This document presents a case study of a 45-year-old male carpenter who presented with chronic pain in both legs for two years and recent pain and blackening of his right great toe. On examination, his right great toe was found to be blackened, shriveled and mummified, with absent pulses below the knee. He was provisionally diagnosed with gangrene of the right great toe due to peripheral vascular disease, likely thromboangitis obliterans. The case was presented by a surgery resident and moderated by an associate professor to discuss the patient's history, examination findings, and provisional diagnosis.

1. CASE
PRESENTATION
ON CHRONIC
CRITICAL LIMB
ISCHAEMIA
• PRESENTED BY – DR BHASKAR SHARMA
• 2nd year Surgery PGT
• MODERATED BY- DR S S BHATTACHARJEE
• Associate Prof Department Of Surgery

2. PATIENT PARTICULARS
• NAME – HAFIZUR RAHMAN
• AGE – 45 YEARS
• SEX – MALE
• RELIGION – ISLAM
• OCCUPATION – CARPENTER
• ADDRESS – HAILAKANDI
• DATE OF ADMISSION – 20/6/20
• DATE OF EXAMINATIOM – 21/6/20

3. CHIEF COMPLAINS
1. Pain in both the legs for 2 years .
2. Pain in the right foot for 1 month.
3. Blackening of right great toe for 15 days .

4. HISTORY OF PRESENT ILLLNESS
The patient complains of pain both the legs since 2
years . Patient complains that the pain starts while
walking for 400-500 metres . Patients experiences pain
in the calfs . No pain in the thighs or buttocks . Pain is
severe and cramp like compelling the patient to stop .
Pain subsides on taking rest for 3- 5 minutes and
paitient can again walk for equivalent distance before
the reappearance of pain .

5. Now the patient complains of pain even on walking for
100-150 metres. Since last 1 month the patient is
having pain in the right foot . Pain is severe ,
continuous and interferes with sleep. Pain is not
relieved by analgesia and partially relieved by hanging
the leg by the side of the bed. There is no history of
numbness, paraesthesia and night cramps.

6. The patient also complains of blackening of the great
toe of right foot since 15 days. Discoloration was
gradually progressive and involved the whole great toe.
It is not associated with swelling or foul smelling
discharge. There is no history of trauma , abrasion
,pustule ,application of irritant or excessive heat. There
is no history of chest pain,syncope,giddiness,polyuria
,polydipsia or impotence.

7. HISTORY OF PAST ILLNESS
There is no history of any major or minor illness for
which the patient was admitted in the hospital . There
is no history of diabetes mellitus , hypertension,
tuberculosis or thyroid disorder . There is no history of
surgical intervention in the past .

8. FAMILY HISTORY
• There is no history of similar illness in the family . Patient live with his
wife and 3 childrens.

9. DRUG HISTORY
• Patient gives history of intake of Analgesics, on & off

10. PERSONAL HISTORY
The patient takes mixed Indian diet . His appetite ,sleep, bowel and
bladder are normal . He was chronic smoker for last 25 years . He used
to smoke 30- 40 bidis /day. He stopped smoking since last 2 weeks.

11. IMMUNISATION HISTORY
Exact imminisation status is not known .BCG scar is absent .

12. ALLERGIC HISTORY
Patient is not allergic to any known inhalant , ingesant or contactant.

13. SOCIOECONOMIC HISTORY
• Patient belongs to lower socioeconomic strata of the society . He live
in a semi-pucca house.

14. GENERAL EXAMINATION
• Patient is conscious well oriented to time , place and person .
• Fairly built and well nourished .
• Pallor – absent
• Icterus –absent
• Cyanosis- absent
• Clubbing –absent
• Oedema- absent
• Lymphadenopathy- absent

15. SYSTEMIC EXAMINATION
• CHEST – Bilateral air entry present.
• CVS- S1 S2 heard.
• ABDOMEN- Scaphoid , umbilicus centrally placed , no scar or dilated
veins , soft on palpation ,no organomegaly, no fluid thrill or shifting
dullness and on auscultation bowel sound is heard.

16. LOCAL EXAMINATION
• INSPECTION –
Right great toe – black discoloration
shrivelled and mummified, extends to the
proximal interphalangeal joint where it
ends is a zone of hyperaemia.
No ulceration or discharge.
No pallor ,congestion, skip area and veins
are filled with blood and aligned well.
Skin over the lower part of the legs and
shin are shiny scanty hair and reduced
subcutaneous tissue.
Brittle deformed nails over the toes

17. • Capillary filling time – 20 seconds
• Venous fillinhg time – 10 seconds
• Buergers postural test – pallor appears at 30 degree
• Cross leg oscillatory movement – R leg- absent
L leg -present

18. • PALPATION-
Skin over the right great toe is cold ,non tender and greasy .
Proximal limb is cold upto the knee .
There is no tenderness over the artery.
There is no oedema or crepitus.
All the movements of the right great toe is absent .
Rest of the joints are normal .
Plantar reflex flexor
Delayed capillary refilling .
Delayed venous refilling.

19. PULSATION-.
FA PA PTA ATA DPA
Right + FEEBLE - - -
Left + + - - -
Radial Ulnar Brachial Axillary Subclavian
Right + + + + +
Left + + + + +

20. • Pulsations over Bilateral Carotid artery, facial artery , superficial temporal
artery are present. The condition of arterial wall is normal and there is no
special character of the pulse.
• AUSCULATION – NO BRUIT HEARD

21. PROVISIONAL DIANOSIS
• The patient is provisionally diagnosed to be a case of gangrene right
great toe with development of demarcation due to peripheral
vascular disease probably Thromboangitis obliterans.

22. THANK YOU