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  • MR DR SHD M-7

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    Asis Fitriana
    5 просмотров11 страниц
    1. A 57-year-old female presented with left cheek swelling for 1 week and inability to open her mouth for 3 days. 2. On examination, she had swelling and redness of the left mandibular region with tenderness and pain. 3. She was assessed with left submandibular cellulitis and underwent incision and drainage with local anesthesia along with antibiotics.

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    morning report bedah

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    1. A 57-year-old female presented with left cheek swelling for 1 week and inability to open her mouth for 3 days. 2. On examination, she had swelling and redness of the left mandibular region with tenderness and pain. 3. She was assessed with left submandibular cellulitis and underwent incision and drainage with local anesthesia along with antibiotics.

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    © All Rights Reserved
    Скачайте в формате PPTX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    5 просмотров11 страниц

    MR DR SHD M-7

    Загружено:

    Asis Fitriana
    1. A 57-year-old female presented with left cheek swelling for 1 week and inability to open her mouth for 3 days. 2. On examination, she had swelling and redness of the left mandibular region with tenderness and pain. 3. She was assessed with left submandibular cellulitis and underwent incision and drainage with local anesthesia along with antibiotics.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате PPTX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 11

    KASUS 1 DM ASIS

    2 Mei 2018
    IDENTITAS PASIEN
    Nama : Ny. Wagini
    Usia : 57 th
    Alamat : Sumberan Karanganyar Ambulu Jember
    Waktu datang : 2 Mei 2018 pukul 15.30 WIB
    No HP :-
    SUBYEKTIF
    KU : MULUT BENGKAK
    PRIMARY SURVEY
    A : paten, stabilisasi c spine, gargling (-), snoring (-)
    B : Jejas (-) RR: 20x/menit, SpO2 98%, retraksi (-) Sonor
    (+/+) Ves (+/+) rh (-/-), wh (-/-)
    C : warna kulit: kemerahan, N: 85x/mnt kuat angkat, TD
    160/90 mmHg
    D: GCS 4-5-6, PBI 3mm/3mm, RC +/+
    E : Regio mandibula sinistra
    INITIAL ASSESSMENT
    PLEGMON SUBMANDIBULA SINISTRA

    INITIAL PLANNING
    Inj antrain 500 mg
    Inj ceftriaxone 1 g
    Cek DL, GDA
    SECONDARY SURVEY
    A : (-)
    M: Amoksisilin & Kataflam
    P : HT (+)
    L : 11.00 (2 Mei 2018)
    E : (-)

    RPS : pasien mengeluh tidak bisa membuka mulut sejak 3


    hari yang lalu. Pasien sempat sakit gigi rahang atas kiri 10
    hr yll. Mulai bengkak 1 minggu yll. Pasien sulit makan,
    sesak (-) mutah (-)
    STATUS GENERALIS
    Keadaan umum : CM
    Kesadaran : GCS 4-5-6
    Vital sign : TD : 150/90 mmHg
    Nadi : 88x/menit, regular kuat angkat
    RR : 20x/menit

    Suhu Aksila: 36,8o C


    Kepala/Leher : anemis (-), ikterik (-), sianosis (-), dyspnea (-)
    Thoraks : Cor = S1 S2 tunggal, e/g/m = -/-/-
    Pulmo = sim +/+, ret -/-, ves +/+, rh -/-, wh -/-
    Abd : flat, BU (+), soepel, timpani
    Ext : akral hangat (+/+)(+/+), edema (-/-) (-/-)
    STATUS LOKALIS MANDIBULA SINISTRA

    L : rubor (+) edema(+)

    F : nyeri (+) VAS 7, kalor (+) nyeri tekan (+)


    HASIL LAB
    HB 12.5
    Leu 15.9
    Hct 40.5
    Tr 288
    GDS 144
    ASSESMENT
    Pleghmon submandibula sinistra
    TERAPI
    MRS
    Insisi drainage dg LA
    Inj antrain 3x 500 mg
    Inj ceftriaxone 2x1 g

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