Patient Identity

• Name : Jamilah
• Sex : Female
• Age : 58 years old
• Address : Abdya
• MR : 1-12-97-85
• Phone :
• Admission time : 04.35 AM
 Time Response

Date/hour Examinat Laboratory Radiology Hour of Date/ DPJP

patient ion hour Examination Examination Diagnosti hour
came to ER cs patient
out from
ER
Send Result Send Result

May 19th 04.40 AM 05.15 06.55 Dr.

2017 AM AM Suhardi
04.35 AM Sp. BTKV
Chief Complaint :
Necrotic the right leg

Present illness history

The patient was referred from Tgk
Peukan district hospital with a chief
complaint of necrotic of the right leg
since 2 weeks ago
• Initialy, the patient felt pain at her right
leg and then his leg appeared darker. she
felt cold at her feet
• History of diabetic mellitus (-) and Hystory
of hypertension (-), history of smoking (-),
history of an unhealing gangrene (-)
• She routinely underwent blood
transfusion since 2 years ago
 Physical examination
Vital sign
• BP : 110/70 mmHg
• RR : 20 breaths/ minute
• Pulse : 108 beats/minute
• Temp : 36,6o C
• L/S at the right leg
• Look: mottling (+) skin looked darker
(+), pin prick test (-)
• Fell : Pain (-) NVD (+),
Vascular state of the lower extremity

Right Lower Limb Left Lower Limb

A. Femoralis + ++

A. Poplitea - ++
A. Tibialis - ++
anterior
A. Dorsalis
Pedis - ++
• SpO2 0% of the first toe : 0 %
• SpO2 0% of the second toe : 0 %
• SpO2 0% of third toe : 0 %
• SpO2 0% of fourth toe : 0 %
• SpO2 0% of fifth toe : 0 %

• ABI was unable to perform

 VAS : Mild

Mild 1-3 Moderate 4-6 Severe 7-10

Non opioid + Opioid + nonopioid Opioid + nonopioid
adjuvant + adjuvant + adjuvant
- COX-2 - Codein - Oxycodone
- Ibuprofen - Propoxyphene - Morphine
- Aspirin - Hydrocodone - Hydromorphone
- Acetaminophen - Tramadol - Fentanyl
Assesment
• Acute limb ischemic of the left leg
 Management
• IVFD RL 20 drips/minute
• Inj Ceftriaxone 1 gr
• Inj Ketorolac 30 mg
• Urinary catheter
• Laboratory examination
 Laboratory result
• Hb : 2,3 gr/dl  transfusion
• WBC : 40,500/ul
• Platelets : 532.000/ul
• Hematocrit : 8%
• CT/BT : 9’/3’
• Glucose ad random : 36 mg/dl
• Sodium : 141 meq/L
• Potassium : 5,2 meq/L
• Chloride : 108 meq/L
• Ureum : 151 mg/dl
• Creatinine : 2,2 mg/dl
Diagnose
1. Acute limb ischemic of the right leg
(ICD 10 CM M79.6)
2. Anemia ( ICD 10 CM D64.9)
3. CKD ( ICD 10 CM I12.9)
Consult to TCV surgery division
• Doppler USG
• CT angiography