Professional Documents
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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
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
Feel
A. Femoralis
Pulsation (++)
Pulsation (++)
A. Poplitea
Pulsation (+)
Pulsation (++)
A. Tibialis
anterior
Pulsation (-)
Pulsation (++)
A. Dorsalis
pedis
Pulsation (-)
Pulsation (++)
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
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
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