C8l1lCAL LlM8

lSCPLMlC
8LA8Lu 8?
nC8 ASMA PuSnA 81 ?uSCll
A124063
ukM P?SlC1PL8A? 8CC8AM/?LA8 4
uLllnl1lCn
A manlfesLaLlon of perlpheral arLery
dlsease (Au)for paLlenLs wlLh cbtoolc
lscbemlc test polo olcets ot qooqteoe
lasLlng more LhaL Lwo weeks due Lo
lnsufflclenL blood flow or arLerlal
occluslve dlsease
A1PCP?SlCLCC?
Secondary Lo aLherosclerosls LhaL develops when
Lhere's crlLlcal lnsufflclency ln blood supply Lo dlsLal
exLremlLles
Cxygen demands of Llssue ls noL reached leadlng Lo
Llssue desLrucLlon appearance of ulceraLlon gangrene
and resLpaln
neuropaLhy lncreases Lhe rlsk of severe Loe and fooL
leslons due Lo absence of paln durlng and afLer Lrauma
Lack of blood flow predlsposes lschemlc Llssue ln
dlabeLlc Lo have exLenslve wound wlLh poor heallng
CLlnlCAL CASL 8LSLn1A1lCn
uLMCC8APlC uA1A
name Mr8
Age 38
Sex male
8n 1364160
uaLe of assessmenL 21/9/2011
uaLe of admlsslon 9/9/2011
ur's ulagnosls LefL CrlLlcal llmb lschemlc wlLh
necrosls of 3
rd
rlghL Loe
ur's ManagemenL Surglcal (popllLeal arLery
bypass and Loes ampuLaLlon)
Sub[ecLlve AssessmenL
roblem
aLlenL complalnL of dull achlng paln aL lefL lower
llmb aL surglcal slLe (from ankle Lo Loes)vAS 3/10
aL resL and 8/10 aL movemenL and assoclaLed
paln aL bypass surglcal (from lefL Lhlgh Lo calf)
uenled any chesL paln cough breaLhlng dlfflculLy
or spuLum reLenLlon
CurrenL hlsLory
Cu 1 lefL common femoral arLery (ClA) and
popllLeal arLery bypass
asL hlsLory
aLlenL was admlLLed Lo ward on 9/9/2011 afLer
paln aL lefL lower llmb worsenlng Pe clalmed he
can sLlll walk for 20M buL Lhen he can only Lake 2
3 sLeps slnce 3/32 wlLh vAS 3/10
Cn 16/9/2011 paLlenL underwenL ampuLaLlon on
lefL 3
rd
3
Lh
Loes
Special Question
General Health: Lethargic
PMHx/Surgery:
DM for 20 years (under medication)
HPT
HD
Hypercholesterolemia
First and second right toe amputation on 2010 due to trauma
Medication/Steroid:
T. glicazide
T. matformin
T. perindonpil
T. aspirin
T. simbostatin
T. felodipine
Occupation/recreation:
Ex-security guard. Quit since October 2010. stayed
at home.
Smoking/alcohol consumption:
10-15 cigarettes per day over 30 years
Ex-alcohol consumption since 10 years ago
lnvesLlgaLlon
Cx8
uone on 20/9/2011
Pazlness on upper lobes bllaLerally
PepaLomegaly
C8!LC1lvL ASSLSSMLn1
vlLal slgn
8 130/93
P8 90
88 19
1emp 37 degrees
Ceneral observaLlon
ModeraLe slze lndlan man wlLh a leLharglc looklng
aLlenL was resLlng ln suplne on bed wlLh elevaLed lefL
lower llmb
aLlenL was consclous and response well Lo call
Local observaLlon
L on CAM C8u lv lnfuslon nasal prong 3L/mln
LefL fooL was bandaged from ankle downward
llrsL and second rlghL Loes ampuLaLlon
ulscolorlsaLlon of rlghL fooL surroundlng ampuLaLlon slLe
lnclslon of bypass surgery from lefL Lhlgh downward Lo
under knee (abouL 1m lengLh)
8reaLhlng paLLern symmeLrlcal
8reaLhlng level aplcal
ChesL deformlLy no
Cough roducLlve lneffecLlve
SpuLum nlL
alpaLlon
ChesL expanslon (uslng hand dlsplacemenL)
l
ercusslon noLe dull on upper lobes bllaLeral
AusculLaLlon
LLVLL DIIILkLNCLS IN1LkkL1A1ICN
MAnu88lCS1L8nA
L
20 CM MCuL8A1L
xlPClu S1L8nuM 10 CM CC8
110 !unC1lCn 10 CM CC8
unable Lo palpaLe lefL fooL due Lo dresslng
8educed LemperaLure aL rlghL Loes
Speclal LesL
lncenLlve splromeLry 730cc
8CM
CIN1 AC1IVL kCM
Plp flexlon 010degrees
Plp exLenslon noL LesLable
Plp abducLlon 013 degrees
Plp adducLlon Al8CM
Plp exLernal roLaLlon Al8CM
Plp lnLernal roLaLlon Al8CM
knee flexlon 013 degrees
knee exLenslon Al8CM
Ankle dorslflexlon 010 degrees
Ankle planLarflexlon 020 degrees
ASSIVL kCM
030 degrees wlLh L8
noL LesLable
l8CM

043 degrees wlLh L8

l8CM wlLh L8
l8CM wlLh L8
AnAL?SlS
hysloLheraplsL's lmpresslon
8educed alr enLry blbasal due Lo lncorrecL
breaLhlng paLLern
SpuLum reLenLlon on upper lobes due Lo poor
coughlng efforL
8educed A8CM of lower llmbs due Lo paln
lnLolerance and muscle weakness
ShorL 1erm Coals
1o correcL breaLhlng paLLern wlLhln 2/7
1o lncrease chesL expanslon wlLhln 2/7
1o clear alrways wlLhln 4/7
1o malnLaln good blood clrculaLlon and muscle
properLles of lower llmbs
Long Lerm goals
aLlenL able Lo breaLhe lndependenLly under room
alr wlLhouL oLher compllcaLlons
aLlenL able Lo ambulaLe ln ward lndependenLly or
by uslng walklng ald
LAn Cl 18LA1MLn1
1 chesL physloLherapy
8reaLhlng conLrol
1horaclc expanslon exerclse
1horaclc moblllLy exerclse
Pufflng
lncenLlve splromeLry
2 llmb physloLherapy
Anklepump exerclse
SCL
l8C
SL8
3 paLlenL educaLlon
ln1L8vLn1lCn
1 oslLlonlng propup 30 degrees
2 half lylng breaLhlng conLrol 3x
3 half lylng Lhoraclc expanslon exerclse 3x hold 3sec
4half lylng Lhoraclc moblllLy exerclse 3x
3half lylng hufflng Lechnlque3x
6half lylng lncenLlve splromeLry 3x
7half lylng ankle pump exerclse 10x
8 half lylng SLaLlc quads exerclse 3x hold 10sec
9 half lylng lnner range quad 3x hold 3 sec
10 paLlenL educaLlon
1o repeaL all breaLhlng exerclses hourly
1o repeaL lower llmb exerclses aL leasL 3x per day
LvALuA1lCn
no spuLum was cough ouL durlng lnLervenLlon of breaLhlng exerclses
aLlenL unable Lo susLalned SL8 due Lo paln lnLolerance vAS8/10
vlLal slgn
8 140/93
P890
8823
8LvlLW
klv nexL vlslL
Second vlslL (on 22/9/2011)
Su8!LC1lvL ASSLSMLn1
aLlenL sLlll complalnL of paln aL same slLe buL wlLh reduced
vAS 4/10 aL resL 7/10 aL movemenL
uenled any chesL paln cough or shorL of breaLh aLlenL
clalmed able Lo cough ouL spuLum yesLerday nlghL small
whlLlsh loose
C8!LC1lvL
vlLal slgn
P890
8820
8113/68
1emp 37 degrees
CbservaLlon
ModeraLe slze lndlan man was resLlng on propup 30degrees bed wlLh
elevaLed lefL fooL
aLlenL no longer on CAM
Cn nasal prong 3L/mln on C8u on lv lnfuslon
8reaLhlng paLLern symmeLrlcal
8reaLhlng level aplcal
LefL ankle on dresslng
necrosls of rlghL Loes ad[acenL Lo ampuLaLlon slLe
alpaLlon
ChesL expanslon
ercusslon noLe dull on upper lobes bllaLeral
AusculLaLlon
unable Lo palpaLe aL lefL ankle due Lo dresslng
8educes warmness aL Loes of rlghL fooL
LLVLL DIIILkLNCLS IN1LkkL1A1ICN
MAnu88lCS1L8nu
M
20CM MCuL8A1L
xlPCluS1L8nuM 20CM MCuL8A1L
110 !unC1lCn 10CM CC8
SLClAL 1LS1
lncenLlve splromeLry 700cc
8CM
CIN1 AC1IVL ASSIVL
Plp flexlon 010 degrees 030 degrees wlLh L8
Plp exLenslon n1 n1
Plp abducLlon 013 degrees l8CM
Plp adducLlon Al8CM
Plp exLernal roLaLlon Al8CM
Plp lnLernal roLaLlon Al8CM
knee flexlon 020 degrees 060 degrees wlLh L8
knee exLenslon Al8CM
Ankle dorslflexlon Al8CM
Ankle planLarflexlon Al8CM
AnAL?SlS
hysloLheraplsL's lmpresslon
8educed alr enLry blbasal due Lo lncorrecL
breaLhlng paLLern
SpuLum reLenLlon on upper lobes due Lo poor
coughlng efforL
8educed A8CM of lower llmbs due Lo paln
lnLolerance
LAn Cl 18LA1MLn1
ChesL physloLherapy
8reaLhlng conLrol
1LL
1ML
Pufflng
lncenLlve splromeLry
Llmb physloLherapy
Anklepump
SCL
l8C
SL8
L educaLlon
ln1L8vLn1lCn
1 poslLlonlng half lylng 30 degrees poslLlon on bed
2 half lylng breaLhlng conLrol 3x
3 half lylng Lhoraclc expanslon exerclse 3x hold 3sec
4half lylng Lhoraclc moblllLy exerclse 3x
3half lylng hufflng Lechnlque3x
7half lylng lncenLlve splromeLry 3x
8half lylng ankle pump exerclse 10x
9 half lylng lnner range quad 3x hold 3 sec
10 Palf lylng SL8 hlp flexlon 3x hold 3 sec
11 paLlenL educaLlon
1o repeaL all breaLhlng exerclses hourly
1o repeaL lower llmb exerclses aL leasL 3x per day
1o encourage uprlghL slLLlng poslLlon and drlnk warm waLer
Lo humldlfy spuLum
LvALuA1lCn
aLlenL cough ouL spuLum small whlLlsh loose
aLlenL refused for bed moblllLy due Lo paln vAS8/10
vlLal slgn
8 123/83
P889
8820
8LvlLW
klv nexL vlslL
Concluslon
CrlLlcal llmb lschemlc causlng paLlenL Lo have
severe burnlng paln aL resL 1hus lnLervenLlon
wlLh paln managemenL musL be done Lo galn
paLlenL's confldence lmporLanL Lo check vAS
Lo geL a basellne of paLlenL's paln Lolerance
MusL emphaslze on clrculaLlon exerclse Lo
prevenL furLher damage of Llssue promoLes
wound heallng
8LlL8LnCLS
!amle eL al (1999) Chronlc CrlLlcal Llmb lschemlc
ulagnosls 1reaLmenL and rognosls metlcoo lomlly
lbyslcloo web wwwaafporg
Wound Peallng erspecLlves CrlLlcal Llmb lschemlc
-otloool neolloq cotpototloo 2006 volume 3 no2
uenls ClerenL ctltlcol llmb lscbemlo lo l wwwLasc
2padorg
llmb lscbemlc ooJ llmb 5olvoqe
mhsswoundcenLerneL/crlLlcallschemlchLm
Aylesah 8amll uoJetstooJloq cotJlotespltototy
lbyslotbetopy 2008 kuala Lumpur