The document provides a detailed case study of a 50-year-old male, Ramesh, who presents with pain, black discoloration, and ulcers on his left foot, indicating probable peripheral arterial disease due to diabetes and hypertension. The patient has a history of chronic smoking, and clinical examination reveals features of dry gangrene and ischemia with amputations previously performed. The management plan includes smoking cessation, blood sugar control, antiplatelet therapy, and potential surgical interventions.

1. -Chaitra
CASE ON PERIPHERAL
VASCULAR DISEASE

2. PATIENT PARTICULARS
 Name: Ramesh
 Age: 50 years
 Sex: Male
 Occupation: Daily wage worker
 Address: Malavalli, Mandya
 Education: No formal education
 Socio-economic status: Class 4 (Modified BG
Prasad’s Classification)

3. CHIEF COMPLAINTS
 Pain in the left foot since 4 months
 Blackish discoloration of left foot since 3 months
 Ulcer on left foot and ankle since 1 week

4. HISTORY OF PRESENTING ILLNESS
 Patient was apparently well 4 months back. Then
he started feeling pain the left foot on walking,
which is continuous, severe, localized to left foot
and dull aching nature. Pain aggravates on lying
down and relieves by hanging leg down. There is
no diurnal variation.
 History of intermittent claudication present with
claudication distance of 500 meters, increased to
become rest pain in the foot within 1 month
 No history of claudication in right thigh, gluteal
region, both upper limbs and right lower limb

5.  History of blackish discoloration of left 1st
toe
noticed 3 months back which was insidious in
onset, associated with increased sensation. (He
had underwent amputation of left 1st
and 2nd
toe at
local hospital)
 Then the blackish discoloration progressed to
remaining toes of left foot, the whole of left foot and
lower part of left leg since 1 month. It is associated
with loss of sensation of left foot
 The dried black area over dorsum of foot and lateral
part of ankle sloughed of and he developed
ulceration 1 week back, which spontaneously
developed, painful and hypersensitive with no
discharge
 No history of trauma

6.  He is a known case of diabetes mellitus type 2 since 7
years, was on oral hypoglycaemic agents since 7 years
and on insulin since 1 month
 He is a known case of hypertension since and on
medication since 4 years
 He is a chronic smoker who smokes 4-5 cigarettes per
day for last 20 years
 No history of fever
 No history of superficial phlebitis
 No history of previous episodes
 No history of fainting, transient blackouts, blurring of
vision
 No history of abdominal pain, chest pain
 No history of weakness of upper limb
 No history of impotence

7. PAST HISTORY
 Known case of diabetes mellitus type 2 since 7
years and hypertension since 4 years
 History of amputation of 1st
and 2nd
toe of left foot
3 months back
 No history of major surgery/long term
hospitalisation
 No history of TB, coronary artery disease

8. DRUG HISTORY
 Tab. METFORMIN 500mg 1-0-1 for 7 years
 INSULIN since 1 month
 Tab. TELMISARTAN 40mg 1-0-0
 Tab. HYDROCHLOROTHIAZIDE 12.5mg 1-0-0
 No history of any drug allergy

9. PERSONAL HISTORY
 Diet: Mixed
 Appetite: Normal
 Bowel and Bladder: Regular
 Sleep: Undisturbed
 Habits: Chronic smoker since 20 years, 4-5
cigarettes per day; consumes alcohol
ocassionally

10. FAMILY HISTORY
 No history of MI, stroke in the family
 No history of similar complaints in the family

11. SUMMARY
 A 50 year old gentleman, daily wage worker by
occupation presented with pain in left foot since 4
months, blackish discoloration of the left foot since
3 months and ulcer over the left foot and ankle
since 1 week. He is a known case of diabetes
mellitus Type 2 since 7 years and hypertension
since 4 years. He has undergone amputation of 1st
and 2nd
toe of left foot 3 months back
 Probably peripheral arterial disease of left foot with
arterial ulcer and gangrenous changes
 Differential Diagnosis:
 Thromboangitis Obliterans (TAO)/ Buerger’s Disease
 Atherosclerotic disease of lower limb

12. GENERAL PHYSICAL EXAMINATION
 Here is a middle aged male patient, moderately
built and nourished, conscious and cooperative,
well oriented to time place and person,
comfortable with legs hanging below the level of
bed
 Consent was taken
 Height: 155cm; Weight: 55 cm; BMI: 22.89kg/m2
 Pallor present
 No icterus, cyanosis, clubbing, edema
 No generalized lymphadenopathy

13. VITALS:
 Temperature: Clinically afebrile
 Pulse: 100bpm, right radial, regular rhythm,
normal volume and character, no radio-radial
delay, no radio-femoral delay, no vessel wall
thickening
 Blood Pressure: 130/90mmHg in both arms,
supine position
 Respiratory rate: 16 cycles/minute,
abdominothoracic

14. LOCAL EXAMINATION
 Patient is explained about the procedure and is
examined in supine position under adequate light
exposure
 Both lower limbs are completely exposed from
the level of ASIS to tip of toe

15. INSPECTION
 Right Lower Limb:
No signs of ischemia
Buerger’s test: 45° vascular angle
Capillary and venous filling: Prolonged
 Left Lower Limb:
Attitude of limb: Legs hanging down the bed
1st
and 2nd
toe amputated
There is black mummified appearing dry gangrene
of remaining toes with blackish discoloration of
entire foot and lower part of leg till 2cm above
malleolus with clear line of demarcation

16. Left leg below knee shows signs of ischemia:
 Thinning of skin
 Loss of hair
 Loss of subcutaneous fat
 Lustreless
 Nails show transverse ridges and are brittle
There are 2 ulcers:
 5x4cm over dorsum of foot and 5x3cm over lateral malleolus
 Both are irregular in shape, punched out edges, grey fibrotic tissue
on floor, extensor tendons exposed at dorsum, lateral malleolus
exposed on lateral side, no discharge
 Surrounding skin is dry and pale
Wasting of calf muscle seen
Buerger’s vascular angle: Toes already gangrenous
indicating severe ischemia
Capillary filling time: Prolonged
Venous refilling: Delayed and veins are guttered

17. PALPATION
 Right lower limb- Normal
 Left foot cold compared to right side
 Left toes are gangrenous appearing mummified
and shrivelled
 Tenderness noted at junction of gangrenous and
normal tissue
 Cross leg test/ Fuchsig’s Test: Oscillatory
movement of left foot noted
 Ulcer: Inspectory findings confirmed on palpation

18. ARTERY RIGHT LEFT
Dorsalis Pedis + -
Anterior Tibial ++ -
Posterior Tibial ++ -
Popliteal ++ +
Femoral ++ ++
Radial ++ ++
Ulnar ++ ++
Brachial ++ ++
Axillary ++ ++
Subclavian ++ ++
Temporal ++ ++
Common Carotid ++ ++
PeripheralVessels:
++ Normal
+ Weak
- Absent

19. MOTOR SYSTEM EXAMINATION:
 Movements of joints(left side) at intertarsals,
tarsal, ankle: Lost
 At Knee and hip, movements are possible
 Bulk of Muscle: Decreased on left side
 Tone: Normal
 Power: Normal
CIRCUMFERENCE RIGHT LEFT
Calf 35cm 29cm
Thigh 50cm 50cm

20. SENSORY SYSTEM OF LEG:
 Crude and fine touch, pain sensation,
temperature above ankle, above 2cm-medial
malleolus: Normal
 Hyperesthesia of left foot present
 Patellar reflex present on both sides
 Ankle reflex not able to elicit on left side
 Plantar reflex absent on left side
 Regional lymph node examination: Normal

21. UPPER LIMB EXAMINATION:
 Allen’s test: Both radial and femoral arteries are
patent on both sides
 EAST/Roos Test: Able to perform opening and
closing of hands for 5 minutes without any
difficulty
 Adson’s Test: Radial pulse not obliterated
 No palpable thrill on palpating arteries
 No bruit heard on auscultation

22. SYSTEMIC EXAMINATION
 CVS: S1 and S2 heard, no murmur
 RS: normal vesicular breath sounds heard, equal
bilateral air entry, no added sounds
 CNS: No abnormalities detected
 Per Abdomen: Soft, not distended and non tender
abdomen, no organomegaly detected, bowel
sounds heard

23. SUMMARY
 50 year old male patient who is a known case of
diabetes, hypertension and a chronic smoker, has
come with pain in left foot since 4 months,
blackish discoloration of left foot since 3 months
and ulceration on left foot and ankle since 1 week
 On examination of left leg, 1st
and 2nd
toe
amputated, other toes and foot showing features
of dry gangrene, 2 arterial ulcers over dorsum of
foot and left lateral malleolus of left lower limb,
both capillary and venous refilling time delayed,
features of chronic ischemia seen with no
regional lymph node enlargement

24. PROVISIONAL DIAGNOSIS
 Peripheral rterial disease of left lower limb with
arterial ulcer and dry gangrene of left foot
probably due to tibial artery occlusion secondary
to atherosclerosis

25. MANAGEMENT- INVESTIGATIONS:
 Blood: CBC, Sugar, HbA1C, urea and
electrolytes, Lipid profile
 Urine: Sugar, serum creatinine
 ECHO, ECG
 Ultrasound Doppler Blood flow detector
 DUPLEX scan
 ABPI
 CT angiography, MR angiography
 Digital subtraction angiography

26. TREATMENT
 Cessation of smoking
 Controlled regularized exercise
 Care of limb: Avoid injuries
 Control of blood sugar and BP
 Control lipid abnormality with diet and drugs(Low fat
diet and statins)
 Heel rise shoes
 Analgesics: for rest pain ( DICLOFENAC/
ACECLOFENAC 100mg BD)
 Aspirin, Clopidogrel>Antiplatelet drugs(decreases
coagulation); Cilostazol, Pentoxphylline(decreases
viscosity)

27.  Specific Measures: The gangrenous area should
be cleaned with antiseptic solution like povidone
iodine and dry dressing is done with antibiotic
powder
 Surgical management: Conservative amputation
of left leg
 Other surgeries: Endarterectomy, Atherectomy,
Thrombectomy(rarely done), Transluminal
angioplasty+stenting

28. THANK YOU