This document presents a case study on a 37-year-old Filipino fisherman diagnosed with Buerger's disease in his left foot. He was admitted to the hospital with complaints of left foot pain, discoloration, and swelling. Tests showed thrombotic arterial occlusive disease and total occlusion in his left lower leg arteries. He underwent a below-the-knee amputation of his left foot. The document provides details on his medical history, examinations, diagnosis, treatment, and anatomy and physiology background on vascular systems and Buerger's disease.

1. Vicente Sotto Memorial Medical Center
Ward VIII – Orthopedic Ward
A Case Study on
Buerger’s Disease
(Thromboangitis Obliterans)

2. Patient Profile
 Name: Mr. BMM
 Age: 37 y.o.
 Sex: Male
 Civil Status: Married
 Address: Curva, Medellin, Cebu City
 Occupation: Fisherman
 Nationality: Filipino
 Religion: Roman Catholic

3.  Name of Hospital: Vicente Sotto Memorial
Medical Center
 Date of Admission: August 6, 2011 at 3pm
 Ward and Bed No.: Ward VII, Bed #34
 Case No.: 253294
 Chief Complaint: Left foot pain,
discoloration and swelling
 Medical Diagnosis: Buerger’s disease, left
foot
 Operation: Below the knee amputation

4. Summary of Significant Findings
Patient, Mr. BMM, is a 37 year old male,
married, Filipino, living in Curva, Medellin, Cebu
City, works as a fisherman, was admitted in
VSMMC Ward-VIII Orthopedic Ward last August
6, 2011, at 3pm due to left foot pain,
discoloration and swelling eventually diagnosed
to have Buerger’s disease of left foot, planned
to have below-the-knee amputation.

5.  Health Assessment
~ History of Present Illness
Onset of intermitent claudication especially
after walking was 8 months prior to admission,
usually located at the gastrocnemius radiating
at the inguinal area, relieved with rest. No
consult done.
Patient then had an injury at the 4th toe,
left foot 2 months PTA. No medications taken.
Blackish discoloration of the 4th left toe
eventually noted. Wound progressed. No
consult done.

6. Spread of the necrotic tissue extending
to the 5th, 3rd, and 1st toe of left foot
continued 2 weeks PTA. Sought consult and
was advised to have Doppler study of left
foot by Dr. Vicuna in VSMMC, and then
diagnosed with Buerger’s disease.
Admitted to Ward VIII-Orthopedic Ward of
VSMMC, below-the-knee amputation of left
foot was done without complications.

7.  Functional Health Patterns
~ Health Perception and Health Maintenance
“Dili mi ganahan masakit kay wala mi kwarta ika
palit ug tambal” as verbalized by patient. Not
knowledegeable on testicular examination. No
dental checkups. Over-the-counter med use for
common illnesses. Is a heavy smoker, consumes ½
pack of cigarettes daily called Mighty, occasional
alcoholic about 1-2 bottles of beer per episode. No
allergies. Not complete on immunizations. Prior
hospitalization noted only last 1990 at Verallo
Hospital for ulcer. No surgeries done, no
complications.

8. ~ Nutrition and Metabolism
He is 5 feet 4 inches tall, 140 pounds. Weight
after surgery was 134 pounds. No diet restrictions
before and after surgery. No supplements taken.
Appetite was normal but has decreased after
surgery. Consumes 2 to 3 cups of rice. Seldom
eats meat and chicken. No swallowing difficulties.
No chewing difficulties. Assisted by his mother
during meals currently on postoperative day 1.
~ Elimination
Normal bowel and bladder movement before
surgery. Has not defecated since after surgery. No
Foley catheter attached. No urination difficulties.
No dysuria, hematuria, urgency, frequency or
nocturia. No burning upon urination.

9. ~ Activity and Exercise
No specific exercises, just brisk
walking. Wakes up at 4 am to go fishing,
works in a nearby hacienda at 10 am, rests
at home at 7pm. He is the breadwinner of
their family. He was a little dizzy when he
first attempted to sit on bed on his second
postoperative day. Needs 2 crutches to
assist him in ambulating after discharge.

10. ~ Cognition and Perception
Fatigued and somewhat lethargic due to the
recent surgery. He is initially uncooperative on
first interview, but has opened up on the
second day. Calm and speaks only when
questioned. Sadness and deep concern over his
loss of limb is observed. Irritable sometimes
when talking to his mother. He is oriented to
person, place and time. Facial grimacing
evident when he tries to move his left leg on
changing positions in the second postoperative
day most especially on wound dressing, he
rates as 9 to 10/10.

11. ~ Sleep and Rest
Sleeps 6 to 8 hours every night. Naps in the
hacienda after lunch break for 30 minutes. Now
is only able to sleep well when his leg pain
episodes do not come. Positive snoring at night.
~ Sexuality and Reproduction
No prostate problems. No penile discharges.
Doesn’t know how to do self-testicular
examination. No HIV history, sexually active
with his wife. No use of any contraception. He
does have 4 children. He reveals that he is now
concerned on his own body image in terms of
sexual relations with his wife. He feels that him
and his wife might not be sexually aroused
because of his physical appearance now.

12. ~ Self-perception and Self-concept
Calm and cooperative on our second
interview, but sadness still noted. Feels anxious
about the future and how he can earn money.
Little eye contact on our conversation, always
looking the other side or the ceiling. Now
perceives himself as “pabigat” in his family due
to the loss of 1 limb.
~ Roles and Relationship
Living with his family in their own nipa
house. Married to a 33 year old woman. His
support systems are his 6 siblings. He is
concerned more on his role as a father and as a
husband now that his left foot is amputated. He
has no conflict with any of the persons in his
community.

13. ~ Stress Tolerance and Coping
Stressors are his occupation and his illness.
Deals with his occupational stress by smoking.
Now stressed about the future after his left leg
amputation. Stressed also on not be able to
care more on his newborn.
~ Values and Belief
Roman Catholic, but not active on church
activities. Believes on the local manghihilot in
their community.

14.  Physical Examination
~ General Survey
Fatigued. Obvious amputated leg in his left
feet wrapped in elastic bandage. He is clearly
sad about his limb loss and doesn't cooperate
much on our initial interview with him. He has
not yet bathe since after surgery, so he has
some postoperative Betadine smell.
~Skin
Abrasions and scars noted on the upper
and lower extremities. Uneven skin tone in his
sun exposed areas of the body. Pinpoint brown
moles, not raised, diffusely located on upper
and lower extremities. Break of skin in the
amputated leg. Mild localized erythema in the
surgical site.

15. ~Hair
Dandruff seen on scalp, uncombed hair.
~Nail
Unclipped nails in both hands and feet with
observable dirt under the nails in the 4th and 3rd
digits of the right hand metacarpals, 1st and 4th
digits in the right feet metatarsals.
~Head
Normal.
~Neck
Normal.
~Cervical Lymph Node
Normal.

16. ~Mouth
Has dental caries in the upper and lower
portions of the teeth.
~Nose
Normal.
~Sinus
Normal.
~Eyes
Normal.
~Ears
Little ear wax noted bilaterally.

17. ~Thoracic and Lung
Normal
~Cardiovascular
Normal. Distant S1 and S2.
~Breast
Normal.
~Abdomen
Normal.
~Genitourinary
Not assessed. Patient declines.
~Reproductive
Not assessed. Patient declines.

18. ~ Musculoskeletal/Extremities
Stump of left foot is observed wrapped with
elastic bandage. Reports achy throbbing pain,
tingling and mild numbness of the surgical site.
Reluctance to move. Dorsalis pedis and posterior
tibial pulses of right foot noted.
~ Neurologic
General weakness noted throughout his
body due to postoperative surgery. Patient
reports feeling like the amputated left foot is
“still there”.
~Cranial Nerves
All are intact and normal.

19. Diagnostic and Laboratory Tests
~All laboratory tests are normal.
~Diagnostic findings shows: X-ray of the left foot
to be normal, no joint or bone fractures. Arterial
duplex scan shows thrombotic arterial occlusive
disease causing total occlusion of the left
femopopliteal junction segment, left popliteal
artery and tibioperoneal trunk. The left dorsalis
pedis artery and terminal arterior tibial artery
are totally occluded by thrombosis. The distal
right portion tibial artery is >50% occluded by
thrombus. Venous duplex scan shows no
evidence of venous thrombosis or significant
reflux in the lower extremities.

20. Anatomy and Physiology

22. The vascular system is a closed transport
system where blood circulates. The main
components of the vascular systems are
arteries, veins and capillaries. Arteries carry
blood away from the heart while the veins
return the blood to the heart. Arteries are thick-
walled vessels which transport oxygen and
blood via the aorta from the heart to the
tissues. They branch into arterioles. The 3
layers of the arteries are tunica intima, the
inner layer of endothelium; tunica media, the
middle layer of the connective tisses, smooth
muscles, or elastic fibers; tunica adventitia, the
outer layer of connetive tissues.

23. Arteries direct blood away from the heart
and towards the cells of the body. They tend to
lay deep in the body tissues, partially to
protect them from trauma. Arteries have
several layers; a tough outer layer, a middle
layer of smooth muscle, and an inner layer of
very smooth cells. The tough outer layer allows
the artery to withstand the high pressure that
occurs with each beat of the heart. The smooth
inner layer of the artery gives red blood cells
and the fluid surrounding the red blood cells
(called plasma), a friction-free pipe to get to all
of the cells of the body.

24. The muscular wall (the middle layer) of the
artery helps the heart pump the blood. When
the heart beats, the artery expands as it fills
with blood. When the heart relaxes, the artery
contracts, exerting a force that it strong
enough to push the blood along. This rhythm
between the heart and the artery results in an
efficient circulation system.
The smooth muscle in the walls of arteries
also allows them to selectively constrict and
dilate. This is very important, because blood
does not flow to all organs in the same amount
consistently.

25. The main artery from the heart is called the
aorta. It is large, and has a thick wall because of
the high pressure of blood that is flowing through
it. The ascending aorta supplies the head with
blood through arteries called the brachiocephalic
trunk, eventually branching to the carotid arteries.
The descending aorta goes through the thoracic
cavity and supplies the rest of the body from within
the abdomen. A branch of the descending artery,
called the coronary artery, supplies the heart.

26. As an artery gets further from the heart it
gets smaller and eventually becomes an
arteriole. An arteriole is smaller in diameter
than an artery, and is found closer to the
target organ. For example, a branch off the
descending aorta, called the renal artery,
supplies the kidneys. As the renal artery enters
the kidneys it breaks up into many small
branches called arterioles.

27. The arterioles also are lined with smooth
muscle, allowing further refinement of blood
flow to a target cell.
At the level of the cell the arteriole branches
into even smaller vessels called capillaries. They
do not contain smooth muscle, and cannot
selectively constrict or dilate like arteries and
arterioles. They are very small in diameter, so
only one red blood cell can pass at a time. In
fact, the capillary is so small that red blood cells
literally have to squeeze their way through in
many cases.

28. The wall of capillaries are only one cell
thick, all for a reason. It is at the capillary
level that oxygen flows from hemoglobin,
contained in the red blood cell, into the actual
kidney cell or liver cell. At the same time, the
hemoglobin picks up carbon dioxide that is
coming out of the cell. This red blood cell,
whose hemoglobin is now saturated with
carbon dioxide instead of oxygen, eventually
flows back to the lungs to rid itself of carbon
dioxide and take on a new load of oxygen for
delivery to some other cell in the body. After
about 90 days the red blood cell wears out
and is metabolized by the body.

29. The capillaries are thin-walled vessels
located in the tissues. They connect the
arterioles with the venules, where exchange of
gases, nutrients and metabolic wastes
products occur.
As the capillary leaves the individual cells it
is assigned to supply, and starts the journey
back to the heart, it becomes a venule.
Venules are small veins, and have a job similar
to arterioles, although there are many more
venules than arterioles. Their numerous
branches drain an organ, eventually coalescing
into veins on their trip back to the heart.
As the venules coalesce they eventually
form veins and continue on their way through
the cardiovascular system.

30. The veins are thin-walled vessels which
transport deoxygenated blood from the
capillaries back to the right heart. The veins are
distensible, allowing accumulation of large
volumes of blood. This is because of lesser
connective tissues and smooth muscles than in
the arterial walls.
Veins have 3 layers just like arteries,
although each layer is thinner and not as strong.
They don't need to be as strong because the
blood is under much lower pressure in the
venous system. The blood in the veins is darker
in color compared to the blood in the artery
because they contain less oxygen. about 2/3 of
the blood in the body resides in the veins at any
one time.

31. Those veins in the back of the body
eventually drain into the posterior vena cava,
and into the right atrium of the heart. The
veins that drain the head and upper part of
the body eventually drain into the anterior
vena cava and into the right atrium of the
heart. The pressure in the veins is much lower
than in the arteries and arterioles.
Veins have one-way valves, directed
upward which allow blood flow against the
gravity. Also, the skeletal muscle surrounding
these veins continuously contracts in small
amounts, further pushing blood in the right
direction.