Student’s Name: Firm C (CRH)

Clerkship Date: January-March 2015

Patient’s Name: Age 38 Reg#: 21-10-21

Address: Farm District, Savanna-la-mar P.O.

Occupation: Unemployed

Religion: Christianity

Denomination: Seventh-Day Adventist

Admitted: February 6, 2016

 Patient was assigned 1st/3/16

PC: Pain in both feet with darkening feet and toes

HPC: Known HIV patient since 2008. Claims to be complaint with medication,
maintained on Zidolam-N 150mg bd.

Patient was relatively well until 10/12 prior to admission experienced intermittent
pain in the thighs, legs and feet only upon walking a specific distance that was
relieved by rest. Pain burning in character and non-radiating. No medication was
taken for the pain. No associated swelling of legs or ulcers. No fever. Medical
attention was sought at Savanna-la-mar Hospital, for which pain medication was
given.

9/12 prior to admission pain worsened, medical attention sought at Black River
Hospital. Was not able to walk from then. Pain remained. Analgesics were given.
Right leg looked pale with darkened areas.

8/12 prior to admission third digit on right foot started to swell and became black
(dry gangrene).

5/12 prior to admission third digit on right foot fell off (auto amputation) with
dark discoloration on plantar and dorsal aspect of feet. Numbness in right toes.

4/12 prior to admission sought medical attention at Tifi Clinic.

1/12 prior to admission sought medical attention at CRH. Received pain killer
(patient cannot recall name) and iron tablets. Left foot began to get dark as well
(dry gangrene).

3 weeks prior to admission, both legs were gangrenous from toe to mid foot, with
hyperpigmentation extending to the mid leg.

1
Past Medical History: HIV positive since 2008

Asthma since age 28

Drug History: Lyrica 7mg 1d

Daflon 500mg 2d

Ranitidine 300mg 1d

Acetofenac 200mg 1d

Zidolam-N 150mg bd

FEB

Past Surgical History: Tubal ligation 2008

Family History: Mother, Patricia Kentish, deceased at 42 yo, Cervical cancer

Father, Windel Kentish, age?, Cancer?

Brother, Desmond Kentish, 47, Asthma

Sister, Sharon Kentish, 44, Hypertension

Sister, Marcia Kentish, age? Hypertention

Sister, Sandy Kentish, 39, Hypertension

Sister, Roxanne Kentish, 28, Diabetes

Son, Stephen Wilson, 25, Cruise warden

Son, Nicko Campbell, 19, Unemployed

Daughter, Shaquilla Campbell, 17, Student

Family history of hypertension, diabetes and asthma

Social History: Retired hairdresser

Lives with care taker, “Mama G”, 72 yo, retired farmer. Concrete house, I bed
room with 3 large beds.

Modern living amenities

Garbage collected

No pets, no rodent problem

Has travelled.

Does not drink alcohol

2
 Smoked marijuana and cigarettes (1 pack a day for 24 years = 24 pack year), both
since age 14. Stopped 2 weeks before being admitted to CRH.

Normally eats breakfast, lunch and dinner.

Review of systems: Respiratory: denies cough, dyspnoea, wheezing and shortness of breath.

Cardiovascular: denies chest pain, orthopnea, pedal oedema and palpitations.

Gastrointestinal: denies diarrhea, constipation, vomiting and hematochezia.

Genitourinary: denies hesitancy, urgency, frequency, dysuria, hematuria, penile

discharge, micturition D/N 3:2, loin pain. Has good urinary stream.

Central Nervous: denies seizures or loss of consciousness, diplopia, wears

glasses, no tinnitus, no dizziness, vertigo, joint pain. No headaches.

Endocrine: denies polyuria, polydipsia and polyphagia. no excessive sweating,

hyperactivity or irritability, no temperature change intolerance.

Summary: 38 year old female, known to be HIV positive since 2008 controlled on Zidolam-
N 150mg bd, claims to be compliant with medication. Recently ceased smoking
cigarettes and marijuana 2 weeks before admission. Present with a 11/12 history
of leg pain, 8/12 history of gangrene third digit on right foot, 5/12 auto digitation
of the third digit on right foot, 1/12 history of bilateral hyperpigmentation from
mid foot to mid leg and gangrenous digits. Admitted for further medical
attention.

Differential Diagnosis

Condition Pros Cons

Buerger’s Gangrene limbs

Disease
Hyper pigmented skin

History of smoking

 Raynaud's phenomenon Gangrene limbs Has a history of limbs becoming blue and red as
a response to cold environment
Hyper pigmented skin

Egotism Gangrene limbs Has not ingested Rye

Hyper pigmented skin Prominent in Russia and Mediterranean, Patient

history does not show travel to such areas

3
Drug Dose/route of admin/times Class of drug Mechanism of
daily action

Pethidine 75mg IM q6hrly Analgesic (opioid) Agonist of opioid

mu receptors in
CNS which causes
analgesia or
decreased pain
perception

Baralgin 2cc IV q8hrly Analgesic (NSAID) Inhibits

(Metamizole) prostaglandin
Antipyretic, synthesis by COX
Antispasmodic inhibition. Also
cannabinoid
receptor activator.

Heparin 5000 & 10000 U S/C BD Anticoagulant Binds to antithrobin

III to inactivate
thrombin and
Factor Xa

Augmentin 1.2g IV TDS Antibiotic (Penicillin, Inhibits the

(Amoxicilin beta-lactam type) synthesis of
Clavulanate) bacterial cells in
gram-positive
bacteria.

Flagyl 500mg IV TDS Antibiotic Inhabits nucleic

acid synthesis
which disrupts
DNA creation

Zantac 150mg PO BD H2 antagonist Inhibits acid

production by acid
producing cells of
the stomach

Nifedipine 20mg PO td Calcium channel blocker Decreases the

arterial smooth
muscle contractility
and cause
subsequent
vasoconstriction

4
9:30pm
6/2/16
Day 1 of Admission

S: In Pain

O/E: Vital Signs Temp 97.8 degrees Fahrenheit, BP 186/105 mmHg , PR 98/min , RR 22/min

All values are normal except, High BP

Mucus membranes pink and moist, afebrile, anicteric, acyanotic

RS: Clear, AEEB

CVS: S1, S2 no murmur, Regular
Abd: Soft and depressible, non-tender, no masses or organomegaly

CNS: GCS 15/15

Right and left lower limb

Pain – tender from mid leg to foot

Cold – From mid leg to foot

Numb

Pulseless

Blue foot and toes

A: Acute or chromic arterial insufficiency (occlusion), h/o C13

P: Heparin 5000u IV td
Pethidine 50mg IM q 6hrly
Zantac 50mg IM q 6hrly
F/U blood results
Request cardiac enzymes and ESR
ECG
CXR
F/U official Doppler with repeat

11:57 Bloods taken off for PT, PTT, INR

5
4:40am
7/2/16
Day 2 of Admission

∆ Acute or chronic arterial insufficiency, C13

S: Nil complaints

O/E: Vital Signs Temp 96.6 degrees Fahrenheit, BP 142/104 mmHg , PR 112/min , RR 20/min

Mucus membranes pink and moist, afebrile, anicteric, acyanotic

RS: Clear, AEEB

CVS: S1, S2 no murmur, Regular
Abd: Soft and depressible, non-tender, benign

CNS: GCS 15/15

MSK: Both lower limbs cold and tender from md leg to feet

A: Acute or chromic arterial insufficiency (occlusion), h/o C13

P: Pull old docket

For CT angiogram
Ensure medication
Heparin 5000u IV td
Pethidine 50mg IM q 6hrly
Zantac 50mg IM q 6hrly

7:10pm
8/2/16
Day 3 of Admission

∆ Acute or chronic arterial insufficiency, C13

Patient not known to be hypertensive.

Blood pressure trend 162/109 142/104  141/98  164/114  171/120
Ass: Newly diagnosed hypertension
Plan: Nifedipine 20mg PO td

6
29/2/16
Day 24 of Admission

∆ Buerger’s Disease, C13

S: In Pain

O/E: Vital Signs Temp 97.2 degrees Fahrenheit, BP 124/86 mmHg , PR 122/min , RR 20/min

All values are normal except, PR high

Patient seems depressed and frustrated with condition. Broke down in tears many times.

Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

Pathidine 75mg IM q4hrs

Heparin 5000u S/C BD

A: Stable

P: Continue allow for demarcation

Ensure Pethidine order, signed for yesterday
Ensure Zantac 150mg PO BD

SOCIAL WORKER NOTES

Visited patient today no improvement. In pain. Crying for injection. Effort to reach her father via
telephone unsuccessful. Try again today.

8:15 am
1/3/16
Day 24 of Admission

∆ Buerger’s Disease, C13

S: Pain in lower limbs all night. Just want to get rid of the pain.

O/E: Vital Signs Temp 98 degrees Fahrenheit, BP 129/91 mmHg , PR 142/min , RR 20/min

All values are normal except High blood pressure is high, PR high

Patient seems depressed and frustrated with condition. Broke down in tears many times.

7
 Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

Pathidine 75mg IM q4hrs

Heparin 5000u S/C BD

Young female, seen lying in bed at 30 degrees. No cardiopulmonary distress, mucus membranes
moist and pink, anicteric, afebrile and acyanotic.

RS: Breathing is thoraco-abdominal, chest shape normal, trachea central.

Anterior and posterior chest expansion normal. Tactile vocal fremitus normal. Percussion
note resonant throughout lung fields, Vocal resonance equal on both sides, Air entry
equal bilaterally, Breath sounds vesicular. No crepitation or wheezes. No added sounds.
CVS: Pulse fast, normal volume, symmetrical, non-collapsing
Heart S1 and S2 heard and normal. S3 & S4 not heard. No murmurs heard
Apex beat appreciated in the 5th intercostal space in the mid-clavicular line
No radio-femoral but femoral pulse weak. Dorsalis Pedis pulse absent, Popliteal pulses
faint.
No clubbing in hands.
Abd: Soft and non-tender. Normal liver, kidneys and spleen.

CNS: Higher mental functions normal

Alert and oriented in time, place and person

Time: Year: “2016”, Month: “March”, Day: “1”
Place: “Cornwall Regional”, Ward “7 East”.
Person: Who am I? “My Doctor”
o Follows 1 and 2 step commands

 Look up
 Look up then turn head to the left
MSK: Lower limbs cold to touch from mid leg to feet and also tender. Numb, pulseless,
hyperpigmented.

A: Stable

P: Allow for demarcation

Ensure Pethidine

8
8:30 am
2/3/16
Day 25 of Admission

∆ Buerger’s Disease, C13

S: Pain in lower limbs. Needs to get rid of pain.

O/E: Vital Signs Temp 98.6 degrees Fahrenheit, BP 137/100 mmHg , PR 120/min , RR 20/min

All values are normal except High blood pressure is high, PR high

Decubitus ulcers on left buttocks

Patient seems depressed and frustrated with condition. Broke down in tears again while being
SOAPed

Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

Pathidine 75mg IM q4hrs

Heparin 5000u S/C BD

Young female, seen lying in bed at 30 degrees. No cardiopulmonary distress, mucus membranes
moist and pink, anicteric, afebrile and acyanotic. Lower limbs cold to touch

RS: Air entry equal and bilateral

CVS: Heart S1 and S2 heard and normal. S3 & S4 not heard. No murmurs heard
Pulse fast, normal volume, symmetrical, non-collapsing. No radio-femoral delay but
femoral pulse weak.
Abd: Soft and non-tender. Normal liver, kidneys and spleen.

CNS: Higher mental functions normal. Oriented with time, place and person.

A: Stable

P: Pethidine 75mg q hrly IMx3

Allow for demarcation
Seniors to assess ulcer

9
WR Dr. Anderson
Plan NPO
CBC and U&E, PT/PTT/LFT
CMP and 2 units of FP
Consent for bilateral Above Knee Amputation
Give 2.5L N/S

7:57 am
3/3/16
Day 26 of Admission

Day 1 Post Op Bilateral Above Knee Amputation

∆ C13

S: Mild pain. Feeling much better than before. No stool or flatus passed.

O/E: Vital Signs Temp 98.2 degrees Fahrenheit, BP 121/86 mmHg , PR 120/min , RR 20/min

All values are normal except High blood pressure is high, PR high

Patient is much happier in demeanor since operation.

Hb 8.9 (low), WBC 7.2, Platelets 795 (high)

PT 13.0, INR 0.95, PTT 35.5

U&E repeated

Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

Flagyl 500mg IV TDS

Pathidine 75mg IM q4hrs

Panadol

Young female, seen lying in bed at 30 degrees. No cardiopulmonary distress, mucus membranes
moist and pink, anicteric, afebrile and acyanotic. IV line in left arm 500 mls N/S and 100 mls
Flagyl

10
 MSK: Bilateral above knee amputation, bandages intact.

RS: Air entry equal and bilateral

CVS: Heart S1 and S2 heard and normal. S3 & S4 not heard. No murmurs heard
Pulse fast, normal volume, symmetrical, non-collapsing. No radio-femoral delay but
femoral pulse weak.
Abd: Soft and non-tender. Normal liver, kidneys and spleen.

CNS: Higher mental functions normal. Oriented with time, place and person.

A: Stable

P: CBC and U & E

Try clear fluids
Ensure Pethidine
Continue management

7:45 am
4/3/16
Day 27 of Admission

Day 2 Post Op Bilateral Above Knee Amputation

∆ C13

S: Moderate pain in both legs (> in left leg). No stool but flatus passed. Feeling hungry

O/E: Vital Signs Temp 97.9 degrees Fahrenheit, BP 98/60 mmHg , PR 106/min , RR 20/min

All values are normal except PR slightly high, BP reduced drastically

Patient is still much happier in demeanor since operation.

Hb 6.9 (low), WBC 12.6, Platelets 663

PVC 23, MCV 101, RBC 2.3, MCH 30, MCHC 30

Na 135, K 3.6, Cl 103 (low), HCO3 21, BUN 1.7 (low), Ca 1.98, Phos 0.73, Crea 58

Tprot635, Alb 21 (low), Tbili 4, Dbili 3, Alk P 135 (high) GGT 75, ALP 46, AST 99 (high), ALT
50 (high)

CPK 1449, CPK-MB 63 (high), LDH 259

11
 Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

Flagyl 500mg IV TDS

Pathidine 75mg IM q4hrs

Panadol

Young female, seen lying in bed at 30 degrees. No cardiopulmonary distress, mucus membranes
moist and pink, anicteric, afebrile and acyanotic. IV line in left arm 500 mls N/S

MSK: Bilateral above knee amputation, bandages intact.

RS: Air entry equal and bilateral

CVS: Heart S1 and S2 heard and normal. S3 & S4 not heard. No murmurs heard
Pulse fast, normal volume, symmetrical, non-collapsing. No radio-femoral delay but
femoral pulse weak.
Abd: Soft and non-tender. Normal liver, kidneys and spleen.

CNS: Higher mental functions normal. Oriented with time, place and person.

A: Stable

P: To check wound tomorrow

Continue management

5/3/16
Day 28 of Admission

Day 3 Post Op Bilateral Above Knee Amputation

∆ C13

S: Nil new complaint

O/E: Vital Signs Temp 97 degrees Fahrenheit, BP 117/81 mmHg , PR 116/min , RR 20/min

All values are normal except PR high, BP remains reduced

Medication: Baralgin 2cc IV q8hr

Augmentin 1.2g IV TDS

12
 Flagyl 500mg IV TDS

Pathidine 75mg IM q4hrs

Panadol

MSK: Bilateral above knee amputation, clean healthy stump

RS: Air entry equal and bilateral

CVS: Heart S1 and S2 heard and normal. S3 & S4 not heard. No murmurs heard
Pulse fast, normal volume, symmetrical, non-collapsing. No radio-femoral delay but
femoral pulse weak.
Abd: Soft and non-tender. Normal liver, kidneys and spleen.

CNS: Higher mental functions normal. Oriented with time, place and person.

A: Stable

P: Home for today

SOPD x 1/52
Every 2 days dressing of stump at health center
Prescription Hb Forte 1 tab PO BD x 1/12
TTH Voltaren 75 PO BD
Ranitidine 150mg PO BD

PATIENT DISCHARED THE 5th March 2016

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Case Discussion

Discussion seeks focus on the presentation and management of Buerger’s Disease and therapeutic
effect of surgical intervention. Buerger’s Disease or Thromboangiitis obliterans (TAO) is a non-
atherosclerotic segmental inflammatory disease which affects the medium sized arteries, veins, nerves,
arms and legs. The disease can be found worldwide, most commonly occurring in the Middle and Far
East. Japan has a prevalence of 5/100,00 for example. Its appearance in Jamaica is rather rare. There is a
variability in diagnostic criteria, hence it prevalence ranging from 0.5 to 5.6 in Western Europe to large
values of 45 to 65 in India and 80% among Jews in Israel. Such statistics has to be employed because of
is rarity on the Western Hemisphere. Onset is stated to be generally between ages 40 and 45 years, with
an occurrence biased towards males. This is expected as the disease is strongly linked to smoking, for
which still remains generally a habit of men. As with habits that were associated with men almost
exclusively in the past, women are now greater partakers in such habits, hence an increase in occurrence
of women as well, cigarette usage is one such example. 70 to 90 percent of patients diagnosed with the
disease are men with the remaining 9 to 30 percent being female. This study falls in that 9 to 30 percent.

The obvious risk factor for such a pathological development is definitely heavy smoking of
cigarettes. One study showed that an average of 23 years of smoking cigarettes in patients diagnosed with
Buerger’s Disease (BD from here on after). BD is not exclusive to tobacco usage as patients who were
exclusive marijuana smokers, cigar smoker, smokeless tobacco as chewing tobacco have been diagnosed
with the disease as well. The patient in this study has a smoking pack year of 24 years and smoked
marijuana for just as many years.

The cause of the diseases is not understood extensively, however exposure to tobacco is seen as
the main source of disease initiation. Presentation attributed to an immunological response progressing to
vaso-dysfunction and inflammatory thrombi, possibly due to increased sensitivity of collagen types I and
II and elevated serum anti-endothelia cell antibody, suggesting a genetic component. Development of the
diseases is biased towards individuals with higher human leukocyte antigen (HLA) A9, A54 and B5. For
the patient in question, there is a high probability that the pathology manifested itself much earlier on the
background of HIV, making the patient immunocompromised and susceptible. Limited resources are
available on the coexistence of both conditions (BD and HIV) in a patient. A small unofficial study on
four individuals show that the age group of occurrence lies between the 30-39 age range, which is similar,
the study states that all members were men however.

14
 As seen from the patient’s history, the similitude with what is considered the generic presentation
of BD. Moderate to severe claudication with swift progression to critical limb ischemia features such as
rest pain and tissue loss. In this study, it took 9 months for both lower limbs to be involved with the right
limb losing the third digit in 7 months. The features of acute limb ischemia were also present such as
pain, paresis, pallor and mottling. The efficacy of pharmacological intervention is generally considered as
having little effect, as was experienced by patient in study for almost a year. Quality of life deteriorated
rather quickly, with fleeting relief provided by drugs. Pain relief was experienced best when the
analgesic, Pethidine when administered. Baralgin aided in this front as well. Cessation of smoking is said
to be the initial step in preventing progression of the disease, unfortunately patient in study commenced
cessation two (2) weeks before being admitted. CT Angiogram proved to be the best investigation to give
an intuition into the condition, showing aorto-iliac thrombosis and femoral artery thrombosis with high
collateral. This gives good reason for the complication of hypertension that was experienced by a patient
who was never before hypertensive. Nifedipine was appropriately administered to control the elevated
blood pressure. Heparin administration due to the patient’s immobility and increased probability of
thrombus formation.

Waiting for demarcation was the medical protocol that was followed to aid in identifying where
best to amputate. It is well known that amputations below the knee are much better than amputations
above the knee, hence the decision to wait for demarcation. This is so, as prosthetic limbs are easier to
manage. However due to the patient’s distress and pain, amputation was requested. Amputations are done
in this case where the limb is a nuisance and is of no use, falling under the category of Dead Loss.

It should be noted that throughout the patient’s hospital stay, she was visited by a social worker
for counsel. This points to the psychological strain that such a condition may place on a patient. Surgery
provided much relief, as there was drastic change in demeanor and outlook on life.

15
References
Arkkila, Perttu ET. "Thromboangiitis obliterans (Buerger's disease)." Orphanet Journal of Rare Diseases
(2006): 1750-1172.

Fine, Fogo. "Thrombotic microangiopathy and other glomerular disorders in the HIV-infected patient."
Seminars In Nephrology (2008): 545-555.

Norman S. Williams, Christopher J.K. Bulstrode, P. Rohan O'Connell. Bailey & Love’s Short Practice of
Surgery. Edward Arnarld Publishing, 2008.

Olin, Jeffrey W. "Thromboangiitis obliterans (Buerger's disease)." (1990).

16