CASE REPORT

Saturday, Friday 15th .2014

Team on duty :

I.

II.

dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Fachrul Razi
Nazir T
Munawar
Aa Ahmad Dimyati
Raja Raharja Marlunglung
Sumrahdi Manurung
Andri Mulia
Oki Oktadi
Kas Mulyadi

Patient Identity
Name
Sex
Age
Address
MR
Phone
Patient came at

: Jumiati
: Female
: 50 years old
: Muara Dua Aceh Utara.
: 1-01-43-76
: 085371120858
:

Chief Complain:
Pain at the left leg

III. Present illness history

The patient referred from cut meutia hospital to Zaenoel Abidin hospital with
chief complain pain at the right leg. The complain started for 1 weeks. Initially
firsly she feel numbness at the left leg but for the last week she feel pain at the left
leg. History of trauma (-) hyperaemic (+)
IV. Physical examination
Generally condition
BP
Pulse
RR

: Moderately
: 150/100 mmHg
: 84 beats/ minute
: 20breaths/ minute

: Exposure
L/S at the left leg
Look : hyperemic (+) wound (-)

Fell : Pain (+), NVD (+) Pulsness (+)

Move : ROM limited

V.

Assessment
Critical limb ischemic at the left leg

VI. Management
Stop oral intake
IVFD RL 2000 cc
Inj Ceftriaxone 1gr
Inj Ketorolac 3%
Inj Ranitidine
Routine laboratory examination
Radiology examination
VII.

Routine Laboratory examination

Haemoglobin
: 15,6 gr/dl
White Blood Count
: 17.100/ul
Platelets
: 214.000/ul
Hematocrit
: 47 %
CT/BT
: 7/2
Blood glucose random
: 361 mg/dL
Ureum
: 54 mg/dL
Creatinin
: 0,6 mg/dL

VIII.

Diagnose
Critical limb ischemic at the left leg

X.

Consult tocardio vascular surgery division

Prepare for arteriography + thrombectomy

XI.

Operativ Report
Patient in supine position with general anesthesia
Asepsis and antisepsis procedure
Identification of necrotic soft tissue until upper third extremity
Founded seropurulen liquid until SIAS
Perform above knee amputation, founded multiple thrombus at the A.V
femoralis
Surgical Wound was allowed to open
Hospitalize in ICU

XII.

Diagnose
Critical limb ischemic at the left leg

XII.

Follow Up

Date
18 Agust 2014
POD 2

S
Pain(+)
decrease

O
VS
BP 150/80
mmHG
HR 80 beat/
minute
RR 20 Breath/
Minute

A
Critical limb
ischemic at the
left leg