CASE REPORT

Wednesday, August 26th 2015

Team on duty
dr. Hendra Kastiadji
(Jaga 1)
dr. Tommy Rivelino
(Jaga 2)
dr. Zumirda
(Jaga 3)
dr. Kas Mulyadi
(Jaga 4)
dr. Arfan Asmadi
(Jaga 4)
dr. Herdi Gunanta Syaiful (Jaga 5)
dr. Ike Yoganita Bangun
(Jaga 5)
dr. Sanwinata
(Jaga 6)

Patient identity
Name
Age
Sex
Address
CM
Phone
Admission Time

:
:
:
:
:
:
:

Sardi
54 years old
Male
Samadua Kab. Aceh Selatan
0 87 27 31
08596654766
02.00 WIB

Date/h Examinati Laboratory

Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
August
27th
2015
02.00

02.00

02.15 02.45

02.45

Date/ho DPJP
ur
patient
out from
ER
Dr.
Suhardi
SpBTKV

Chief complaint
Pain at the left lower leg
Patient illnes history
The patient was referred from Yulidin Away South Aceh District Hospital to
Zainoel Abidin emergency room with a chief complaint pain at the left lower leg
for 3 days ago. Initially patient was felt pain and cold at the left lower leg and
getting worse at a last day. History of pain while he walking and dissapear while
he resting (+). There was no history of trauma.

Physical examination
Vital Sign
BP
: 130/ 80 mmHg
HR
: 90 beats/ minute
RR
: 20 breath/ minute
T
: 36,5o C
L/S of the lower leg
LEFT

RIGHT

Look

Necrotic (-), pin prick

test (+)

Necrotic (-), pin prick

test
(+)

Feel

Pain (+) NVD (+), cold

(+) SpO2 : 85%

Pain (-) NVD (-), warm

(+) SpO2 100%

A. Femoralis

Pulsation (++)

Pulsation (++)

A. Poplitea

Pulsation (+)

Pulsation (++)

A. Tibialis
anterior

Pulsation (-)

Pulsation (++)

A. Dorsalis
pedis

Pulsation (-)

Pulsation (++)

ABI = Sistole brachial/ sistole cruris

= 130 / 150
= 0,86

SpO2 of the left pedis

1st finger
: 86 %
nd
2 finger
: 85 %
3rd finger
: 85 %
th
4 finger
: 85 %
5th finger
: 90 %
Assessments:
Acute Limb Ischemic at the left lower leg

VAS : Mild

Management
Stop oral intake
IVFD RL 20 drips /minutes
Inj. Ceftriaxone 1 gr/ 12 hours
Inj Ketorolac 30 mg
Laboratory examination
Laboratory examination
Hb
: 12.7 gr/dl
White blood count
: 19.700/ul
Platelet
: 225.000 /ul
Ht
: 40 %
CT
: 8 minute
BT
: 2 minute
Blood glucose ad random : 96 gr/dl

Consult to TCV Division

Vascular exploration arteriography
Trombectomy emergency

Consult to Cardiology Division

Sinus tachicardia, LAD, RBBB, Left atrium vasicular
block, CAD OMI anteroseptal and inferior.
Moderate tolerance for surgery
Th/
Atorvastatin 20 mg/24 hour
Cardace 25 mg/24 hour
Aspilet 100 mg/24 hour

Operative Report
Performed incision at the left ingunal
Identified A. Femoralis
Performed arteriography multiple trombus at the poplitea artery until distal
performed trombectomy with forgaty catheter
Arteriography :
Multiple trombus at the Poplitea Artery until tibialis posterior
Diagnose post operatif:
1. Acute Limb Ischemic (ICM 10 CM M62.622)
2. Multiple trombus at the Poplitea Artery (ICD 10 CM S85.009)
3. CAD Omi anterolateral and inferior (ICD 10 CM I25.10)
Follow Up
Date

August
Pain
27th 2015 (+)
13.00 WIB

VS/
Post Arteriografi + eksplorasi
BP : 120/70 mmHg
Vaskular + Trombectomi :
HR : 86 beats/minute
1. Acute Limb
RR : 20 breaths/
Ischemic (ICM 10
minute
CM M62.622)
2. Multiple trombus at
the Poplitea Artery
(ICD 10 CM
S85.009)
3. CAD Omi
anterolateral and
inferior (ICD 10 CM
I25.10)

IVFD RL 20
drips/minute
Inj. Ceftriaxone 1
gr/12 hour
Inj. Mitamizole
sodium 1 g/8 hour
Inj. Ranitidin 50
mg/12 hours
Heparin 5000 IU/ 24
hours
Pentoxifiline 400 mg/
12 hours

Date

14.00 wib Chest pain BP : and arrest HR : RR : ECG Flat

Pupil dilatation

A
Post Arteriography
Vascular exploration +
Trombectomy:
1. Acute Limb
Ischemic (ICM 10
CM M62.622)
2. Multiple trombus
at the Poplitea
Artery (ICD 10
CM S85.009)
3. CAD OMI
anterolateral and
inferior (ICD 10
CM I25.10)

Performed CPR
Adrenaline inj. Sub
cutan
Patient pass away
COD :
- cardiac arrest due
to MCI due to
susp. emboly