Sunday, 2nd July 2017

In Emergency Installation, we received 10 patients, consist of:

1. Laceration wound (S076.00) : 1 patient  Wound toilet + suturing +
Amoxycillin + Mefenamuc acid  Discharge
2. Vulnus morsum (dog) regio cruris sinstra (E.906.0) : 1 patient 
Linear incision + amoxicillin + mefenamic acid + ATS inj. + TT inj.
 Discharge
3. Soft tissue swelling on labialis oris – mentale region (M.79.9) : 1
patient  Ceftriaxone inj. + Metronidazole inj + ketorolac inj + 
C1LD
4. 2nd grade snake bite on left hand (T63.001A) : 1 patient  Linear
incision + ceftriaxon inj + ketorolac inj + ATS inj. + TT inj. + SABU
inf.  R2B
5. 2nd grade burn injury 19 % (left upper limb 5%, back 4%, left lower
limb 8%, riget lower limb 2%) cb gasoline fire 6 hours before
admission (T31.1) : 1 patient  Baxter’s rescucitation ceftriaxon inj
+ ketorolac inj + silversulfadiazin  C1LD
6. SOL on left frontal region + history of seizure (R90.0) : 1 patient 
Oxygenation + head up 30’ + observation + phenitoin inj + ranitidin
Inj + dexamethasone inj + pro MSCT craniocerebral with contrast
R2A
7. 2nd grade open fracture oblique undisplaced of 1/3 middle of left
tibia (S82.102B) : 1 patient  Splint application + Ceftriaxone inj+
Ketorolac inj + pro ORIF  GER D
8. Acute limb ischemic on right lower limb (I99.8) : 1 patient 
Embolectomy + heparin inj + clopidogrel oral  R2B
9. Invasive carcinoma of NST of right breast rTxN0Mx, post MRM 2
months ago + anemia (C50.921) : 1 patient  PRC transfusion 
R2A
10. Hematuria cb bladder carcinoma suspect malignancy TxNxMx +
moderate hidronefrosis of right and left kidney (C67.5) : 1 patient 
3 way urethral catheterization + tranexamid acid  Transit
CASE REPORT (23.00)
Male, 45 years old, came to emergency instalation, referred from Jepara General
Hospital
Chief complaint : pain and dark color on his right leg, inserted 1 iv line

History of Illness :
24 hours before admission, patients complaint pain on his right leg, and accompanied
with change of foot skin color to be bluish dark. He complaint that his right leg is more
cold he can not walk anymore. By His family, he was brought to Jepara General
Hospital, because lack of facilities, patient referred to RSDK.
History of past illness :
Hypertension (-)
Diabetes melitus (-)
Stroke (-)
Claudicatio intermitten (-)
History of cardiac ilness (-)
History of trauma (-)
History of immobilization (-)
Physical examinations:
General conditions: Looks moderatelly ill
Fully Consiousness
Vital signs:
RR= 20 x/min, regular, and enaught in depth
PR= 88 x/min regular, adequate tone and volume
BP = 130/80mmHg
t = 36,5 0C
Pain scale = 4-5 VAS

Head : Injury mark (-)

Eyes : Palpebra conjunctiva wasn’t pale
Round isocoric pupil  3mm, light reflex (+)/(+)
Neck : No injury mark, JVP not increase, trachea in the middle
Thorax: retraction (-)

Heart:
I : Ictus cordis not visible
P : Ictus cordis palpated on the 5th ICS, 2cm medial from the
left MCL.
P : Heart configuration WNL
A : Heart sound clear, no additional sound

Lungs:
I : Static: left hemithorax = right hemithorax
Dynamic : left hemithorax = right hemithorax
P : Tactile fremitus left = right
P : Sonor on all area
A : Vesicular on area, additional sound (-)
Abdomen:
I :Injury mark (-), Flat
P :Smooth, no tenderness, no muscle rigidity.
P :Tympanic, liver dullness(+), flank dullness (+) normal,
shifting dullness (-)
A :bowel sound (+) normal.

External genitalia: Male, WNL

Extremity Sup Inf
Edema -/- -/-
Capp refill <2”/<2” >2 ‘/<2’’
Motorik 555/555 diffilcult to assses/555
Sensorik +N/+N <</+N

Local State
Right Lower limbs:
I : Skin color was bluish dark from finger until 5 cm above right
knee
Pa : Pain (+) , cold rather than contralateral, pulse of dorsalis pedis
artery (-), posterior tibialis artery (+ weak), femoralis artery (+),
CRT > 2”, sensibility (+) decrease
ROM : Active and passive movement limited by pain
Working Diagnose (23.10)
• Suspected acute limb ischemic on right lower extremity

Initial management
• IP. Diagnose:
– S:-
– O: Doppler Ultrasonography
• IP. Therapy:
– IVFD RL 20 drops/min
– Ketorolac Injection 30 mg intravenous
• IP. Monitoring:
– Laboratory study : complete blood count, PPT, APTT, electrolyte,
blood glucose, ureum, creatinine, thorax foto, electrocardiografy
• IP. Education:
– Differential diagnostic, sonography examination
Laboratory Study (02.00)

• Hb : 16,9 gr % (13 – 16)

• Ht : 52,9 % (40 – 54)
• L : 16.700 /mmk (4.000-110.00)
• T : 260.000/mmk (150.000-450.000)
• GDS : 94 mg/dl (70-150)
• Ureum : 39 mg/dl (15-40)
• Creatinin : 0,9 mg/dl (0,5-1,3)
• Na : 137 mmol/L (135-145)
• K : 4,1 mmol/L (3,5-5,5)
• Cl : 104 mmol/L (96-106)
• PPT : 12,1/10,9 detik
• APTT : 33,0/33,0 detik

ECG : normal sinus rhytm

Radiology Examination (11.00)

Doppler ultrasound
Diagnose:
• Acute limb ischaemic on right femoral artery ec total occlusion on
common femoral artery, proximal mid distal femoral artery, and
right popliteal artery

Management
• Diagnose:
– S:-
– O: -
• Teraphy:
– Pro embolectomy
• Monitoring
– Complaint, General condition, vital sign, right lower limb
• Education
– Informed consent, Diagnosis, operation procedure, prognosis
OPERATION REPORT (18.30-19.30)
• Patient lied supine under regional anesthesia
• Atiseptic and aseptic operation area
• Performed longitudinal incision in proximal femur region, deepened
incision layer by layer, identification of right femoral artery  place
vascular fixation at proximal and distal of the artery by nelaton
• Performed longitudinal incision in the arterial wall, thrombus (+),
inserted fogarty catheter no. 5 Fr into distal region  Performed
embolectomy  thrombus (+) + 20 cm, darkened red, back flow (+)
• Inserted fogarty catheter no. 5. caudally  Performed embolectomy
 thrombus (+) + 10 cm, darkened red, flow (+)
• Suture the artery using polyprophylene 6.0, remove vascular fixation
evaluation : active bleeding (-), imbibition (-)
• Evaluation of distal artery: right femoral artery (+) adequate;
improvement, a. dorsalis pedis (+), a. Tibialis posterior (+)
• Suture the surgical wound layer by layer.
• Operation finished
Post operation diagnose (19.30)
• Acute limb ischaemic on right femoral artery ec total occlusion on
common femoral artery, proximal mid distal femoral artery, and
right popliteal artery
• Post embolectomy

Management:
• Diagnose:
– S:-
– O: -
• Teraphy:
– IVFD RL 20 dpm
– Heparin injection 500 IU /hours intravenous
– Clopidogrel 80 mg/24 hours
• Monitoring:
– Complaint, general condition, vital sign, right lower limb
• Education:
– Diagnosis, operation findings, prognosis
Evaluation Day 1

S : pain on right leg

O : General conditions: looks moderatelly ill
Fully Consiousness
Vital signs:
RR= 22 x/min, regular, and enaught in depth
PR= 90 x/min regular, adequate tone and volume
BP = 110/700mmHg
t = 36,7 0C
Pain scale = 4-5 VAS

localize state :
right lower limb :
I : Swelling, tighness
Pa : Pain (+) increase , warm than contralateral, pulse of dorsalis pedis
artery (+weak) posterior tibialis artery (weak), CRT >2” ,
sensibility (-)
ROM : Active and passive movement limited by pain
A:
•Acute limb ischaemic on right femoral artery ec total occlusion on
common femoral artery, proximal mid distal femoral artery, and right
popliteal artery Post embolectomy day 1
• Compartement syndrome on right lower limb

P:
• Pro fasciotomy cito
• Consult to anesthesia departement
OPERATION REPORT (15.00-15.30)

• Patient lied supine under regional anesthesia

• Atiseptic and aseptic operation area
• Performed longitudinal incision in medial and lateral part of right
cruris , deepened incision layer by layer until fascia, open fascia
sharply
• Control bleeding
• Evaluation of distal artery: right femoral artery (+) adequate;
improvement, a. dorsalis pedis (+), a. Tibialis posterior (+)
• Wound care with moist gauze and dry gauze
• Operation finished
Post Operation Diagnosed (15.30)
• Acute limb ischaemic on right femoral artery ec total occlusion on
common femoral artery, proximal mid distal femoral artery, and
right popliteal artery post embolectomy Day 1
• Compartement syndrom of right lower lmb post fasciotomi

Management:
• Diagnose:
– S:-
– O: -
• Teraphy:
– Infus RL 20 dpm
– Inj. Ceftriaxon 2 gram/ 24 hour intravenous
• Monitoring:
– Complaint, general condition, vital sign,right lower limb
• Education:
– Diagnosis, operation findings, prognosis
Evaluation Day 2

S :-
O : General conditions: looks moderatelly ill
Fully Consiousness
Vital signs:
RR= 18 x/min, regular, and enaught in depth
PR= 95 x/min regular, adequate tone and volume
BP = 110/700mmHg
t = 36,5 0C
Pain scale = 4-5 VAS
SpO2= 99%
localize state :
right lower limb :
I : wound cover by gauzed imbibition (+)
Pa : Pain (+) decreased , temperature same with contralateral pulse of
dorsalis pedis artery (+ ) posterior
tibialis artery (+), CRT <2”, sensibility (-)
ROM : Active and passive movement limited by pain
A:
•Acute limb ischaemic on right femoral artery ec total occlusion on
common femoral artery, proximal mid distal femoral artery, and right
popliteal artery Post embolectomy day 1
• Compartement syndrome on right lower limb post fasciotomi

P:
• Infus RL 20 drops/minute
• ceftriaxon 2 gram /24 hours intravenous
Sunday, 2nd July 2017