RSCM REPORT

Monday, July 13th – 16th 2020

Doctor in charge : drg. Eky Nasuri, Sp.BM, drg. Wenny Yulvie, Sp.BM
Chief Poli : drg. Destiana Nur Fitri
On Duty 2 : drg. Febri, drg. Wawan, drg. Asep
On Duty 1 : drg. Fahmi, drg. Dharma, drg. Arda, drg. Mala
 Emergency Unit Operation Recapitulation

No Identity Diagnose Treatment Plan

1. Mr. Ari BM O2 3 lpm
Wibowo Abcess Buccalis Dextra e.c 46 Head up 30°
52 y.o Gangrene Radix IVFD Nacl 0.9 % 500 cc/8 jam
449-26-11 IPD Inj. Meropenem 2x500mg
Sepsis e.c SSTI Inj. Metronidazole 3x500mg
Mild KAD Inj. Ranitidine 2x50mg
AKI dd/ acute on CKD Inj. Paracetamol 3x1000mg
Hypoalbuminemia Laboratorium check
Hyponatremia Ro. Thorax PA
Diabetes Mellitus type II Ro. Panoramic
Pro evacuation focus Infection
Maintain oral hygiene
 Elective Operation Recapitulation

No Identity Diagnose Treatment Plan

1. Mrs. Bianca Susp. Benign Neoplasma Incision Biopsy
Felizia Mandibular Sinistra
23 y.o
448-18-62

2. Eka Susp. Benign Neoplasma Radical Curretage + Mandibular

Permana Mandibular Sinistra dd/ Detigerous reconstruction (Recon plate and screw)
14 y.o cyst
448-16-97

3. Mr. Impacted teeth 18,28, and 48 Odontectomy 18,28, and 48

Barnabes
Matias
25 y.o
448-22-81
NAME : Mrs. Bianca Felizia
AGE : 23 y.o
MR : 448-18-62

ADM : BPJS
Anamneses
• Chief Complain: Swelling in the left lower jaw since 2 month before
came to the hospital.
• History of present illness: patient began swelling in the left lower jaw
since 2 months ago. The swelling was getting bigger and more painful in
the lower left molars. The patient agreed to see a specialist. Then the
patient went to the RS Pasar Minggu a week ago. From the panoramic X-
ray image there was lump in her left lower jaw. The patient was referred
to the RSCM with a suspicion of ameloblastoma. The patient had not
reported weight loss in the past 6 months. There was no pain, the lump
was not felt to enlarge quickly. There was no history of bleeding from
her mouth, nor was a history of impact on her jaw.Currently the patient
has no complaints of the pain. Good regular diet, good mobilization.
• Previous illness: Diabetes Mellitus, Hypertension, hearth disease and
lung disease was denied. Pasien was allergic to cataflam.
Physical Examination
Extra Oral

Inspection :
• Facial Asymetry (-)
• Has the same colour
with surrounding tissue
Palpation :
• No temperature difference
with surrounding tissue
• No Swelling
• No enlargement of the
lymph nodes
 Physical Examination
Intra Oral
• Inspection:
• No Swelling
• Has the same color with
surrounding tissue
• Pus discharge (-),
bleeding (-), ulcer (-)

• Palpation
• No felt of lump
• Slippery surface
• No tenderness
• No difference
temperature with
surrounding tissue
• Tongue elevation (-)
OPG
Laboratory Examination
( RSCM,06-07-2020)
Result Normal Range
Hb 11.0 12.0 – 15.0
Ht 35.4 36.0 – 46.0
Leuko 10.630 4.00 – 10.00
Thrombosit 390000 150 - 400
PT 10.4 9.8 – 12.6
APTT 33.9 31 – 47
SGOT 19 5 - 34
SGPT 21 0 - 55
GDS 87 60 - 140
Na 134 136 - 145
K 4.6 3.5 – 5.1
Cl 102.6 98.0 – 107.0
Ur 11.7 15 - 40
Cr 0.7 0.55 – 1.02
Laboratory Examination (RSCM, 08-07-2020)
 Working Diagnosis
• Benign Neoplasma Mandibular Sinistra

Treatment Planning

Incision Biopsy
Operation Report
• Consultant in charge : drg. Wenny Yulvie Sp.BM
• Operator : drg. Wenny Yulvie Sp.BM
• Assistant : drg. Febri
Mrs. Bianca/23 y.o/448-18-62
Dx. Pre-Op : Benign Neoplasma Mandibular Sinistra
Dx. Post-Op : Benign Neoplasma Mandibular Sinistra
Plan : Incision Biopsy

- Patient supine under general anaesthesia, desinfection of operative site with povidone iodine,
and apply sterile dressing.
- Injection Vasoconstrictor 1:10.000 in buccal vestibulum region 37-38
• Performed sulcular incision in region mesial 37 until distal 38 using blade no. 15.
• Performed flap retraction with rasparatorium.
• Identification of lession.
• Performed aspiration of lession with 3cc syringe, Founded yellow clear fluid.
• Performed bone exploration using round bur in region 38 until lession expose
• Performed reverse triangular insicion in region 38 and extraction the tooth
• Mucosa sutured with vycril 3-0.
• Irigation operation area with NaCl 0,9%
• Bleeding control
• Operation accomplished.
NAME : Eka Permana
AGE : 14 y.o
MR : 448-16-97

ADM : BPJS
• Main Complaints: Patients with complaints of pain in the right back
tooth since 1 year of SMRS
NAME : Mr. Barnabes Matias
AGE : 25 y.o
MR : 448-22-81

ADM : BPJS
Anamneses
• Main Complaints: Patients with complaints of pain in the right
back tooth since 1 year of SMRS
• History of presenst illness: Patients with pain in the right back
tooth since 1 year of SMRS. Initially the patient went to the
Tambora puskesmas, then was referred to Sumber Waras
Hospital. There a panoramic photo was taken to get an impact
on the three wisdom teeth. The patient is then referred to RSCM
for further management. Back teeth pain disappear. Currently
there is no swelling, fever and tightness. Mobilisazation good.
Regular diet.
• Previous illness: Diabetes, Hypertension, cardiac disease were
denied. Allergic to amoxicillin. limfona operation record back
in desember 2019
Physical Examination
Extra Oral

Inspection :
• Facial Asymetry (-)
• No open mouth
limitation
Palpation :
• No temperature difference
with surrounding tissue
• No Swelling
 Physical Examination
Intra Oral
• Inspection:
• No Swelling
• No difference colour with
surrounding tissue
• Partial Impacted tooth 48
vertical
• Partial Impacted 18 and 28
vertical
• Calculus in maxilla and
Mandibular

• Palpation
• No tenderness
• No temperature
difference temperature
with surrounding tissue
OPG
Laboratory Examination
( RSCM,14-07-2020)
Result Normal Range
Hb 15.5 12.0 – 15.0
Ht 45.5 36.0 – 46.0
Leuko 7.9 4.00 – 10.00
Thrombosit 267 150 - 400
PT 11.4 9.8 – 12.6
APTT 33.6 31 – 47
SGOT 17 5 - 34
SGPT 13 0 - 55
GDS 85 60 - 140
Na 141 136 - 145
K 3.6 3.5 – 5.1
Cl 106.6 98.0 – 107.0
Ur 16.1 15 - 40
Cr 0.9 0.55 – 1.02
Laboratory Examination (RSCM, 14-07-2020)
Working Diagnosis
• Impacted teeth 18,28, and 48

Treatment

Odontectomy 18,28, ad 48
Operation Report
• Consultant in charge : drg. Eky Nasuri Sp.BM
• Operator : drg. Febri
• Assistant : drg. Fahmi
Mr. Bernabes/25 y.o/448-22-81
Dx. Pre-Op : Impacted teeth 18,28, and 48
Dx. Post-Op : Impacted teeth 18,28, and 48
Plan : Odontectomy 18,28, and 48
• Patient supine under general anaesthesia, desinfection of operative site with povidone iodine,
and apply sterile dressing.
• Injection Local Anasthesi in buccal vestibulum region 18,28, and 48
• Performed triangular incision in region 48 using blade no. 15.
• Performed flap retraction with rasparatorium.
• Reduction buccal bone using round bur in region 48
• Elevation tooth 48 with elevator(bein)
• Extraction tooth 48 from the socket
• Performesd Curretage in the socket
• Irigation operation area with NaCl 0,9%
• Mucosa sutured with silk 3-0.
• Elevation tooth 18 with elevator(bein)
• Extraction tooth 18 from the socket
• Performesd Curretage in the socket
• Repeat step 11,12, and 13 for tooth 28
• Bleeding control
• Operation accomplished.