Casualty Report

Day/ date: Friday/ September 20th 2019

Doctors on duty: Ucha, MD / Arsi, MD
/ Achie, MD - Anita, MD - Ibeth, MD

Consultant on duty:
Harim Priyono, MD, ORL-HNS
Larynx Pharynx Consultant on Duty:
Syahrial MH, MD, ORL-HNS
Identity & Chief Complaint

Male,
53 years old

Chief complaint : Swollen

on the right neck
Medical History

Swollen Pain on the

Pain when
right lower
and pain gum 2 weeks
swallowing
on the right and sore
prior, no fever.
throat (+),
neck, since There was
difficulty of
3 days history of
swallowing +,
toothache on
prior upper right
history of DM
admission +
mandible,
Medical History

There were Went to general

practiotioner
no history and was given Referred
of antibiotic but no
accidentally changing in to
swallowing
symptoms then
went to ENT
CMGH
bone Specialist
Physical Examination

General condition: Dyspnea (-), retraction

compos mentis (-), stridor (-), gargling (+)

Vital sign:
• BP: 130/70
• HR: 96x
• RR: 20x
• Temperatur: afebrile
• O2 Sat: 99% on nasal canule O2
3lpm
 ENT Examination

Ear Nose Throat

• wide ear • wide nasal • Symmetric

canal, no cavity, inferior pharyngeal arch, not
discharge, turbinate hyperemic, uvula was
no eutrophy, no in the middle, tonsil
T1-T1 not hyperemic,
cerumen, discharge, no
posterior pharyngeal
intact septal deviation, wall not hyperemic
tympanic good air
membrane passage
ENT Examination

Neck
• Mass on the right submandible regio spreading to sternal notch
hard, fixated, no fluctuation
ENT Examination
RFL September, 20th 2019
ENT Examination
Laboratory Examination RSCM ER
(September, 1st 2019)

 Hb : 14 mg/dl  pH : 7.435
 Ht : 39 %  pCO2 : 25.2
 WBC : 12510 u/l  PO2 : 149.7
 Platelet : 274000 u/l  SO2 : 98.4
 Ureum : 68.7 mg/dl
 BE : -5
 Creatinine : 1.5 mg/dl
 HCO3 : 17.1
 AST :9
 ALT : 13
 Sodium : 131 mEq
 Potassium : 4.8 mEq
 Chloride : 95 mEq
 Blood sugar : 480
 Beta hydroxi barbiturare :
3.3
Radiological Findings CMER
(September, 20th 2019)
 Radiological Findings CMER
(September, 20th 2019)

 Thorax X-Ray:
 No radiological
abnormalities on heart
and lungs
Working Diagnosis

submandibular infiltrate (K12.2)

Type 2 diabetes mellitus

with ketosis (E11)
Management
Report to Syahrial MH, MD, ORL-HNS:
• Approved to be hospitalized
• Ampicillin-sulbactam 4x 1, 5 gr iv
• Metronidazole 3x500 mg
• Methylprednisolon 1x125 mg IV
• Ranitidin 2x50mg iv
• Consult to Internal Medicine for management of
hyperglycemia
• Consult to Oral Surgery for further evaluation and
management
Consultation to Internal Medicine
Department September 20th 2019:
A: P:
- Submandibular - Intake per NGT
infiltrate - IVFD NS 0.9%
- DM with ketosis 500ml/8h
- Novorapid drip 2 IU/h
- Examination serial
Glucose
- Picyn 4x1500 mg IV
 Consultation to Oral Surgery Department
September 20t 2019

A: P:
• Right submandibular • Pro panoramic x-ray
abscess et causa • Pro teeth extraction
gangrene radix teeth number 17, 14 and
number 17, 14 drainage inscission
• DM type II, uncontrolled
 Larynx Pharynx Division
September 21st -23rd 2018

• S: Adequate contact, no dyspneu

• O: Compos mentis, BP 120/80, HR 76, RR 18, T afebrile, SaO2
98%
• Colli: lump, size 8x4x1 cm, soft, not fluctuative, pain on
palpation, minimal hyperemic
• A:
• Submandibular infiltrate
• DM type II
• P:
• Observation vital sign and general condition
• Tredelenburg position
• Diabetes Mellitus therapy according to endocrine division
internal medicine
Thank You