Peripheral Vascular Disease Case Presentation

Peripheral arterial occulsive disease with gangrene of toes due to atherosclerotic vascular disease.

1. CASE PRESENTATION ON PERIPHERAL VASCULAR DISEASE By Yashonidhi Tomer Roll No- 161 Surgery 2 nd Year Posting Jawaharlal Nehru Medical College, Belgaum

2. DEMOGRAPHICS NAME – Barappa B. Konkanwadi AGE - 61 years SEX – Male OCCUPATION – Farmer ADDRESS – Kalloti , Shimong RELIGION- Hindu SOCIO-ECONOMIC STATUS- Average

3. CHIEF COMPLAINTS Pain in right lower limb since 2 years Blackening over Right great toe , 2 nd toe and 3rd toe since 3 months

4. HISTORY OF PRESENTING ILLNESS Patient was apparently alright 2 years ago when he developed pain in right calf muscle while walking but he could still walk with effort. Pain was dull aching type , insidious in onset and progressive in nature. It appeared after walking 500 meters and disappeared after taking rest and reappeared on walking same distance. The walking distance has gradually shortened over a few months and he developed pain at rest in the toes four months back which is continuous and aching in nature aggrevated at night. He noticed black discolouration over Right great toe 3 months ago which has progressed slowly and has involved 2 nd and tip of 3 rd toe.He also felt numbness in the toes. For the above complaints he consulted a local doctor in Gokak and was given medication . But following no improvement, he was referred to KLE Hospital.

5. No H/O similar complaints in other limb No H/O pain, swelling or discolouration along the course of superficial veins No H/O pain ,pallor, discomfort on exposure to cold. No H/O pricking pins like sensation. No H/O transient blackouts or loss of consciousness. No H/O abdominal pain or other gastrointestinal symptoms like nausea , vomiting, constipation , diarrhoea, bleeding per rectum. No H/O Impotence. No H/O fever and blurred vision. No H/O ulceration in any other parts of the body.

6. PAST HISTORY He had a single attack of chest pain 3 years ago Known case of hypertension since 3 years and on treatment. No H/O TB, Diabetes mellitus , Jaundice , Asthma and Blood transfusion No H/O Frost bite. No H/O previous surgeries. No H/O similar complaints in past.

7. FAMILY HISTORY No History of similar complaints in family. No History of TB , Diabetes, Hypertension, Asthma. No History of any inherited disorders in family.

8. PERSONAL HISTORY Patient is on Vegetarian diet, with Normal appetite, and Normal Sleep pattern. His Bowel and Bladder habits are normal. He has no addiction to Smoking ,Tobacco or Alcohol.

9. GENERAL PHYSICAL EXAMINATION Patient is an elderly male of moderate built and nourishment . He is conscious , cooperative and well oriented to time ,place and person. VITALS- PULSE- 88 BPM in the Right radial artery with normal rhythm, volume and character. BLOOD PRESSURE- 130/80 mmHg in Right and Left Brachial artery and 120/70mmHg in Right and Left Femoral artery with no radio femoral delay. RESPIRATORY RATE- 22 Breaths per minute TEMPERATURE is afebrile by palpation Pallor is present. No evidence of Odema , Icterus, Cyanosis, Clubbing or Lymphadenopathy.

10. SYSTEMIC EXAMINATION CNS- Higher mental functions are intact , No tremors. RESPIRATORY SYSTEM- Normal vesicular breath sounds heard, no added sounds heard. CVS- S1,S2 heard, no added sounds. PER ABDOMEN- Abdomen is flat, umbilicus centrally placed, no dilated veins , strain, scar. On Palpation abdomen is soft, no tenderness, no guarding, no rigidity is present. On Percussion no free fluid is present and normal bowel sounds are present on auscultation

11. LOCAL EXAMINATION

12. INSPECTION Slight pallor is present in both the legs. Muscle wasting is evident in calf muscles of right lower limb compared to left. Buerger’s Postural Test- Guttering of veins is evident on elevation of right limb to 30 degree. Signs of Ischemia - like thin and shiny skin, loss of subcutaneous fat, loss of hairs are present on both limbs but no gangrenous change is seen in opposite limb. Loss of nail plate on great toe and brittle and deformed nails are present over other toes. Dry and shriveled Great toe , 2 nd and 3 rd toes. Blackening over toes present.Line of demarcation present and no Skip lesions. Capillary filling time- 20 seconds Venous refilling time - 10 seconds

13. BUERGER’S POSTURAL TEST The patient is in supine position. Ask the patient to raise his legs one after the other keeping the knees straight. The legs of normal individual remains pink even if raised to 90 degree. But in case of an ischaemic limb elevation to a certain degree will cause marked pallor. The angle between the limb at which such pallor appears and the horizontal plane is known as Buerger’s angle or Vascular angle. Vascular angle <30 degree- severe ischameia .If no pallor it indicates arterial occlusion.

14. PALPATION Right foot and leg is cold on palpation as compared to left limb. At the level of thigh temperature is similar in both limbs. Dry gangrene felt as hard and shriveled area is present over Right greater toe, 2 nd toe and 3 rd toe with loss of sensation over gangrenous part and loss of movement at metatarso-phalangeal joints. There is Hyperesthesia over dorsum of right foot. No Crepitus present. Delayed capillary and venous refilling. No tenderness or pitting odema in adjacent normal limb. Reflexes of the limb like plantar reflex are intact. Ankle, hip and knee flexion and extension against resistance present.

15. PULSATIONS- The condition of the arterial wall is normal with no special character of pulse Crossed leg test - Oscillatory movements are absent. No Inguinal lymphadenopathy. Femoral Artery Popliteal Artery Post. Tibial Artery Ant. Tibial Artery Dorsalis Pedis Artery Right + - - - - Left + + + - - Radial Artery Ulnar Artery Brachial artery Axillary Artery Subclavian Ar. Right + + + + + Left + + + + + Facial Artery Carotid Artery Temporal Artery Right + + + Left + + +

16. Crossed leg test (Fuchsig's test). This is performed to detect popliteal pulsation. The patient is asked to sit with the legs crossed one above the other so that the popliteal fossa of one leg will lie against the knee of the other leg. The patient's attention is diverted by taking history. The crossed leg will show oscillatory movements of the foot which occur synchronously with the pulse of the popliteal artery. If the popliteal artery is blocked, this oscillatory movement will be absent .

17. AUSCULTATION No Bruits heard. Reactive Hyperaemia Test- red flush appears in 8 seconds Reactive hyperaemia test is performed to know the severity of arterial ischaemia . This is done by inflating a sphygmomanometer cuff around the limb to 250 mm Hg for 5 minutes. Then the cuff is deflated and the time of appearance of red flush in the skin is noticed. It is 1 to 2 seconds in case of normal limb and it will be delayed in case of arterialocclusive disease and it may never appear in case of severely ischaemic limb.

18. PROVISIONAL DIAGNOSIS Peripheral Arterial Occulsive disease affecting both lower limbs with ischaemic gangrene of right greater toe,2 nd toe and 3 rd toe secondary to Atherosclerotic Vascular disease.

19. PERIPHERAL ARTERIAL DISEASE CLASSIFICATION

20. INVESTIGATIONS Blood- Routine blood examination along with blood sugar and Serum P-lipoproteins, Triglycerides and Cholesterol. Doppler Ultrasonography Peripheral Angiography (arteriography)- Seldinger technique CT Angiography MR Angiography Digital subtraction Angiography Segmental Plethysmography Isotope technique ( Technitium 99). Ankle- Brachial index ECG and Echocardiogram Abdomen USG Doppler USG

21. TREATMENT Medical treatment- Risk factor modification Lipid lowering agents like statins. Anti-Hypertensive agents Antiplatelet drugs like Aspirin,Clopidogrel Rheological agents ( Pentoxiphylline ) Antioxidants Surgical procedures- Arterial Bypass surgery. Endarterectomy Stents Balloon Angioplasty Atherectomy Amputation

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