Case History Taking: Thromboangitis Obliterans – TAO (Patient with Intermittent Claudication and Leg Pain)

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Case History Taking proforma(History Taking and Examination): TAO

Name:

Age/Sex:

Occupation:

Presenting Complaints

Pain in Lower Limb- 5 months

Ulcer- 3 months

Blackish Discoloration- 1 month

History of Presenting Illness

  • H/O Pain in lower limb 

    • (Site, Character, Radiation, Onset,Severity, Associated, Timing, Aggravated, Relieved)

  • H/O Intermittent Claudication

    • Site (Foot/ Calf/ Thigh)

    • Claudication Distance

    • Response after claudication pain starts (Pain reduces and he continues to walk/ Pain does not reduce but is able to walk with pain/ pain intolerable and has to take rest) 

    • Progress of claudication over time (Same/Worsened/Improved)

  • H/O Rest Pain

    • Site of Rest Pain (Toes/ Foot/ Calf/ Thigh)

    • Relieved by (Leg Hanging/ Application of warmth)

  • H/O Ulcer

    • Site, Duration, Onset, Progression, Associated, H/O Trauma leading to ulcer

  • H/O Suggestive of Superficial Phlebitis

R/O Raynaud’s

  • H/O Pain/ Pallor on exposure to cold

  • H/O Bluish discoloration on exposure to cold

R/O Anginal Pain

  • H/O Chest pain aggravated by exercise

R/O Cerebrovascular disease

  • H/S/O Transient Ischemic Attack

R/O Ischemic GI Symptoms

  • H/O Abdominal Pain after food

R/O Aorto Iliac disease

  • H/S/O Impotence

Case History Taking proforma(History Taking and Examination): TAO

Past H/O

  • H/O Similar illness in past

  • H/O Collagen Vascular Disease

  • H/O DM/HTN/IHD/COPD/BA/Epilepsy

Personal H/O

  • H/O Smoking

    • Duration

    • No of Cigarettes/ Bidis per day

  • H/O Tobacco chewing

  • H/O Alcoholism

Family H/O

H/O Similar illness

(Atherosclerosis/ Hypercholesterolemia/ Collagen Vascular Disease)

Treatment H/O

H/O Ongoing Medications

Allergic H/O

H/S/O Allergy to specific medications  

Summarize the History

General Examination

Conscious/ Oriented/ Cooperative

Moderately built and nourished

ECOG (0-asymptomatic , 1-restricted strenuous activity, 2-ambulant capable of self care but no work activities, 3-Capable of only limited Self care, 4-bed ridden)

Pallor/ Cyanosis/Clubbing/ Pedal Edema/ Generalized Lymphadenopathy

Decubitus – Keeps legs hanging from the bed

B.P-120/80

PR-88/ Min (Rate, Rhythm, Volume, Character, Delay- Radioradial, Radiofemoral) 

Systemic Examination

CVS: S1 S2 Heard, No Murmurs

RS: Bilateral Air Entry +, Normal Vesicular BS, No Added Sounds

CNS: No neurological deficits

P/A: Soft, Not tender, BS+

Case History Taking proforma(History Taking and Examination): TAO

Regional Examination

Inspection

With both limbs on the bed beside each other

  1. Attitude of limb

  2. Any deformity—loss of toes or any other deformity

  3. Any muscle wasting in thigh, calf or foot

  4. Condition of veins

  5. Whether normally filled veins are seen in both lower limbs any discoloration along the veins

  6. Look for any guttering along the course of veins (In ischemic limb, the vein may remain collapsed and pale blue gutter may appear across the course of vein. This may appear with the patient in supine position or asking the patient to elevate his leg.

  7. Look for signs of peripheral ischemia

    1. Thin shiny skin

    2. Loss of subcutaneous fat

    3. Loss or diminished hair over toes, dorsum of foot

    4. Nails are brittle and there are transverse ridges on the nail

  8. Gangrene

  9. Site and extent of gangrene

  10. Type (dry or moist)

  11. Color of the gangrenous area

  12. Line of demarcation—note the level and depth of demarcation—whether skin, muscle or bone deep

  13. Limb above the gangrenous area—whether pale, congested or edematous

  14. Look at the areas of pressure points —heel, malleoli, ball of the foot and tip of the toes.

  15.  

Palpation

  • Skin temperature: Start palpating from the foot and find at what level temperature becomes normal, comparing with the normal skin temperature of the patient.

  • „Gangrene

    • Site

    • Sensation

    • Tenderness

    • Any local crepitus

    • „Limb adjacent to gangrenous area

    • Tenderness

    • Pitting edema.

  • Test for assessment of circulatory insuffciency

    • Buerger’s Angle

    • Capillary Filling Time

    • Capillary Refill Time

    • Venous Refilling  (Harvey’s Sign)

    • Crossed leg test (Fuchsig’s Test)

  • Movement of joint adjacent to gangrenous area

  • Examination of nerve lesions in lower limbs (Sensory/ Motor deficits/ Reflexes)

  • Palpation of regional lymph nodes

  • Palpation of peripheral pulses

++ Normal | +Feeble | -Not palpable

Dorsalis Pedis

Anterior Tibial

Posterior Tibial

Popliteal

Femoral

Auscultation

Any bruit along the major vessels

Summary of the case

Provisional Diagnosis

  • Peripheral Arterial Occlusive Disease

  • With Grade IIa Claudication 

  • Probable level of Obstruction below Popliteal artery level  

  • Probably due to Thromboangitis Obliterans 

  • With Gangrene of Left Big Toe

  • With Ischemic Ulcer of Left Second Toe

Differential Diagnosis

Investigations

 

References

https://amzn.to/3kTbF4u

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