Name : Mr. Kannan
Age : 40 years
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Sex: Male
Address: Tambaram
Occupation: Works in a fruit shop
Socio Economic Class: Upper Lower class
Chief Complaints :
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Pain in the left leg for the past 2 years more for the past 2 months
History of presenting illness
The patient was apparently normal 2 years back after which he developed
PAIN – In his left leg
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For 2 years more for the past 2 months
In the calf and foot region
INTERMITTENT - Brought about by walking
Cramping and Excruciating type of pain
Not radiating, Not referred
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Aggravated on walking up stairs
Initially relieved on standing and now on rest
BOYD'S CLASSIFICATION – GRADE 3
OF INTERMITTENT CLAUDICATION
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Claudication distance and progress of claudication
- Initially pain occurred only after 2 kilometers of walking which gradually reduced and now pain occurs if the patient walks 10 feet
No H/O rest pain
No H/O effect of warmth or cold on the pain
NO H/O suggestive of local causes of pain such as trauma to the legs, swelling of legs, fever
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No H/O tingling or numbness sensation
No H/O ulcers over the leg
No H/O blackish discolouration of any part of the leg
No H/O suggestive of superficial phlebitis such as pain, swelling, redness, cord like thickenings along the course of veins
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No H/O suggestive of Raynaud's Phenomenon such as attacks of pain, pallor,bluish or dusky red discolouration on exposure to cold
No H/O blackish discolouration of finger tips after such attacks
No H/O suggestive of occlusive arterial disease elsewhere in the body :
No H/O Chest pain, palpitations, breathlessness
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No H/O Black outs, loss of consciousness, weakness of limbs
No H/O Blurring of vision
No H/O Abdominal pain
No H/O Impotence
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Past history
- For the past 2 years, the patient has been visiting private clinics and has taken native medications but symptoms did not resolve
- No H/O similar complaints in the past
- No H/O diabetes mellitus, hypertension, tuberculosis asthma, epilepsy, jaundice
- No H/O Cardiac diseases, cerebrovascular accidents, hyperlipidemia, collagen diseases
- No H/O previous hospitalisation /surgery
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Personal history
- Patient consumes non-vegetarian diet
- Normal bowel and bladder habits
- H/O Smoking from the age of 13 years No of years of smoking : 27 years Smokes 3 packets of cigarettes per day SMOKING INDEX : 810 PACK YEARS INDEX : 81
- H/O Alcohol consumption for the past 1 year 180 ml per day
- No H/O drug abuse
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Allergy history
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No H/O allergy to any food or drugs
Family History
No H/O Similar complaints in the family
No H/O suggestive of atherosclerosis in the family
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Summary
A 40 year old male, who is a chronic smoker presented with complaints of excruciating pain in calf and foot during walking which is relieved by rest of BOYD'S GRADE 3 with history suggestive of progressive claudication.
The probable diagnosis is peripheral vascular disease involving femoral, popliteal, tibial arteries.
General examination
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After getting consent from the patient, the general examination was done.
Conscious, oriented, moderately built and nourished
No pallor
No icterus
No cyanosis
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GRADE 1 clubbing present
No pedal edema
No generalised lymphadenopathy
SIGNS OF ATHEROSCLEROSIS – NO Arcus senilus, no transverse ear crease, no xanthomas
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Vital signs
Pulse rate : 82/min, regular in rhythm, normal in volume and character, no vessel wall thickening, no radioradial/radiofemoral delay
Dorsalis pedis, posterior tibial and popliteal pulsations absent in the left lower limb
Respiratory rate : 16/min, abdominothoracic
Blood pressure : 110/70 mm hg measured in left upper arm in sitting posture
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Patient is afebrile
Examination Of Lower Limbs
After explaining the procedure and getting consent, patient was exposed from mid thigh and examination was done under bright light
INSPECTION – patient in supine posture with both the legs kept side by side
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Attitude: the limbs are extended at both hip and knee joint
No deformity present
Muscle wasting present in the calf region in left leg
No redness, swelling along the course of superficial veins
NO COLOUR CHANGE VISIBLE
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Examination of lower limbs
Signs of peripheral ischemia : present in left limb
- There is diminished hair over the left limb - calf
- Thinning of skin present
- There is Loss of subcutaneous fat
- Shininess present
- Trophic changes in nail : brittle nail present
- No ulceration in pressure areas like heel, malleoli, ball of foot, tip of toes
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A scar of 5 x 4 cm is present over the inner aspect of calf in the right leg, scar is healthy – history suggested as silencer burn
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Left
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Right
Tests on inspection
GUTTERING OF VEINS: present on elevation of the limbs
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BUERGER'S POSTURAL TEST : was not able to appreciate the pallor and pink appearance as the patient was dark skinned
CAPILLARY FILLING TIME :was not able to appreciate the pallor and pink appearance as the patient was dark skinned
VENOUS REFILLING : in the left lower limb veins collapsed at 30 degree and refilling was slower when compared to the right side
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EXAMINATION OF LOWER LIMBS
NO GANGRENE OR ULCER PRESENT OVER BOTH THE LOWER LIMBS
PALPATION
Skin temperature : skin is warm over both the lower limbs except for the left foot which is cold
No tenderness present
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No swelling, tenderness, cord like thickening of veins
Tests on palpation
Capillary refilling :
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There was delay in the time taken for blanched toe of left lower limb to turn pink when compared with the right side
Venous refilling (harvey's sign):
Refilling of vein segment slow in the left lower limb when compared to the right side
Crossed leg test (FUCHSIG'S TEST): was not well appreciable
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Examination of Peripheral pulses
| RIGHT | LEFT | |
|---|---|---|
| Superficial temporal artery | ++ | ++ |
| Carotid artery | ++ | ++ |
| Brachial artery | ++ | ++ |
| Radial artery | ++ | ++ |
| Femoral artery | ++ | + |
| Popliteal artery | ++ | - |
| Posterior tibial artery | ++ | - |
| Dorsalis pedis | + | - |
Examination Of Joints
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| Movements of | Right | Left |
|---|---|---|
| Interphalangeal joint | N | N |
| Metatarsophalangeal joint | N | N |
| Ankle joint | N | N |
| Knee joint | N | N |
| Hip joint | N | N |
Examination of nerves
| MOTOR | RIGHT | LEFT |
|---|---|---|
| Bulk (Calf) | 31cm | 28cm |
| Tone | normal | normal |
| Power | 5/5 | 5/5 |
| Reflexes | normal | normal |
| Plantar response | flexion | flexion |
| SENSORY | ||
| Crude / fine touch | + | + |
| Pain | + | + |
| Temperature | + | + |
| Vibration | + | + |
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Examination of lymph nodes
Inguinal lymph nodes are not enlarged
Auscultation
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No bruit
No murmurs
Reactive hyperemia test :
To be done
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Systemic examination
Respiratory system :
Normal vesicular breath sounds heard. No added sounds
Cardiovascular system :
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S1 S2 heard. No murmurs
Central nervous system :
No focal neurological deficit
Abdomen :
Soft, non tender, no organomegaly, no free fluid, hernial orifices free, external genitalia normal
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Spine and cranium : normal
Diagnosis
Compensatory Peripheral vascular disease of left lower limb in the form of Thromoangiitis Obliterans (Buerger's disease) with probably Femoropopliteal occlusion ( type 3) without any complications.
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Differential diagnosis :
Atherosclerosis
Vasculitis
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Management
Investigations
Baseline: Complete blood count – TC, DC, ESR
Hb%, blood grouping and typing, BT, CT
Blood sugar, urea, serum creatinine
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Urine routine : albumin, sugar, deposits
X ray chest, ECG
Serology : HIV, VDRL, HBsAg
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Specific investigations
- Blood sugar : fasting, post prandial, HbA1C
- LIPID PROFILE
- Anti nuclear Ab, Anti Phospholipid Ab, homocysteine levels
- DOPPLER ultrasound
- DUPLEX SCAN
- Angiography
- BROWN'S VASOMOTOR INDEX
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Treatment
Non surgical methods
SMOKING ABSTINENCE
MEDICAL MANAGEMENT
ANALGESICS-Tramadol-50mg TID
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Ketorolac-20mg TID
PENTOXYFILLIN 400mg TID
Used to treat intermittent claudication.
Improves blood flow through the peripheral blood vessels by increasing flexibility of RBC, decreasing platelet aggregation and thrombus formation, reduces blood viscosity.
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Beurger's position
Beurger's exercise
Heel raise : to decrease load on calf muscles
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)
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