NISCHIT B M

MBBS 2018
AIIMS BHOPAL
 DEMOGRAPHY
Name: RAMKISHAN

Age: 52 yr

Gender: Male

Residence: Bhopal, MP

Occupation: LABOURER

Socioeconomic status: Lower class according to modified Kuppuswamy scale

 PRESENTING COMPLAINS AND HISTORY-

C/C - PAIN AND BURNING SENSATION IN THE FOOT SINCE 6 MONTHS.

• The pain was gradual on onset, progressive and episodic.

• Initially the pain used to occur whenever he switched from rest to activity but would
gradually subside with the continuation of activity
(Activity= Mansionary/walking long distances with BARE FOOT)- Boyds class 1

• Over the course of 4 months, the Sx progressed such that the pain used to start on
walking, increased in intensity as he continued walking, and used to get releived on
rest.- Boyds class 3.

• Multiple visits to local hospital were unsuccessful in establishing a proper diagnosis and
he was treated with analgesics.
 CASE PROGRESSION

• Over the course of next 2 months the Sx even worsened with

1) BLACKISH DISCOLORATION OF GREAT TOE WITH MULTIPLE WOUNDS
OVER IT.
2) INABILITY TO MOVE THE TOE WITH LOSS OF SENSATION.
3) INCREASED PAIN INTENSITY

• Following which he visited AIIMS on 27th Dec, got his great toe amputated
and, advised for daily dressing, and was dischared after 4 days of
hospitalization.
• Since 10 days the is complaining of Pain and discharge from the site of
amputation.
WAIT GUYS...... THE HISTORY IS NOT DONE YET

H/O smoking beedi since 30 years (2 packs per day).

No H/O pain in the left leg and upper limbs.
Not a known case of Hypertension or Diabetes Mellitus.
No H/O trauma, burns or cold exposure.
No H/O chest pain, transient blackouts, LOC, or abdominal pain.

PAST and PERSONAL HISTORY

No H/O previous chronic illness, surgeries, hospitalization, Drug allergy, TB,
asthma, syphilis, alchohol consumption.
Sleep and apetite, bowel n bladder habits- NORMAL.

FAMILY HISTORY - Not significant

 GENERAL PHYSICAL EXAMINATION
• GAIT- The patient limps on his left leg to avoid bearing weight of his
right foot and uses a stick while walking.

• The patient is examined in sitting position in a well lit room with

verbal consent. ( Examiner standing on the right side of the couch)

• The patient is conscious, cooperative and well oriented to time, place

and person.

• The patient is thin built, with adequate nutritional and hydration status.
 VITALS
• TEMPARATURE :- Afebrile to touch
• PULSE:- 78 beats/min in radial artery with rythymic , normovolumic ,
arterial wall was is not palpable.
There was no radio-radial and radio-femoral delay
(EXAMINATION OF PERIPHERAL PULSES IS DONE ALONG WITH LOCAL
EXAMINATION.)
• BP:- 112/78 mmHg in right arm in sitting position with adult sized Riva-
Rocci cuff.
• RESPIRATORY RATE:- 18 cycles/min- Thoracoabdominal
breathing.
• SpO2 : 100% in Room Air
 HEAD TO TOE EXAMINATION.
• Pallor and icterus- Absent
• Oral hygiene is poor, cyanosis - Absent.
• Cervical and axillary lymphadenopathy- Absent
• No dilated veins on neck and chest

• Clubbing- PRESENT (GRADE III)

(Nail signs- Erosion of nail bed and transverse ridge on right little finger)

• Pedal edema- Absent

 LOCAL EXAMINATION
The local examination is carried out with adequate exposure of lower limbs (Till
waist) and by comparing the normal limb with the diseased limb.

INSPECTION
• Both the limbs are eqally bulky and there is no evidence of wasting.
• Movements at all the joints is preserved (Except for the Amputated toe).
• SKIN OVERLYING BOTH THE FOOT show ischemic changes-
1) Loss of hair
2) Loss of subcutaneous fat
3) Trophic changes in nails with transverse ridges.
• Skin over the plantar aspect- Thick, soiled and show multiple small ulcerations
over the pressure areas (heel).
• ULCER-

 An irregular shaped ulcer of about 4/3 cm (in widest dimensions) is present

on the right foot extending from the stump of the amputated toe (great toe)
to the plantar aspect of 2nd and 3rd toe)
The floor of the ulcer has pale granulation tissue with patchy necrosis
The edge is non healing, slopy with sloughing of tissue and active pus
discharge.
Line of demarcation is not appreciated.
Skin sorrounding the ulcer looks edematous and necrotic.
Rest of the limb above the ulcer apprears normal
SKIP lesions- ABSENT.

• BUERGERS POSTURAL TEST- Could not be assessed due to dark complexity of

the pt and soiled soles.
 PALPATION
• TEMPARATURE- The local temparature is decreased (Cold peripheries
indicate ischemia) and the skin is dry inelastic.
• TENDERNESS PRESENT over the margins and floor of the ulcer.
• PALPATION OF ULCER-
 MARGINS- Indurated, ischemic and tender.
(On applying pressure over the margin towards the ulcer oozing of pus is
observed)
EDGES- Non healing, slopy with sloughing of tissue and active pus discharge.
FLOOR- Pale granulation tissue with patchy necrosis, soft on palpation and
FIXITY TO THE BASE IS ABSENT
BASE- Is formed by Plantar muscles, Phalanges of 2nd & 3rd toe, and
metatarsophalangeal joint.
• CAPILLARY REFILLING TIME- 7 sec on Right side
4 sec on Left side

• VENOUS REFILLING TIME- 22 sec on the Right side

16 sec on Left side

• FUCHSIG’s TEST- OSCILLATORY MOVEMENTS SEEN

• PALPATION OF VESSELS OF AFFECT LIMB

 Skin overlying the superficial veins is normal (Non tender, Non indurated)-
NO EVIDENCE OF THROMBOPHLEBITIS.
 PERIPHERAL PULSES.
 LOWER LIMB
FA PA ATA PTA DPA
RIGHT + + + + -
(Hypovolumic) GRADE I
GRADE II
LEFT + + + + +
(Hypovolumic) (Hypovolumic)
GRADE II GRADE II

 UPPER LIMB
AXILLARY BRACHIAL RADIAL ULNAR
RIGHT + + + +

LEFT + + + +
 SYSTEMIC EXAMINATION
Abdominal examination:-
-Flat in shape, Umblicus is central and inverted
- No dilated veins, tenderness or palpable lump
Central nervous system:-
-HIgher mental functions are intact.
- No sensory and motor deficit with preserved deep tendon reflexes
Cardiovascular system:-
-S1, S2 heard over all the cardiac ares and S1 is synchronised with carotid pulse.
-No added sounds and murmurs.
Respiratory system:-
B/L air entry is present. Normal vesicular sounds were present all over the lung
No added sounds were heard
 PROVISIONAL DIAGNOSIS

52 YEAR OLD CHRONIC SMOKER WITH PERIPHERAL ARTERIAL

OCCLUSIVE DISEASE (PROVISIONALLY BEURGER’S DISEASE) POST

AMPUTATION OF RIGHT SIDE GREAT TOE WITH NONHEALING

ULCER OVER THE STUMP (INFECTED STUMP)

APPROACH AND DIFFERENTIAL
DIAGNOSIS
DIFFERENTIATING OTHER CAUSES OF CLAUDUCATION
INVESTIGATIONS
 GENERAL INVESTIGATIONS
• Complete blood count
• Lipid profiling
• Renal function test
• Urine:- Routine and Microscopy
• Electrocardiography
• Roentgenogram of affected area
• Pus culture for microorganism and drug sentitivity
• Gram staining of pus.
ANKLE- BRACHIAL INDEX
DUPLEX SCAN
DIGITAL SUBSTRACTION
ANGIOGRAPHY (DSA)
CT ANGIOGRAM
PLETHESMOGRAPHY
MANAGEMENT
PHARMACOTHERAPY