Gangrene Hand of Mrs. Mustiah, 86 Yo
Gangrene Hand of Mrs. Mustiah, 86 Yo
Gangrene Hand of Mrs. Mustiah, 86 Yo
Physician in charge
IA : dr. Niko, dr. Reyhan
IB : dr. Adam
II HCU : dr. Dandi
II Medical Consultation : dr. Jonny
II Incovit : dr. Dheni
II IGD : dr. Ros, dr. Helsa
II IGD Incovit : dr. Akbar
Chief on duty : dr. Ajeng
Consultant on duty : dr. Laksmi Sasiarini,Sp.PD-KEMD
Facilitator : dr. Laksmi Sasiarini,Sp.PD-KEMD
Summary of Database
Mrs. M / 86 yo / ward 28
Heteroanamnesa
Chief Complaint:
Gangrene of the right hand
History of Present Illness:
• Gangrene of the right hand was complained since 2 weeks ago. At the start, her right
forearm was injured, become swollen, hitted by fallen desk that happened 3 weeks ago.
She and her family did not seek treatment well for the injury, so it became blackened,
started from the finger tip, and rapidly spread up to her right elbow, and it really made
her suffering from pain.
• Yesterday, she was taken to the ER, treated by Orthopedic & Traumatology Department,
having amputation of her right forearm. Pain was complained after the surgery.
• Diagnosed with hypertension since 15 years ago, but never been consuming drug
routinely.
• History of diabetes was denied. There was no shortness of breath nor cough.
Summary of Database
Past Medical History:
There was no past medical history being recorded.
Family History:
There was no history of diabetes, or hypertension in his family.
Social History:
She is a widow. She had 2 children, that already died. She is now living and taken care
by her granddaughter and grandson-in-law.
Review of System:
Low intake (+)
Hard to sleep (+)
Weak energy (+)
Memory decline (+)
Physical Examination
General appearance looked moderately ill Sat O2 96 % RA, VAS 6 / 10
GCS E4V5M6 compos mentis
BW: 40 kg; BH: 155cm; BMI: 16,6 kg/m2 (underweight)
BP 172/93 mmHg PR 96 bpm regular strong RR 20 tpm Tax 36,8 oC
Head Anemic conjunctiva(-)
Neck JVP R+2 cmH20
Chest symmetrical
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : - | - Wheezing : -|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Sonor | Sonor Vesicular | Vesicular
-|- -|-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 8 cm, epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Edema (-), pale (-), MMT 5 | 5, amputated right forearm with bandage (+)
5|5
Gangrene
03/09/2021 05/09/2021
Laboratory Findings (04/09/21)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 20.930 4.700 – 11.300 /µL Ureum 42,5 20-40 mg/dL
Hemoglobine 12,9 11,4 - 15,1 g/dl Creatinine 0,32 <1,2 mg/dL
PCV 37,9% 38 - 42% BUN/Cr 19,85
Conclusion:
- Suspect of Pneumonia
- Sclerotic aorta
- Spondylosis at thoracolumbalis
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
X-Ray Antebrachii-Manus D +
Elbow
• Suspect of Osteomyelitis
POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Infection
Decrease of Geriatric
CAP Falling
immunity problem
Increased
Decreased of appetite
Catabolism
General Wound
Hypoalbuminemia
weakness
Reduced Intake
Osteomyelitis
Boyiadzis, Frame, Kohler, Fojo. McGraw-Hill Education. Hematology Oncology Therapy. Second Edition. New York:; 2014
Key Message Social
• GCS: E4VxM6
• BP: 178/95 mmHg
• PR: 98 bpm
• RR: 20 tpm
• Tax: 36.7 C
• Spo2 : 98 % RA
• VAS: 5/10