180711 rahmi-od
DESCRIPTION
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Operation Report18th July 2011
Mr. Arry Budi L, 23 yo
357 41 06
Anamnesis
• Chief complain : pain from his left mandibular wisdom teeth
• History of illness : two weeks ago patient complained pain from his left mandibular wisdom teeth. He went to a dentist and given medication. One week afterward the pain was relieved and he seek further treatment to have his wisdom teeth extracted to RSCM
• Previous Illness : (-)
Physical Examination
• Extra oral : Within normal limit
• Intra oral : 38, 48 partial erupted with horizontal position, edem (-), hyperemia (-)
Radiograph Examination
Laboratory FindingsResult Normal Range
Hb 12,6 12.0-14.0 g/L
Ht 37,6 37.0-43.0 %
Leu 5.170 5.000-10.000/μL
Tromb 288.000 150.000-400.000/μL
BT 2,30 1.00-6.00 sec
CT 11,00 10-15 sec
PT 12,4 (12,8) 9,8-12,6 sec
APTT 37,2 (35,7) 31-47 sec
SGOT 25 < 27 U/L
SGPT 31 < 36 U/L
Ur 24 < 50 mg/dL
Cr 0,6 0,6-1,2 mg/dL
GDS 85 Mg/dL
Working Diagnosis
Impacted 38, 48
Intra-Operatif
Intra-Operatif