Operation tolerance:
◦ Cardiology: mild-moderate
◦ Metabolic: moderate
◦ Pulmonology: moderate
◦ Hematology: mild-moderate
 Anesthesia Operation Tolerance

◦ ASA 3
◦ ACC in Cito condition
◦ GA
◦ Post op ICU
◦ Blood transfusion in accordance with The
surgeons
Intra operation
Post operation
OMFS Post op Instructions ENT post op Instructions
◦ General condition, bleeding and vital signs ◦ General condition and vital signs observation
monitoring ◦ Liquid diet via NGT
◦ Maintain intra oral gauze for 2 hours post op ◦ GV once daily
◦ Liquid diet via NGT ◦ Medication:
◦ Do not touch the post op wounds with finger or ◦ R/ Picyn 4x1500 mg IV
tongue
◦ R/ Metronidazole 3x500 mg IV
◦ Pro nasal canule 3 lpm if shortness of breath is
present ◦ R/ Methylprednisolone 1x125 mg IV

◦ Medication in accordance with ENT ◦ R/ Ranitidine 2x50 mg IV

◦ R/ Ketorolac 3x30 mg IV
◦ R/ Tranexamat acid 3x500 mg IV
Pus Culture test RSCM
Result
June 15th 2022
Thank you