Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Surgery Final Year Case Presentation Thromboangiitis Obliterans TAO Clinical Examination Discussion and Treatment
Age : 40 years
Sex: Male
Address: Tambaram
Occupation: Works in a fruit shop
Socio Economic Class: Upper Lower class
Chief Complaints :
Pain in the left leg for the past 2 years more for
the past 2 months
History of presenting il ness
The patient was apparently normal 2 years back after which
he developed
PAIN ? In his left leg
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
Aggravated on walking up stairs
Initial y relieved on standing and now on rest
BOYD'S CLASSIFICATION ? GRADE 3
OF INTERMITTENT CLAUDICATION
Claudication distance and progress of claudication
- Initial y pain occurred only after 2 kilometers of
walking which gradual y 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
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 , swel ing , redness , cord like
thickenings along the course of veins
No H/O suggestive of Raynaud's Phenomenon
such as attacks of pain , pal or ,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
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
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 mel itus , hypertension , tuberculosis
asthma ,epilepsy ,jaundice
- No H/O Cardiac diseases , cerebrovascular accidents ,
hyperlipidemia, collagen diseases
- No H/O previous hospitalisation /surgery
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
Al ergy history
No H/O al ergy to any food or drugs
Family History
No H/O Similar complaints in the family
No H/O suggestive of atherosclerosis in the
family
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
After getting consent from the patient , the general
examination was done.
Conscious, oriented, moderately built and nourished
No pal or
No icterus
No cyanosis
GRADE 1 clubbing present
No pedal edema
No generalised lymphadenopathy
SIGNS OF ATHEROSCLEROSIS ? NO Arcus senilus , no
transverse ear crease , no xanthomas
Vital signs
Pulse rate : 82 /min , regular in rhythm ,normal in
volume and character , no vessel wal 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
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
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 , swel ing along the course of superficial veins
NO COLOUR CHANGE VISIBLE
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 , mal eoli , bal of
foot , tip of toes
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
Left
Right
Tests on inspection
GUTTERING OF VEINS : present on elevation of the limbs
BUERGER'S POSTURAL TEST : was not able to appreciate the
pal or and pink appearance as the patient was dark skinned
CAPILLARY FILLING TIME :was not able to appreciate the
pal or and pink appearance as the patient was dark skinned
VENOUS REFILLING : in the left lower limb veins col apsed at
30 degree and refil ing was slower when compared to the
right side
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
No swel ing ,tenderness , cord like
thickening of veins
Tests on palpation
Capil ary refil ing :
There was delay in the time taken for blanched toe of left
lower limb to turn pink when compared with the right side
Venous refil ing (harvey's sign):
Refil ing 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
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
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 + +
Examination of lymph nodes
Inguinal lymph nodes are not enlarged
Auscultation
No bruit
No murmurs
Reactive hyperemia test :
To be done
Systemic examination
Respiratory system :
Normal vesicular breath sounds heard . No added
sounds
Cardiovascular system :
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
Spine and cranium : normal
Diagnosis
Compensatory Peripheral vascular disease of
left lower limb in the form of Thromoangi tis
Obliterans (Buerger's disease) with probably
Femoropopliteal occlusion ( type 3)without any
complications .
Differential diagnosis :
Atherosclerosis
Vasculitis
Management
Investigations
Baseline: Complete blood count ? TC , DC , ESR
Hb% , blood grouping and typing ,BT,CT
Blood sugar , urea , serum creatinine
Urine routine : albumin ,sugar,deposits
X ray chest , ECG
Serology : HIV , VDRL , HBsAg
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
Treatment
Non surgical methods
SMOKING ABSTINENCE
MEDICAL MANAGEMENT
ANALGESICS-Tramadol-50mg TID
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.
Beurger's position
Beurger's exercise
Heel raise : to decrease load on calf
muscles
This post was last modified on 08 August 2021