Case presentation at Civil hospital,Ahmedabad. A case of lower limb arterial occlusive disease due to atherosclerosis.

1. Case Presentation on Peripheral
Arterial Occlusive Disease
By Dr. Neel Patel
3rd Year Resident,
Tuesday Surgical Unit,
Civil Hospital, Ahmedabad.

2. History
A 52 year old female patient Pankunvar Mishra, residing at Bhind district in
Madhya Pradesh,is a housewife coming from lower socio economic class came to
Civil Hospital Ahmedabad with chief complain of
Pain in right leg since 2 years
Blackening over Right great toe, 2nd toe and 3rd toe since 4 months

4. Patient was relatively asymptomatic before 2 years then she developed pain in
right calf muscle while walking. Pain is cramping in nature appears after walking
approximately 500 meters and it disappears after taking rest and reappears on
walking same distance. The walking distance has gradually shortened over a few
months and she developed rest pain 4 months back. She consulted doctors in
AIIMS hospital, New Delhi where some drug was injected on right side of her back
after which she got relief in rest pain and now she can walk 20 steps before onset
of pain.
She noticed black discolouration over Right great toe which has progressed slowly
and has involved 2nd and tip of the 3rd toe.

5. No history of similar complaints in other limb.
No complain of pain, swelling or discolouration along the course of superficial
veins.
No complain of pain,pallor or bluish discolouration on exposure to cold.
No complain of transient blackout or loss of consciousness.
No complain of abdominal pain or other gastrointestinal symptoms like nausea,
vomiting, constipation, diarrhea, bleeding per rectum.

6. Past history of single attack of chest pain 3 years ago.
Known case of hypertension since 3 years for which she is taking furosemide+
spironolactone (20/50) ½ BD, Enalapril (2.5 mg) 1 BD, Digoxin(0.25 mg) ½ OD
Past history of Incision and Drainage over right great toe 9 months ago and right
sided chemical sympathectomy 4 months ago.

7. No history of TB, Diabetes mellitus, Jaundice, blood transfusion.
Patients is on Vegetarian diet with normal appetite and normal sleep pattern at
present. Bladder function is normal. No addiction to tobacco or alcohol
,menopausal since 8 years.
No history of any drug allergy.
No history of similar complaint in family.

8. General Examination
I have examined patient in proper light and exposure. Patient is fully conscious,
cooperative and well oriented to time, place and person.
Patient is fairly built, fairly nourished. Pallor is present. No evidence of Oedema,
jaundice, cyanosis, clubbing or lymphadenopathy.
Temperature is normal by palpatory method.
Pulse is 88/min in right radial artery with normal force, volume and tension. Blood
pressure is 130/80 mmhg in Right and Left brachial artery and 120/70 mmhg in
Right and left femoral artery with no radio femoral delay.
Back and spine normal.

9. Systemic Examination
1. Respiratory: Bilateral air entry is present. No abnormal sounds are heard.
2. Cardiac: S1, S2 sounds are present. No murmur heard.
3. Abdomen: Abdomen is flat, umbilicus centrally placed, no dilated
veins,striae,scar. On palpation abdomen is soft, no tenderness, no guarding,
no rigidity is present. On percussion no free fluid is present and bowel sounds
are present on auscultation.

10. Local Examination
Inspection:
1. Muscle wasting is evident in calf muscles of right lower limb compared to left.
2. Guttering of veins is evident on elevation of right limb to 30 degree.
3. Signs of ischemia like thin and shiny skin, loss of subcutaneous fat and loss
of hairs are present.
4. Loss of nail plate on great toe and brittle and deformed nails are present over
the other toes.
5. Dry and shriveled Great toe,2nd and 3rd toes. Blackening over toes present.
Line of demarcation present. Skip lesion absent.

11. 6. A single 0.5 x 0.5 cm sized ulcer with ill defined margin, punched out edge with
pale granulation tissue in floor and serous discharge from it. No evident ulcer on
other pressure areas like heel, malleoli, ball of toes present.
7. On Buerger's postural test pallor appears at angle of 30 degree.
8. Capillary filling time is 20 seconds.
9. Venous refilling time is 10 seconds.
10.Signs of ischemia present in opposite limb. No gangrenous changes.
11. On crossed leg test oscillatory movements are absent.

12. Palpation
1. Right foot and leg is cold on palpation as compared to left limb. At the level of
thigh temperature is similar in both limbs.
2. Dry gangrene is present over Right great toe, 2nd toe and 3rd 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.
3. No tenderness or pitting edema in adjacent normal limb.

13. Palpation
4.Delayed capillary refilling.
5.Plantar reflex: flexor response.
6.Ankle flexion and extension against resistance present.
7. Knee joint flexion and extension against resistance present.

14. 8. No inguinal lymphadenopathy.
9. Pulsations
FA PA PTA ATA DPA
Right + - - - -
Left + + + - -
Radial Ulnar Brachial Axillary Subclavian
Right + + + + +
Left + + + + +

15. Pulsations over Bilateral Carotid artery, facial artery, temporal artery are present.

16. The condition of arterial wall is normal and there is no special character of the
pulse.
Auscultation: No bruit heard.

17. Diagnosis
This is a case of Peripheral Arterial Disease affecting the both lower limb with
ischemic gangrene of right great toe,2nd toe and 3rd toe most probably due to
atherosclerotic vascular disease.