PRECEPTOR:

Dr.R.M.TJAHJA NURROBI, M.Kes, Sp.OT (K) Hand

Case report
Buerger disease
Isyfaunnisa
030.11.143

SECRETARIAT CLINICAL SURGERY

FACULTY OF MEDICINE TRISAKTI UNIVERSITY
NAVY HOSPITAL Dr. MINTOHARDJO
Case report
 Identity
Name : Mr. Yerri Yolandra
Gender : Men
Place of birth : Padang
Date of birth : September 16th 1960
Age : 55 yo
Adress : Teladan no 19 Bogor
religion : moeslim
education : Senior high school
Marital status : Merried
Work : entrepreneur
 History

Main complaint
Toes of blackned
 History of present illness
Patient complaint left toes blackened until soles of the feet
Patient feel painful
The complaint arises since 2 months ago after baypass
Legs feel numb
The patient has done hyperbarik since on November 24th 2015
until now as much as 27 times. After hyperbarik, patient feel
his legs like an electric shock. Patient has consul with
cardiologist
 Past medical history
- patient has hypertention and CHF ec CAD on November 6th 2015
- patient have been treated to the community health centre with complaint
sweating, dizziness in the nape, and restless

Family history of disease

- Patient have a family history of hypertension and four brothers of patient
have died of hearth disease.

Treatment history:
Patient taking amlodipin since 4 years ago. Patient perform CABG on
November 6th 2015, and patient also perform hyperbaric at the hospital
navy Mintohardjo
 History of habits
Patient smoked since senior high school as 18
cigarettes everyday. Patient taking traditional
herbal medicine. All this time, the patient has
habits of eating padang food and innards.
 Physical examination
General condition Vital sign
Ill impression : moderete Blood pressure: 90/60
Nutritional status : good mmHg
Awareness : Compos Pulse: 90x/m
mentis Temperature: 36C
RR: 18x/m
 Physical examination
General status
Head : Normocephal
Eye : clear cornea, blackish brown iris color, pupil isokor, direct light reflex +/+,
indirect light reflex +/+, conjunctival pallor -/-, sclera jaundice -/-
Nose : normal, no discharge, no blood
Mouth : OH good
Ear : Normotia, no discharge and blood
Neck : Thyroid and lymph nodes no enlarged
Thorax
Lung : Symmetrical, breath sound Vesikuler +/+, Wh -/-, Rh -/-
hearth : hearth sound I &II reguler, gallop (-), murmur (-)
chest and breasts : there are stitches in the sternum after CABG.
Abdomen : flat,noisy bowel (+), Timpani, tenderness (-)
 Physical examination
Urogenital : Normal
Limb : There are gangrens on digiti left toes
I,II,III,IV,V

View before amputation

 Investigation
Hematologic

Routine blood
Lekosit 7.600/ul
Eritrosit 4.10 million/ul
Hemoglobin 11.9 g/dl
Hematokrit 36%
Trombosit 224.000 thousand/ul
Hemostasis
Blood time 300
Cloting time 1130

Clinical chemistry

Blood glucose
Blood glucose in the time 141 mg/dl
Clinical diagnostic
Buerger disease
Treatment
Pre operation operation Post operation

Ceftriaxon 2 Injection RL Injection lasix

gr 20 drops 1 amp
Inj ceftriaxon ISDN 5 mg
2x1 under tongue
Inj ketorolac
3x1
Amputation
digiti left toes
I,II,III,IV,V
Skin graft
Bedrest
Changing
bandages
every 2 days
FOLLOW UP
January, S : No complain
12nd2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,2 C N: 82 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Ceftriaxon 2 gr

January, S : breathless
13th2016 O : Compos mentis, mild pain
TD : 110/70 mmHg S: 36,4 C N: 80 RR= 18x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection RL 20 tpm
Inj ceftriaxon 2x1
Inj ketorolac 3x1
Bedrest
Changing bandages every 2 days
January, S : cough, breathless
O : Compos mentis, mild pain
14th2016 TD : 100/70 mmHg S: 36,3 C N: 90x/m RR= 16x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: Injection lasix 1 amp
ISDN 5 mg sublingual
January, S : cough, breathless
15th2016 O : Compos mentis, mild pain
TD : 100/70 mmHg S: 36,5 C N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra, blood seeped
A: Pro amputation digiti left toes I,II,III,IV,V
P: ceftriaxon 2x1 gr , Ketorolac 2x1 amp , RL
Consul cardiologist (dr.Stephani), EKG every morning , Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg , Bisoprolol 1x25 mg , Avesco 1x1 tab , ISDN 5 mg
sublingual
January, S : breathless
16th2016 O : Compos mentis, mild pain
TD : 110/80 mmHg S: 36,5 C N: 88x/m RR= 26x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti left toes I,II,III,IV,V
P: ketorolac 2x1 amp, Ceftriaxon 2x1 amp, Injection lasix 1 amp
IPG 1x75 mg , Letonal 1x25 mg, Bisoprolol 1x25 mg, Avesco 1x1 tab , ISDN 5 mg
sublingual
January, S : breathless
18th2016 O : Compos mentis, mild pain
TD : 120/80 mmHg S: 36,5 C N: 80x/m RR= 28x/m
Eye : CA -/- SI -/-
Thorax : Breath sound vesikular +/+, rhonki -/-, wheezing -/-
Abdomen : Flat, noisy bowel (+) N, tenderness
Ekstremitas : oedema (-)
Location status:
-attached bandages on pedis sinistra
-attached kassa on inguinal dextra
A: Pro amputation digiti I-V pedis sinistra
P: Cefixime 2x100 gr , Nadiclop 2x25 gr , Lasix 2x1 amp, Neurodex 2x1 gr,
Lantoprazol 2x1 Impepsa 3x1
 Surgery report (january 13th 2016)
Types of surgery : Pro amputation digiti left toes I,II,III,IV,V
Position : Supine
Anesthesia : SAB
Operation time : Wednesday, January 13th 2016 12.00-14.00 oclock
Duration : 2 hours
Surgery report:
Position of supine with SAB
Asepsis and antisepsis location operating
Incision edge of the wound necroting
Spin of area necroting digiti I-V pedis sinistra
Do amputation and necroting
Followed with skin graft ( FTSG)
Drain in inguinal
Doing suture
Thick bandage
View after amputation
Literature review
Anatomy
Artery
Thigh and gluteal region : femoral artery
and obturator artery

Leg : anterior leg (anterior tibial artery),

posterior leg (dorsalis pedis artery)

Foot : dorsalis pedis artery and posterior

tibial artery
Venous
Deep vein
gluteal : inferior and superior gluteal vein
thigh : external iliac vein and femoral vein
Foot and leg : anterior tibial vein, posterior and fibular vein, popliteal
vein, plantar vein
Superficial vein
great saphenous vein
small saphenous vein
Histology

The intima
The media
The adventitia
 TAO

Definition :
Thromboangiitis obliterans (TAO) is an inflammatory,
nonatherosclerotic, occlusive disease of small and medium-sized
arteries and veins that involves distal vessels of the extremities
Cause and risk factor
tobacco exposure of any kind, including smoking, chewing or
snuff.
Aged (predominately 20 to 40 years old)
more common in men
Genetics
Hypercoagulability
endothelial dysfunction
immunologic mechanism
high cholesterol
high blood pressure
diabetes
Pathogenesis

smoking

Genetic
Endothelial
dysfunction

Bueger
disease

Immunologic
mechanism
Hypercoability
Pathology
Clinical description
Two or more limbs being affected
Discoloration of the affected limb
Pain which may increase with activity such as walking and
decrease with rest
Numbness and tingling in the limbs
Raynaud's phenomenon
Skin ulcerations and gangrene of the digits, which are common
Pulses which may be decreased or absent in the affected
extremity
Later symptoms which include enlarged, red, tender cord-like
veins
Diagnostic method
Non-invasive vascular
evaluation
used to check for a lack of
atherosclerotic lesions and
can identify the distal sites
of symptomatic arterial
occlusion and other sites of
lesions
Angiography
The most important diagnostic
criterion is the smooth and regular,
non-atherosclerotic nature of the
artery wall both at the site of, and
also proxmally to arterial
occlusions.
In the legs, infrapopliteal lesions
predominate
In the arms, the lesions primarily
concern the radial and cubital arteries
Laboratory
Treatment
Drug
- vasodilator
- spinal cords stimulators
Surgical
- sympathectomy
- distal limb amputation
 Skin graft and flaps
Graft are measure aimed to remove
healthy skin and attach to the skin wound
Without carrying its own blood supply
Consist of Full thickness- full thickness
Skin graft skin grafts and split thickness skin grafts

Flaps are elevated from a donor site and

transferred to the recipient site with an
intact vascular supply
It survives by carrying its own blood
Flaps supply
Consist of local, regional and distant
flaps
Example for flap regional
Thank you