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Emergency Report
Satur day, December 5th , 2015
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Name : Mr. Aja ahruj!
Se" : Ma#e
Age : $1 year% o#dAddre%% : &un!aga, '!herang,
'!anjur
Re#!g!on : Mo%#em
Statu% : Marr!edMed!ca# Rec No. : 0001$()(*2 + 150002)((
-!me o arr!/a# : 1.50 pm
hone Number : 0*1(122)00021
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S: Se##!ng on the #et chee
S:
A $1 y.o ma#e pat!ent came !th %e##!ng on the #oer
chee b!#atera#. 10 day% pr!or to adm!%%!on, pat!ent a%
comp#a!n!ng o pa!n on h!% #et #oer tooth accompan!ed !th
%e##!ng on the #etchee. 5 day% pr!or to adm!%%!on the pat!ent a%
taen to
pr!/ate ho%p!ta# Dr 3a!4 at '!anjur area and rece!/ed
o
med!c!ne the pat!ent d!dn6t remember the name o
med!c!ne7.&ecau%e o h!% comp#a!nt d!dn6t decrea%e, 8 hour%
pr!or toadm!%%!on the pat!ent a% taen and %ugge%ted to 3a%an
Sad!!n3o%p!ta#. 3!%tory o toothache 97 1 month ago on h!% #et
#oerteeth, h!%tory pa!n hen %a##o!ng 7, h!%tory o denta#
treatment 7, 3!%tory o d!abete% a% den!ed.
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; :
'on%c!ou%ne%%: 'M
& = 1)0+(0 mm3g
= (1 "+m!nute%-emp = (,5 o'
RR = 2( "+m!nute%
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>enera# %tatu% :
•S!n : -urgor 97•3ead : A%ymmetr!ca# ace, %e##!ng at the #et
bucca# chee, #et
%ubmand!b#e and %ubmenta# reg!on
•Eye : Non anem!c conjunct!/a, non !cter!c %c#era
•
Nec : ?
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oca# %tatu% :
E"tra ;ra# :• A%ymmetr!ca# ace, %e##!ng at the #et and the r!ght
bucca# chee that e"tend
to #et and r!ght %ubmand!b#e and % ub#!ngua# reg!on redne%%,
ebr!#e
temperature, #oca#!4ed, %ot con%!%tency, #uctuat!on% 97, pa!n on
pa#pat!on
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Fntra ;ra# :
• >!ngg!/a# : Se##!ng at #et bucca# muco%a 1"1"1 cm !n %!4e,
redne%%,
ebr!#e temperature, #oca#!4ed, %ot con%!%tency, #uctuat!on%,
pa!n
on pa#pat!on
• G#oor o the mouth : e#e/at!on
• Muco%a &ucca# :!th!n norma# #!m!t
• a#ate : !th!n norma# #!m!t
• !p% : !th!n norma# #!m!t
•
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* ) 8 5 $ 2 1 1 2 $ 5 8 ) *
* ) 8 5 $ 2 1 1 2 $ 5 8 ) *
;dontogram
X< <
'M >R >R ''
'M
Mouth open!ng 1 cm
'a#cu#u% 97
<
'M>R
X X X X
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aboratory !nd!ng% :
-
- : 1.5 *.*12.*7 %econd- FNR : 1.1* 0.*21.1)7 %econd
- A-- : 28.) 1$.)$.)7 %econd
- 3b : 1. 1.51).57 g+d
- 3t : ) $0527 H
- B&' : (.800 $.$0011.007 +mm
- R&': $.$( $.58.5 m!##!on+u7
- #ate#et : 2)2.000 150.000$50.0007+mm
actate : 0.8 0.)2.57 mmo#+
Ireum : $$ 15507 mg+d
'reat!n!ne : 0.8( M: 0.)0.(7 mg+d
AS- S>;-7: 50 I+ ) '7
A- S>-7 : $ I+ ) '7
Random b#ood g#uco%e : *( 1$07 mg+d
Sod!um Na7 : 18 151$57 mEg+
ota%%!um J7 : .1 .8 5.57 mEg+
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ood ga% ana#y4ed
- p3 : ).$$8 M: ).$).$$mmo#+
- ';2 : 2*.1 M: 5$5 mm 3g
- ;2 : 111 8(118 mm 3g
- 3'; : 1*.* 2228 mEK+
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-';2 : 5.* 222( mEK+- &a%e E"ce%% : 2.) 27 L 97 mEK+
- ;"ygen Saturat!on : ().* (5(* H
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'he%t Ray
Fmpre%%!on :
• No %!gn o card!omega#y
• No %!gn o act!/e #ung -ubercu#o%!%
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S- Aatera# Ray
Fmpre%%!on :
A!r co##umn at #aryng and pharyng !th!n norma# #!m!t
Retreopharyngea# and retro#aryngea# %pace d!d not !den
Ep!g#ot!% and /a#ecu#a !th!n norma# #!m!t
No %!gn o opaKue %hado or ca#c!!cat!on o the %ot t!%%ue
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A:•
h#egmon en#argement to anter!or co##!
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: -herapy o ora# %urgery dept
• 'omp#ete ood count, -A--, ood >a% Ana#y%!%, actate
• 'he%t, S- Aatera# Ray
•
;2 S!mp#e ma% * !tre+m – F
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Sugge%t!on%
• ;b% o /!ta# %!gn
• F
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Durante ;
