Scribd Logo
Upload

Welcome to Scribd!

  • 27 views

    Duty Report 020717 Fixed Icd

    Uploaded by

    Antonio Paulus
    1. The patient was admitted to the emergency department with pain and dark discoloration of the right leg. Diagnostic testing revealed an acute limb ischemic condition from an occlusion of the right femoral artery. 2. The patient underwent an embolectomy procedure to remove the occlusion. Post-operatively, compartment syndrome developed in the right lower limb, requiring a fasciotomy. 3. On the second day of evaluation, the patient's condition had improved. Pain and swelling in the right leg had decreased, and pulses and capillary refill time in the limb had improved. However, sensation remained decreased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Duty Report 020717 Fixed Icd

    Uploaded by

    Antonio Paulus
    27 views21 pages
    1. The patient was admitted to the emergency department with pain and dark discoloration of the right leg. Diagnostic testing revealed an acute limb ischemic condition from an occlusion of the right femoral artery. 2. The patient underwent an embolectomy procedure to remove the occlusion. Post-operatively, compartment syndrome developed in the right lower limb, requiring a fasciotomy. 3. On the second day of evaluation, the patient's condition had improved. Pain and swelling in the right leg had decreased, and pulses and capillary refill time in the limb had improved. However, sensation remained decreased.

    Original Description:

    tes tes

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. The patient was admitted to the emergency department with pain and dark discoloration of the right leg. Diagnostic testing revealed an acute limb ischemic condition from an occlusion of the right femoral artery. 2. The patient underwent an embolectomy procedure to remove the occlusion. Post-operatively, compartment syndrome developed in the right lower limb, requiring a fasciotomy. 3. On the second day of evaluation, the patient's condition had improved. Pain and swelling in the right leg had decreased, and pulses and capillary refill time in the limb had improved. However, sensation remained decreased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views21 pages

    Duty Report 020717 Fixed Icd

    Uploaded by

    Antonio Paulus
    1. The patient was admitted to the emergency department with pain and dark discoloration of the right leg. Diagnostic testing revealed an acute limb ischemic condition from an occlusion of the right femoral artery. 2. The patient underwent an embolectomy procedure to remove the occlusion. Post-operatively, compartment syndrome developed in the right lower limb, requiring a fasciotomy. 3. On the second day of evaluation, the patient's condition had improved. Pain and swelling in the right leg had decreased, and pulses and capillary refill time in the limb had improved. However, sensation remained decreased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 21

    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

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy