Case of peripheral

vascular disease
DR. SHRESTH MANGLIK
Chief complaint

 Mr G
 62 yr
 Kolkata
 Factory worker

 Painful right leg since 5 months

 Blackening of right 2nd toe since 2 weeks.
History of present illness

 Patient was apparently normal 5 months ago, when he noticed pain in the right
calf for 5 months.
 Pain was insidious in onset; progressive in nature. Initially, cramping pain used to
appear in right calf region after walking for around 1 km which compels the
patient to take rest for some time to get relieved of pain.
 The distance he could walk with out pain gradually shortened over last few
months
 But, for last 2-3 weeks patient is experiencing continuous, severe pain in the right
foot, throughout day and night and disturbing his sleep & life style. The pain
slightly reduces by hanging down the legs below the level of knee but not being
reduced much after taking pain killers.
 blackening of right 2nd toe for 15 days, which started at the tip and gradually progressed to
involve whole of the toe in a span of 10 days. This blackening occurred spontaneously without
any history of trauma, also associated with burning pain, tingling & numbness in the adjacent
area of the normal skin.
 No history of fever/ foul smelling discharge /trauma
 No history of painful swelling with discoloration along the veins.
 No history of similar complaints in the other limbs
 No history of paleness of palms & soles after exposure to cold (History suggestive of Reynaud’s
phenomenon)
 No history suggestive of angina pectoris, TIA`s, mesenteric angina, impotence.
 Comorbidities:
 H/o HTN since 10 YRS and with poor drug compliance

 PAST HISTORY:
 No history of similar complaint in past
 No surgical interventions in the past.

 PERSONAL H/O:
 Known smoker with h/o consumption of more than 10 cigarettes per day for 30 yrs
( smoke year index 300) stopped since 2 weeks.
 No history of tobacco usage in any other form.
 History of occasional alcohol intake is present
 Takes mixed diet
 Bowel and bladder habits are normal.
 Appetite is normal and sleep is disturbed due to pain
 Family h/o:
 no h/o of CVA/TIA/vasculitis/sudden cardiac death/similar complaint in family.

 Treatment h/o: no prior hospitalisation

Summary

 A 62 yr gentleman, known htn and chronic cigarette smoker presented with pain
in right calf and foot since 5 months which is progressed to rest pain.
 Blackish discolouration of right 2nd toe since 2 weeks associated with pain and
loss of sensation.
 With out any h/o trauma,fever,foul smelling discharge.
 No history suggestive of angina pectoris, TIA`s, mesenteric angina, impotence
General survey

 I examined the patient with prior informed consent with adequate exposure and light , giving
respect to his privacy in the presence of a staff nurse.
 Patient is conscious, coherent, co-operative
 Moderate built and nourished with BMI-21
 Hydration status – Well maintained
 Performance scale –kps -80
 No Pallor / Icterus / Cyanosis / Clubbing / Generalized lymphadenopathy/pedal edema.
 Walks with limp on his right leg and prefers not placing right foot on ground.
 Vitals:
 Pulse – 88/min in the right radial artery , normal volume, regular rhythm, no
radio-radial delay and radio-femoral delay in both arms
 BP: 140/80 mmHg in both right arm & left arm in supine position.
 Afebrile
 Respiratory rate: 14 cycles / min (abdomino-thoracic)
 PAIN score (VAS)-6/10
 JVP not raised, neck veins not dilated.
 There is evidence of xanthelesma
Loco regional examination
 Inspection: exposing mid chest to foot with genital covering.
 patient is in discomfort and not willing to lie flat.
 Sitting with his right knee bent and holding the left foot still.
 Abdomen is flat with umbilicus inverted with out scars/sinuses and visible pulsations.
 All quadrants moves equally with respiration.
 On standing there is asymmetry of the both lower limbs
 Attitude of both limbs normal
 No obvious bony deformity seen.

 Left lower limb: appears normal except loss of hair over dorsum of foot up to ankle,nails appear brittle.
 Right lower limb: blackish discolouration with dry shrivelled appearance of 2nd toe up to distal
aspect of proximal phalanx with margin of normal looking skin with a well formed line of
demarcation .
 When limb kept horizontal the foot is pale and capillary filling retarded.
 Muscle wasting can be seen in the calf region
 Skin is thinned and shiny with loss of sub cutaneous fat, loss of hair, thickened,brittle nails with
cracks and transverse ridges – all these changes present below knee
 Apart from this no other ulcer/scars/sinuses/oedema can be seen proximal to this gangrenous area
/ at pressure points.
 No evidence of varicosities along GSV/SSV.
 All toe and ankle movements and reflexes normal.
 PALPATION: RIGHT lower limb
 All of the inspector findings are confirmed
 Decreased temperature/ coldness is present below the knee level
 Dry gangrene of the 2nd toe is present with line of demarcation at the level of the base of toe. Plantar aspect of foot
normal.
 There is hyperaesthesia with tenderness present at the region of line of demarcation.
 There is calf muscle wasting on right side with 1.5 cm girth difference.
 Girth : at mid thigh equal
 at calf left > right
 Buergers test is poitive with Buerger`s angle is at 30 degrees.
 Fuchsigs crossed leg test: no ossilations noted.
 Guttering of veins can be observed at 20 degrees
 Thickened arterial wall and no palpale thrill over any of the vessels
 There is increase in capillary filling time and venous filling time.
 Motor and sensory examination of rest of the limb normal.
 Joint movements affected at 2nd metacarpo phalangeal joint.
 Left lower limb:
 Non tender
 Normal skin temperature all over the limb
 Motor and sensory examination normal.
 All inspection findings confirmed.
 All peripheral pulses felt except- dorsalis pedis artery.

 UPPER LIMB examination normal with all pulses palpable with good volume.
 Abdominal examination:
 No organomegaly
 No palpable thrill or pulsations
 No inguinal l/n palpable
 Hernial orifices normal.
Examination of pulses
 Arterial pulses are palpable in the left limb which are normal in volume and character except
dorsalis pedis artery.
 On the right side…. Femoral pulses are palpable which are normal. Popliteal pulses are
diminished. Dorsalis pedis, anterior tibial and posterior tibial arteries are not palpable.

artery right left

Superficial temporal artery +++ +++
carotid +++ +++
brachial +++ +++
radial +++ +++
femoral +++ +++
popliteal + +++
Ant tibial - ++
Post tibial - +++
Dorsalis pedis - -
auscultation

 No audible bruit over the vessels.

 Cvs: S1 , S2 heard, no murmur

 Chest: normal vesicular breath sounds.
CNS : sensation over the right foot is decreased
power and girth of muscles of right leg decreased.
External genitalia normal.
Summary of case

 A 62 yr gentleman, known htn and chronic cigarette smoker presented with pain in right calf
and foot since 5 months which is progressed to rest pain.
 Blackish discolouration of right 2nd toe since 2 weeks associated with pain and loss of sensation.
 With out any h/o trauma,fever,foul smelling discharge.
 No history suggestive of angina pectoris, TIA`s, mesenteric angina, impotence
 On examination dry gangrene of right 2nd toe with pain and tenderness with line of demarcation
surrounded by normal skin.
 Shiny skin with brittle nails present over the both foot.
 Absent pulses in right popliteal,ant tibial,post tibial and dorsalis pedis artery and left dorsalis
pedis artery.
 Wasting of right calf muscles.
 With out any venous system involvement and normal upper limb and abdominal examination.
Diagnosis

 A 62 year old gentleman known heavy smoker and hypertensive with bilateral
lower limb arterial occlusive disease complicated by dry gangrene of right 2 nd
toe ,probable site of block femoro-popliteal segment ,due to atherosclerosis with
smoking as a risk factor.