Pembimbing: Dr. Andanu Indratnoto, Sp.

B-KBD

PRESENTASI KASUS
Peritonitis et causa Appendicitis perforata

Felani Dwijayanti
030.11.100

Kepanitraan Klinik Ilmu Bedah

Fakultas Kedokteran Universitas Trisakti
Rumah Sakit TNI AL Dr. Mintohardjo
Case report
 Identity
Name : Mr. Yerri Yolandra
Gender : Men
Place of birth : Padang
Date of birth : September 16th 1960
Age : 55 yo
Adress : Teladan no 19 Bogor
religion : moeslim
education : Senior high school
Marital status : Merried
Work : entrepreneur
 History

Main complaint
Toes of blackned
 History of present illness
Patient complaint left toes blackened until soles of the feet
Patient feel painful
The complaint arises since 2 months ago after baypass
Legs feel numb
The patient has done hyperbarik since on November 24th 2015
until now as much as 27 times. After hyperbarik, patient feel
her legs like an electric shock. Patient has consul with
cardiologist
 Past medical history
- patient has hypertention and CHF ec CAD on November 6 th 2015
- patient have been treated to the community health centre with complaint
sweating, dizziness in the nape, and restless

Family history of disease

- Patient have a family history of hypertension and four brothers of patient
have died of hearth disease.

Treatment history:
Patient taking amlodipin since 4 years ago. Patient perform CABG on
November 6th 2015, and patient also perform hyperbaric at the hospital
navy Mintohardjo
 History of habits
Patient smoked since senior hig school as 18
cigarettes everyday. Patient taking traditional
herbal medicine. All this time, the patient has
habits of eating padang food and innards.
 Physical examination
General condition Vital sign
Ill impression : moderete Blood pressure: 90/60
Nutritional status : good mmHg
Awareness : Compos Pulse: 90x/m
mentis Temperature: 36,5C
RR: 18x/m
 Physical examination
General status
Head : Normocephal
Eye : clear cornea, blackish brown iris color, pupil isokor, direct light reflex +/+,
indirect light reflex +/+, conjunctival pallor -/-, sclera jaundice -/-
Nose : normal, no discharge, no blood
Mouth : OH good
Ear : Normotia, no discharge and blood
Neck : Thyroid and lymph nodes no enlarged
Thorax
Lung : Symmetrical, breath sound Vesikuler +/+, Wh -/-, Rh -/-
hearth : hearth sound I &II reguler, gallop (-), murmur (-)
chest and breasts : there are stitches in the sternum after CABG.
Abdomen : flat,noisy bowel (+), Timpani, tenderness (-)
 Physical examination
Urogenital : Normal
Limb : There gangren on digiti left toes I,II,III,IV,V

View before amputation

 Investigation
Hematologic
Routine blood
Lekosit 7.600/ul
Eritrosit 4.10 million/ul
Hemoglobin 11.9 g/dl
Trombosit 224.000 thousand/ul
Hemostasis
Blood time 300
Cloting time 1130

Clinical chemistry

Blood glucose
Blood glucose in the time 141 mg/dl
Clinical diagnostic
Buerger disease
Treatment
View after amputation
FOLLOW UP
January, S : No complain
12nd2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,2 C N: 82 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Ceftriaxon 2 gr

January, S : breathless
13th2016 O : Compos mentis, mild pain
TD : 110/70 mmHg S: 36,4 C N: 80 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection RL 20 tpm
Inj ceftriaxon 2x1
Inj ketorolac 3x1
Bedrest
Changing bandages every 2 days
January, S : cough, breathless
O : Compos mentis, mild pain
14th2016 TD : 100/70 mmHg S: 36,3 C N: 90x/m RR= 16x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection lasix 1 amp
ISDN 5 mg sublingual

January, S : cough, breathless

15th2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,5 C N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra, blood seeped
A: Pro amputation digiti left toes I,II,III,IV,V
P: ceftriaxon 2x1 gr , Ketorolac 2x1 amp , RL
Consul cardiologist (dr.Stephani), EKG every morning , Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg , Bisoprolol 1x25 mg , Avesco 1x1 tab , ISDN 5 mg
sublingual
January, S : breathless
16th2016 O : Compos mentis, mild pain
TD : 110/80 mmHg S: 36,5 C N: 88x/m RR= 26x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: ketorolac 2x1 amp, Ceftriaxon 2x1 amp, Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg, Bisoprolol 1x25 mg, Avesco 1x1 tab , ISDN 5 mg
sublingual

January, S : breathless
18th2016 O : Compos mentis, mild pain
TD : 120/80 mmHg S: 36,5 C N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti I-V pedis sinistra
P: Cefixime 2x100 gr , Nadiclop 2x25 gr , Lasix 2x1 amp, Neurodex 2x1 gr,
Lantoprazol 2x1 Impepsa 3x1
 Surgery report (january 13th 2016)
Types of surgery : Pro amputation digiti left toes I,II,III,IV,V
Position : Supine
Anesthesia : SAB
Operation time : Wednesday, January 13th 2016 12.00-14.00 oclock
Duration : 2 hours
Surgery report:
Position of supine with SAB
Asepsis and antisepsis location operating
Incision edge of the wound necroting
Spin of area necroting digiti I-V pedis sinistra
Do amputation and necroting
Followed with skin graft ( FTSG)
Drain in inguinal
Doing suture
Thick bandage
Literature review
Anatomy
Artery
Thigh and gluteal region : femoral artery and
obturator artery

Leg : anterior leg (anterior tibial artery), posterior

leg (dorsalis pedis artery)

Foot : dorsalis pedis artery and posterior tibial

artery
Venous
Deep vein
gluteal : inferior and superior gluteal vein
thigh : external iliac vein and femoral vein
Foot and leg : anterior tibial vein, posterior and fibular vein, popliteal
vein, plantar vein
Superficial vein
great saphenous vein
small saphenous vein

The intima
The media
The adventitia
Histology

The intima
The media
The adventitia
 TAO

Definition :
Thromboangiitis obliterans (TAO) is an inflammatory,
nonatherosclerotic, occlusive disease of small and medium-
sized arteries and veins that involves distal vessels of the
extremities
Cause and risk factor
tobacco exposure of any kind, including smoking, chewing or
snuff.
Aged (predominately 20 to 40 years old)
more common in men
Genetics
Hypercoagulability
endothelial dysfunction
immunologic mechanism
high cholesterol
high blood pressure
diabetes
Pathogenesis
Pathology
Clinical description
Two or more limbs being affected
Discoloration of the affected limb
Pain which may increase with activity such as walking and
decrease with rest
Numbness and tingling in the limbs
Raynaud's phenomenon
Skin ulcerations and gangrene of the digits, which are
common
Pulses which may be decreased or absent in the affected
extremity
Later symptoms which include enlarged, red, tender cord-like
veins
Diagnostic method
Non-invasive vascular
evaluation
used to check for a lack of
atherosclerotic lesions and can
identify the distal sites of
symptomatic arterial occlusion
and other sites of lesions
Angiography
The most important diagnostic criterion
is the smooth and regular, non-
atherosclerotic nature of the artery wall
both at the site of, and also proxmally to
arterial occlusions.
In the legs, infrapopliteal lesions
predominate
In the arms, the lesions primarily
concern the radial and cubital arteries
Laboratory
Treatment
Drug
- vasodilator inhibitor
- spinal cords stimulators
Surgical
- sympathectomy
- distal limb amputation
 Skin graft
Graft are measure aimed to
remove healthy skin and
attach to the skin wound.
Flaps
Flaps are elevated from a donor
site and transferred to the
recipient site with an intact
vascular supply
can be used when the wound bed is
unable to support a skin graft or when
a more complex reconstruction is
needed.
Terima Kasih